nosis of an abnormal ureteric opening is, as already stated, quite positive.
In the other cases in which symptoms occur, they are usually of an obstructive,
sometimes also of an inflammatory, character, and are manifestly of no dis-
tinctly diagnostic value.
In cases of hydronephrosis, congenital abnormalities of the ureters are to
be thought of.
VARIATIONS IX THE BLOOD SUPPLY OF THE KIDNEY
When cystic tumors are observed in the trigonal region of the bladder, the
diagnosis of an abnormal ureteric arrangement is probable, and tnighl be made
definitely by a careful study "1 the bladder with a cystoscope. For a determi-
1 1 : 1 1 1 • > 1 1 of the actual conditions present, and for the origin and course of the
Beveral ureters, there is uo method bo useful as catheterization with styleted
instruments and X ray pictures of the individual with the catheters in ritu.
VARIATIONS IN THE BLOOD SUPPLY OF THE KIDNEY
Variations in the blood supply of the kidney are exceedingly frequent, and
possess a practical interesl both from a surgical ;m<l pathological point of view.
Tlie norma] 1>1<><><] supply of the kidney i- as follows: Each kidney receives its
arterial supply from a branch of the abdominal aorta — the renal artery: the
vessel is of unusual size for the l>ulk of the organ which it supplies. Each
renal artery is given off from the aorta at righl angles, or nearly so, and com-
monly before entering the hilum of the kidney divides into four branches:
two of these supply the anterior and two the posterior half of the kidney; this
may be described as the common arterial arrangement.
According to Jossel, the following is a frequent type of arterial distribu-
tion: two dt" the four branches supply the anterior half, a third proceeds to
the upper, a fourth to the lower portion of the kidney. Of the two anterior
branches, one supplies the middle, the other the lower portion of the anterior
half of the kidney. The superior branch supplies the upper pole, the posterior
branch the lower two thirds of that portion of the kidney which lie- in contact
with the posterior abdominal wall. Anomalous arrangements are exceedingly
common. The commonest anomaly consists in an increase in the numbeT of
arteries. Both renal arteries may arise from a common trunk given off from
the anterior surface of the aorta.
The origins of multiple arteries supplying the kidney may be very varied,
and the genetic causation id* such variations becomes quite plain when we
study the embryology of the kidney with reference to the development of its
blood-vessels. Thus, multiple branches may be derived from various sources
in the following order of frequency: Suprarenal; second or third lumbar: right
hepatic; colica dextra; external iliac; internal and common iliac; middle sacra]
artery. The renal artery may even originate upon the opposite side <>i the
body; thus Otto reported a case in which a branch of the right common iliac
supplied the left kidney. Accessory arteries usually enter the kidney at the
upper, sometimes at the lower pole, occasionally at other points.
When operating upon kidneys partly supplied by branches entering at
unusual situations, the surgeon may encounter unexpected and serious bleed-
ing when enucleating the organ after the vessels of the pedicle have all been
severed: as stated, this will more often occur when separating the upper pole
of the kidney than in other situations.
77
CHAPTER XII
INJURIES OF THE KIDNEY
On account of the position of the kidney in the abdomen, protected as it is
by the spinal column, by thick layers of muscles, and by the thoracic wall,
great force is necessary to injure it from behind; and its deep position pro-
tects it also from all but extreme degrees of violence from in front. Accord-
ingly, injuries of the kidney are comparatively rare. In battle, injuries of the
kidney, as the result of gunshot wounds, are probably fairly common, but in
most of the cases associated grave injuries of the spine and of the abdominal
viscera so commonly coexist that the wounds rarely come under the care of the
military surgeon. In civil life, also, gunshot and stab wounds of the kidney
are relatively rare injuries. Contusions and ruptures of the kidney, as the
result of blunt violence without external wound, are much more common ; only
very rarely are injuries of the kidney by blunt violence associated with an
extensive contused and lacerated wound. As might be expected, all the forms
of kidney injury are far more frequent in males than in females, and they are
more frequent during the second and third decades of life than earlier or later ;
although in large cities, like New York, where run-over accidents are so com-
mon, a considerable proportion of the ruptures of the kidney occur in children.
A large proportion of all subcutaneous injuries of the kidney are associated
with grave traumatisms to the other abdominal viscera, to the spine, etc.
