INJURIES OF THE ERETERS.
Protected as they are by the parts surrounding them, it might ap pear that lesions of these tubes are well-nigh impossible. This, however, is not the case, for we shall find examples constantly occur ring of their rupture, laceration, and division.
Rupture of a ureter is usually caused by the application of very great violence to the trunk or abdominal region as by crushes and squeezes. It may also be occasioned by gunshot injuries or by the bursting of explosive shells, where the lesions are usually extensive and complicated. A ureter has been severed by a stab wound, and accidentally divided by the knife of the surgeon in the course of an operation. Its lining membrane may be lacerated sufficiently by the descent of a rough calculus to cause a cicatrix and a subsequent stricture or narrowing of the tube. Rupture from external violence most frequently occurs in immediate proximity to the pelvis of the kidney. In one instance I saw, where it was complicated with fracture of the lower ribs, I have no doubt it was caused by the man, while in a state of intoxication, being squeezed between a heavy wagon and a large stone. The patient died the day following his admission to the Liverpool Northern Hospital. Some blood-stained urine was removed by the catheter, but beyond this, and the general nature of the injury, there was nothing to indicate that the left ureter had been torn across immediately below the kidney, as shown by the autopsy. The late Mr. Stanley" recorded two instances of this injury : one where the diagnosis was verified by an examination after death, which took place ten weeks after the injury, and the other where, though the symptoms pointed to the probability of this lesion being present, the patient recovered. In both of these cases a prominent feature was the collection in the cellular tissue behind the peritoneum of fluid resembling urine, which had to be removed by tapping. Mr. Poland has also recorded another instance where, consequent on a crush between a railway platform and a moving train, a ureter was ruptured, the patient surviving, with other serious injuries, for 135 hours.
When the fact cannot be demonstrated to the eye, the possibility of rupture of a ureter must be judged of largely by the nature of the injury and its attending circumstances. In a case reported by Dr. Collins where this lesion must have occurred, and which is more fully referred to in connection with the subject of traumatic hydrone phrosis, the injury was caused by a cart-wheel passing over the abdo men and pelvis of a child. The patient was much collapsed, there
was fracture of the left lower ribs and right innominate bone, and the catheter drew off only a drachm or so of sanions fluid. The disten tion test showed that the bladder was not ruptured, though the urine was blood-stained for some days. The patient eventually developed a right hydronephrosis. In other cases a ruptured ureter has been accompanied by considerable lateral abdominal distention extending to the loin and by slight hvematuria. The effusion of a watery fluid, somewhat resembling very dilute urine, in the neighborhood of the injury has also been noticed in several instances. In one of those cases recorded by Mr. Stanley it is stated that the fluid was found to contain unequivocal evidences of urea, and from its appearance seemed to justify the conclusion that it was of a urinous nature. In the second of Mr. Stanley's cases a cystic collection of a somewhat similar fluid was found communicating with the junction of the pel vis of the kidney and the ureter, where the injury had taken place. In commenting upon these cases the author observes : " They show that the rupture of the ureter or pelvis of the kidney may present this remarkable feature when contrasted with the consequences of a rup ture of the bladder : while in cases of the latter injury symptoms im mediately arise, directly pointing to the organ which has suffered, in cases of the former kind (the lesion of the ureter or pelvis of the kid ney) no symptoms may immediately arise leading to a suspicion of injury to any part of the urinary apparatus." In a paper which deals very fully with the subject of rupture of the ureter Mr. H. W. Page" records an instance in his own practice where it was extremely probable that this lesion existed. A male child five years of age was run over by a cab and sustained abdominal in juries, which were followed by slight hminaturia and the formation of a swelling in the right iliac fossa. As the symptoms did not im prove and the temperature rose, about a month after the injury the abdomen was opened in the right linea semilunaris and forty ounces of fluid were evacuated from a retro-peritoneal swelling. This fluid was analyzed and shown to contain half its bulk or somewhat less of normal urine. In spite of careful drainage a high temperature re turned, the discharge became urinous and offensive, and the powers of the patient began to flag. Two months after the injury nephrectomy was performed and was followed by complete recovery. The kidney was found in an advanced state of pyelonephritis.