The fluid contained in hydronephrotic kidneys is usually urine of a very dilute character, containing traces of the natural constituents. It is nearly always more or less albuminous. Prout detected urea and uric acid in the contents of a double hydronephrosis from a still born infant. In an analysis made by Sir William Roberts the cyst contained 83 ounces of clear fluid of a pale lemon color and urinous smell, sp. gr. 1.002, very slightly acid, with the faintest trace of albumin and presenting under the microscope a few broken-down cells of large size. Occasionally the contents of the sac are of a col loid nature.
Hydronephrosis need not necessarily go on to the complete de struction of the organ. In the case of calculi, the obstruction may be dislodged and the sac emptied without further accumulation. Again instances are recorded where a frequent emptying of the cyst artifi cially has eventually ended in the atrophy of the organ, its place being supplied by the growth of its fellow.
The symptoms of hydronephrosis are extremely variable and are much dependent upon the size which the sac or sacs have attained. In the majority of instances no abdominal encroachment can be made out. On the hand, cases are occasionally met with where these sacs attain such dimensions as to simulate dropsies, and instances are recorded where operations have been undertaken under the belief that ovariotomy was indicated. In a case cited by Mr. Glass 12 where thirty gallons of light coffee-colored limpid fluid were withdrawn after death from a huge sac representing the right kidney, the circumference of the abdomen was found to be six feet four inches, and from the ensi form cartilage to the os pubis it measured four feet and hall an inch. The left kidney and ureter were healthy.
Passing to the opposite extreme it will be found that instances are frequently met with where hydronephrotic kidneys are discovered after death which do not appear to have occasioned any physical signs or objective symptoms during life. Hence I shall proceed to consider those examples where there is some evidence of renal enlargement. When limited to one kidney the condition of the urine is not at all likely to furnish any clue, as the opposite one is quite able to main tain the natural characteristics of the excretion. Under such circum stances surgical interference in a case of renal enlargement presenting an indistinct sensation of fluctuation would hardly be warranted unless inconvenience or pain were occasioned by the dimensions of the growth. Then a lumbar aspiration would be indicated when the
nature of the swelling might probably be with more accuracy de termined. In some instances such a proceeding has been followed by a gradual disappearance of the swelling.
When there are similar reasons for believing that both kidneys are involved, should either or both reach such dimensions as have just been referred to, the aspirator may be employed in the same way. Under the latter circumstances, however, we are much more likely to meet with symptoms of uraemia superadded to the local distress, and rendering the prospects of the patient extremely bad. The efforts of the physician may here be directed toward elimi nating products which the kidneys have little chance of doing. Much may doubtless be done both by medicine and by diet in this way.
A case illustrating several points in the pathology and treatment of hydronephrosis has recently come under my notice, and some reference may be made to it here. It was that of a middle-aged man, long resident in Australia where the disease had probably been con tracted, suffering from hydatids within the pelvis. The disease was of several years' standing on his arrival in this country, and formed a tumor of considerable size. It appeared to be situated in the space between the bladder and the rectum outside the peritoneal cavity. It formed a prominence in the left hypochondrium, the bladder being pushed over toward the opposite side. It was impossible, by reason of the angle given to the urethra, to pass a rigid instrument such as a catheter into the bladder, but a long, flexible bougie was readily in troduced. On passing the finger into the rectum the prostate was to tally obscured by what felt like a solid mass about as large as a festal head. In this way the pelvis may be said to have been completely blocked. During the last few weeks both defecation and urination had become well-nigh impossible in spite of all kinds of expedients. The pain on these occasions was most excruciating, to relieve which the patient of his own accord took large doses of morphine amounting frequently to over six grains a day.