Kuster collected the statistics of 306 cases of injury to the kidney without
external wound. He found that the right kidney was injured more often than
the left, and that 93.98 per cent of the cases were males, 6.02 per cent females.
A nearly similar proportion existed among children under fifteen years of age.
Of these, there were 41 cases, and 33, or 80.48 per cent, were boys; only 8
were girls. Kiister explained the infrequency of kidney injuries in the female
not only by their less active mode of life and less frequent exposure to external
violence, but also on account of the fact that the broader pelvis and more
prominent crests of the ilia in women served to protect the kidney from direct
violence. Further, that women usually have a thicker layer of fat; that their
corsets also probably served to protect them to some extent. The rarity of
injuries of the kidney may be illustrated by the following facts : From January
1, 1890, to October 1, 1898, only 1 cases of injury to the kidney, requiring
operation, entered the Roosevelt Hospital in the city of New York, a hospital
386
[NJUBJE8 01 THE KIDNEY
where the accidenl service is very large. A Dumber of <•■-• - of injury of the
kidney other than these were treated in the hospital by conservative measures,
the kidney lesion qoI being Bevere enough to meril operation. Of the cases
operated upon, all were males, and ;tll but •! were young adults; the
ranged between twenty-eighi and ten years. In 5 of the cases the injur
the kidney was caused by the patienl falling some distance ;ni<l striking against
Borne bard object, which injured the loin or the lateral wall of the belly. One
case was crushed between two cable cars. In the Beventh case the patient,
who was riding a bicycle, collided with the shaft of a wagon, which peneti
his right pleura, diaphragm, peritoneum, liver, and caused a contused and
lacerated wound of the right kidney I Dr. Robert Abbe's case). Thus 6 of these
cases were subcutaneous injuries. Since 1898 only 6 cases of injury <>f the
kidney requiring operation have come under my persona] observation in my
service at the New York Hospital. One of these cases was a rupture of
the liver, the kidney, and the lung. The case history i- given under Inju-
ries of the Liver. One was a rupture of both kidneys, ending fatally. One
was a lacerated wound of the kidney, produced by a fractured twelfth rib;
the broken end of the rib penetrated the substance of the kidney. A fourth
was a gunshot wound of the kidney, associated with wounds of the intestine,
diaphragm, and lung. One was a stab wound of the kidney, requiring 3uture.
One was a subcutaneous laceration of the kidney, requiring nephrectomy on
account of persistent bleeding. 1 recall an unusual case seen by me when I
was house surgeon in IJellevue Hospital in the service of Dr. Frank Hartley,
a stab wound in the right loin, which opened the peritoneal cavity, wounded
the liver, and made a deep cut into the substance of the right kidney. The
knife entered between the ninth and tenth ribs, midway between the mam-
illary and axillary lines, and traversed the right kidney from the outer to the
inner border. A small urinary fistula persisted for six months.
In 189G Keen tabulated 155 cases of injury of the kidney. Of these, 19
were gunshot wounds, 8 were penetrating wounds of other descriptions, 118
were subcutaneous ruptures, G traumatic hydronephrosis, 2 partial nephrec-
tomy for rupture, 2 ruptured ureter (pelvis). From these statistics one sees
that subcutaneous ruptures of the kidney are far more common than open
wounds. The injuries to the kidney substance vary much in severity, from
slight contusions, attended by only a small amount of hematuria, to severe
crushing injuries, in which the kidney may be pulpitiod or torn completely
in two. The causes of rupture of the kidney are falls from a height in which
the individual strikes some more or less prominent hard object, thus injur-
ing the kidney by direct violence; or sudden and very forcible flexion of the
trunk upon itself as the body strikes the ground. Other causes are blows
upon the loin or the front of the abdomen, and sometimes violent muscular
effort. The cases which I have seen of rupture of the kidney have been chiefly
from falls or run-over accidents. A.S Stated under Injuries of the Abdomen.
in general, when the body rests against some firm surface, and a compressing
388 INJURIES OF THE KIDNEY
force is exercised from in front by a moving body, the kidney as well as other
abdominal viscera may be injured. A number of cases of rupture of the kid-
ney from muscular violence have been observed. Thus, Clement Lucas reported
the case of an elderly man who was walking behind a wagon loaded with heavy
sacks ; one of these fell to the ground, and he endeavored to catch it by grasp-
ing it suddenly with both hands. He felt a severe pain in the left side of the
abdomen and back, and passed blood with his urine. A second case was
reported by Campbell. A young girl of fourteen bent her body forcibly to the
left side while jumping over a hedge. She immediately experienced severe
pain in the region of the kidney, and passed blood with her urine.
