CASE. —G. W., aged 5, was admitted into the London Temperance Hospital on November 5th, 1889, in a collapsed state, having been run over by a cart, the wheel passing over the abdomen and pelvis. There was fracture of the left lower ribs and of the right os innomi natum near the eminentia ilio-pectinea. The collapse suggested vis ceral lesion; the catheter drew off only a drachm or two of sanious urine. However, injection of the bladder with two ounces of boracic acid solution, and the subsequent recovery of the same quantity by bimanual expression, proved that this viscus was unruptured. For some days the urine was blood-stained, but he made a good recovery and was discharged on November 30th, passing about twenty-three ounces of urine per diem. A week later he was readmitted on account of a painless swelling discovered in the right loin, extending above to the hypochondrium, below to Poupart's ligament, and inward to the navel. The colon was easily felt in front of the tumor; there was fluctuation. On deep palpation in the right inguinal region a hard, sessile mass was felt at or near the pelvic brim, which was presumed to be callus at the site of the pelvic fracture. There was neither pain nor fever, and the general condition was good. The urine was nor mal, but was reduced to less than half a pint per diem, sometimes only six ounces. December 10th, 1889, the tumor was aspirated from the loin, withdrawing 18 ounces of pale amber-coloredlluid, of specific gravity 1.003, faintly alkaline, containing a trace of albumin and one per cent of urea. The swelling rapidly returned, and on December 16th, 20th, and 30th was again aspirated, withdrawing 25, 29, and 30 ounces respectively. Since this date it was aspirated at increasing intervals down to May 21st, 1891, the patient coming for this purpose as re accumulation occurred. There were sixteen aspirations in all. Since May, 1891, there has been no appreciable return of the swelling, and the boy is in excellent health.
The still more remote effects of these injuries relative to the for mation of a stricture of the ureter and hydronephrosis are exemplified in the following record by Dr. Pye-Smith " : CASE.-" The patient was 24 years of age. About two years preCase.-" The patient was 24 years of age. About two years pre- viously to his coming into Guy's Hospital he had been kicked by a horse on the left side ' under the short ribs.' Ehis was followed by Inernaturia. On his admission to the hospital there was a large tumor
occupying the left half of the abdomen, the physical character of which pointed to its connection with the kidney. The tumor was tapped, and a large quantity of fluid removed. After death the left kidney was found to be in a condition of cystic degeneration. The ureter was dilated for an inch and a half, when it suddenly became contracted, so as not to admit the smallest probe. A few lines nearer to the bladder it again assumed its normal size." These instances are sufficient to illustrate most of the points con nected with the causation of traumatic hydronephrosis.
In some cases a hydronephrosis appears to be intermittent; at one time the renal tumor is tense, while at another it is soft and compres sible, indicating a variation in the amount of its fluid contents. There can be no better guide in the diagnosis of these conditions than the recognition of the fact that a sudden increase in the voluntary dis charge of urine is immediately followed by a corresponding diminu tion in bulk of the swelling occupying the region of the loins. Dr. James reports a case " in which he considered that the contraction of the bladder due to frequent micturition was the origin of a hydrone phrosis, and Morris shows that this explanation may be extended to other causes leading to a considerable straining, such as phimosis and prostatic enlargement.
In illustrating how the ureter is obstructed it might be inferred that hydronephrosis necessarily follows, but this is not invariably the case. In some instances of occlusion from rupture and injury to the ureter where there is risk of urine being extravasated into the sub peritoneal tissues, I have concluded from examinations made by my self as well as by others that extensive renal thrombosis is frequently an immediate sequence of an injury of this kind. Thus urinary ex cretion is modified by the more or less vascular consolidation of the organ involved, and the most serious complication attending such in juries is averted. This I believe proves to be the first step in the process of renal atrophy, in contradistinction to dilatation, which subsequently follows. Mr. Poland and Dr. Moxon have both shown that the blood-vessels of a kidney which has been injured are some times found to be entirely infarcted. This point will again be re ferred to in connection with injuries to the ureters.