While the mechanism of ruptures of the kidney by direct violence, the result
of crushing injuries or blows upon the front of the abdomen or the loin, is
sufficiently clear, other cases of rupture of the kidney occur in which the
violence is exerted against some distant part of the body, as when the patient
falls from a height, and suddenly flexes the trunk violently, either anteriorly
or to one side. Ruptures of the kidney under these conditions have been
explained by the theory of hydraulic pressure, sometimes by the pressure of
the ribs. Unquestionably when the lower ribs are broken the kidney may be
wounded, as in the case of my own cited above. It is comprehensible that
as the result of a sudden violent commotion of the body the kidney might be
projected by its own inertia against the transverse processes of the vertebra?,
and thus injured. The explanation of ruptures of the kidney by hydraulic
pressure was made satisfactorily by Krister, who tried a number of experiments
upon kidneys removed from the body and produced ruptures of various kinds,
indicating that a sudden increase of hydraulic pressure was the cause of the
rupture. He also found that even in the bodies of old persons after the intes-
tine had been removed sudden violent pressure upon the lower ribs of the left
side caused the ribs to bend inward and to come into contact with the kidney.
In ruptures of the kidney from hydraulic pressure the lines of rupture usually
radiate from the hilum toward the twelfth rib. In cases of rupture of the
kidney from muscular violence, it is assumed that the muscles acting upon the
lower ribs cause them to move inward, and thus compress the kidney against
the spinal column.
The character of the injury to the kidney varies, as stated, in a number
of ways : In the cases which I have personally seen, in two a simple transverse
fissure of the kidney existed, running from the hilum to the convex border.
In one the kidney was completely torn in two at about its middle. In one
a contusion of the kidney existed without rupture of the capsule, but with
the laceration of an artery in the kidney substance of considerable size, so that
an arterial hematoma or traumatic aneurism was produced, which bled the
patient nearly to death in the course of about four weeks. In another case,
operated upon in the Roosevelt Hospital by Dr. Frank Hartley, there was
rupture of the kidney capsule, the kidney itself was extensively contused, and
a very large hemorrhage had occurred into its interior, so that the organ was
SUBCUTANEOUS [NJURIES 01 THE KIDNEY 389
greatly increased in size. Much of the disorganization of the kidney sub
stance bad probably been caused by the pressure of extravasated blood. In
another case, a child of ten years, who had received a severe injury from a
fall upon the right loin ;ni<l suffered from marked hematuria. Exposure of
the kidney two weeks after the injury for septic symptoms discovered a necrotic
area in the substance of the kidney, rounded in shape, an inch in diameter,
and about half an inch deep. In another case, where a man was crushed be
tween two cable cars and developed some weeks later septic symptoms, a large
tumor formed in the righl 1 < » i 1 1 ; the kidney was found completely disintegrated
at t lie t inie i>( the operal ion.
SUBCUTANEOUS INJURIES OF THE KIDNEY
The various grades of subcutaneous injury to the kidney were classified by
Schede into five groups :
1. Injury of the Fatty Capsule of the Kidney and of the Fibrous Capsule
without Injury of the Kidney Substance. — In these cases there is usually a
moderate effusion of blood between the kidney and its fatty capsule; the latter
is more or less extensively infiltrated with blood, and may subsequently become
thickened and indurated from the formation of new connective tissue. Occa-
sionally the hematoma results in the formation of a cyst.
2. Contusion of the Kidney with Hemorrhage. — Contusion of the kidney sub-
stance with hemorrhage occurs, sometimes without gross lesion, sometimes with
the formation of solitary or multiple fissures in the kidney, -which may be
transverse or radiating, and are seldom parallel to the long axis of the organ.
The ruptures do not extend into the renal pelvis. Such injuries of the kidney,
although they may be accompanied by marked symptoms and hematuria, which
may be profuse, rarely result fatally unless they become infected, or unless a
considerable blood-vessel is torn with the formation of a traumatic aneurism.
3. Fissures, Single or Multiple, in the Kidney Substance, for the Most Part
Radiating from the Hilum, but Extending into the Renal Pelvis. — In some of
these, as in one of my own cases, the kidney may be completely torn in two.
These cases are attended by profuse hemorrhage into the surrounding structures,
into the fatty capsule, into the retroperitoneal tissues, or if the peritoneum in
front of the kidney is also ruptured, into the abdominal cavity. The tendency
of such hemorrhages is to spread downward into the mesentery of the small
intestine, along the course of the spermatic vessels to the groin, into the scrotum,
into the labia majora of the female, into the pelvis, and to appear superficially
in the skin of the abdominal wall. These eases are very serious. The a< m-
panying extravasation of the urine forms a dangerous complication; a consid
erable tumor is usually present in the loin after a few days. Hematuria may
be absent, since the ureter is often plugged by a clot of blood. As a rule,
unless operated upon, septic symptoms develop as the result of infection of
the mixture of blood and urine with the production of a large abscess or of a
390 INJURIES OF THE KIDNEY
widespread necrotic inflammation of the retroperitoneal tissues. Late sec-
ondary hemorrhages may occur as the result of the necrotic process, and such
may be fatal.
4. Complete Purification of the Kidney. — In these cases the kidney is exten-
sively lacerated and torn, and considerable pieces of kidney tissue may be
completely separated from the rest of the organ. The result is not dissimilar
to class 3. Unless operated upon these patients die of hemorrhage or of septi-
cemia.
5. Injuries of the Kidney, Accompanied by Rupture of the Renal Vessels,
Rupture of the Ureter, or Tearing Away the Vessels and the Renal Pelvis from
the Kidney Itself. — In these cases, unless operated upon at once, death ensues
from hemorrhage or from necrotic and putrid inflammation and septicemia.
A sixth class might be added in which, in addition to the injury of the
kidney, extensive multiple injuries of the other abdominal viscera or of the lung
occur, and while always grave injuries, some of them are saved by prompt
operation.
Symptoms, Course, and Diagnosis of Subcutaneous Injuries of the Kidney. —
Since most cases of rupture of the kidney occur as the result of extreme degrees
of external violence, the symptoms of more or less pronounced shock are usually
present immediately after the injury, and are due, as in other cases of severe
injury to the belly, to the violent mechanical disturbance of the sympathetic
and abdominal plexuses of nerves rather than to any injury of the kidney
itself. In other cases the symptoms of shock, even after very severe injuries
of the kidney, may be entirely absent; the individual may continue to walk
about, or even to work for several hours, until he begins to feel faint from inter-
nal bleeding, or until his attention is attracted to the presence of blood in his
urine. Accompanying the shock, when present, nausea and vomiting are com-
monly observed, together with the other symptoms of shock, as already described.
Pain. — Following injuries of the kidney, severe pain is usually present at
the time of the accident, although it may at first be slight, and gradually
increase in intensity, as the effused blood causes tension and undue pressure
upon the nerves of the kidney and its capsule, and upon the sensory nerves
after their exit from the spinal column. The pain is referred to the region
of the kidney, and often radiates downward along the course of the ure-
ter into the bladder, the external genitals, and the inner surface of the thigh.
External signs of injury in the neighborhood of the kidney may be present or
absent ; such may be abrasions, ecchymoses, the signs of a fractured rib, etc.
Extreme tenderness over the injured kidney is present in all cases. If blood
is poured out in considerable quantity in the vicinity of the kidney, a tumor
mass will be formed behind the peritoneum, which may gradually increase in
size for hours or days, and may extend well down to the umbilicus to one side
of the median line, and be felt as a distinct tumor mass or as a mere sense
of diffused resistance on palpation. Such effused blood may appear after a
day or more upon the skin of the lower abdomen, in the region of the inguinal
SUBCUTANEOUS [NJURIES 01 THE KIDNET 391
canal, in the scrotum, in the fold "I the groin. Usually, if the effusion of
blood is considerable, the patienl will lie with the thigh of thai Bide Hi
to relieve the tension of the muscles of the back and of the abdominal wall.
Hematuria. The mosl characteristic sign of injury to the kidney is the
presence of blood in the urine. It is to be borne in mind, however, thai in
several groups of cases hematuria may be slighl or absent. 1 1 the injur
the kidney involves merely the fatty capsule and the fibrous capsule with-
oul crushing or tearing the kidney substance, no blood will appear in tin;
urine. In very severe injuries of the kidney— namely, those in which the
ureter is tern across, or in which the ureter is soon plugged by a blood clol
the quantity of Meed in the urine may be small, microscopic, or even absent.
I n the cases where the ureter is plugged by a clot the appearance of blood may
be delayed for many hours or may be intermittent. In these cases attacks of
renal colic may occur, followed by the evacuation of blood casts of the ureter.
[f the bleeding proceeds rapidly down the ureter into the bladder, the n j>jm-:i r-
ances will vary in differenl cases. Tlie patient may urinate blood in large
quantities mixed with urine. If the bladder was empty at the time of t ho
accident, the organ may till up with partly coagulated blood. In these cases
the patient will suffer intense pain in the region of the bladder, will have a
COnstanl desire to urinate. The contractions of the bladder wall may, however,
be insufBcienl to force the clotted blood through the urethra, so thai complete
retention may occur with the formation of a tumor above the pubes by the
distended bladder. In other cases the patient may be able to empty the bladder
partly, and will pass urine mixed with blood. From time to time the orifice
of the urethra will be plugged by a clot and the stream of urine interrupted,
causing severe pain. In these cases it may be necessary to empty the bladder
with an evacuator, or to suck it out with a large hand syringe and a lar<re metal
catheter having one or more unusually wide eyes. In many cases the quantity
of blood entering the bladder will be small; the urine will simply be colored
slightly or deeply, and will appear not bright red, but smoky or a dull brown
color, indicating that the blood has been in contact with the urine for some time.
It is, of course, important t<» distinguish whether the blood comes from the
bladder or from the kidney. This is sometimes possible. Tsually in hemor-
rhage from the kidney the urine i* evenly mixed with blood; in hemorrhage
from the bladder, on the other hand, the last portion of urine passed often
contains more blood than the first. The diagnosis may also be made by wasli-
ing out the bladder. The bladder once evacuated and washed clean, if the
hemorrhage comes from the kidney, further washings will be clear or but
slightly stained with blood. If the hemorrhage comes from the bladder, re-
peated washings will usually appear blood-stained, since the mechanical dis-
tention of the bladder by the fluid introduced will usually be sutlicient to
keep up or to inaugurate fresh bleeding. The cystoSCOpe will enable one to
clear up the diagnosis in doubtful cases. If the hemorrhage comes from the
bladder, the fluid medium will usually become opaque almosl at once; if from
392 INJURIES OF THE KIDNEY
the kidney, gushes of bloody urine, in case the bleeding is still going on, may
be seen proceeding from the orifice of one or other of the ureters ; or a clot
may be seen adhering to the orifice of one ureter. If the bleeding has per-
manently or temporarily ceased, the cystoscopic field may be so clear as to
enable us to eliminate the bladder as the source of blood. The passage of
cylindrical blood casts of the ureter per urethram, while characteristic of renal
hemorrhage is inconstant.
When the quantity of the blood that is found in the urine is very large,
it is seldom possible to make a differential diagnosis as to its source from
microscopic examination. Injuries of the kidney are usually followed by
a traumatic nephritis, and after a hemorrhage from the kidney has ceased,
examination of the urine will often detect hyaline casts, sometimes containing
granules, sometimes red blood cells and renal epithelium. Such a traumatic
nephritis is associated with an albuminuria, and the quantity of albumin is
greater than can be accounted for by the small quantity of blood present.
Polyuria is frequently present in these cases. Traumatic nephritis is sometimes
associated with edema of the extremities, and even with generalized edema.
This is, however, a relatively rare occurrence. In the very extensive ruptures
of the kidney the symptoms of internal hemorrhage may be present of any
possible grade. In the worst cases the symptoms of progressive anemia may
increase from hour to hour, and unless operated upon the patient may bleed
to death in a very short time. In such cases the local signs of the formation
of a tumor mass in the region of the kidney will be marked. If the peritoneum
has been ruptured, in addition to the signs and symptoms of hemorrhage, there
will be evidences of an accumulation of blood in the peritoneal cavity. These
signs have been described in another section under the Diagnosis of Injuries
and Diseases of the Abdomen. The hemorrhage following contusion of the
kidney may be intermittent, notably if a considerable artery is torn without