The conditions under which a urinous effusion takes place some days after rupture of a ureter has occurred deserve something more than a passing notice. One would almost be inclined to suppose that the escape of urine either directly from the torn pelvis of the kidney or from the open ureter must be followed by all the rapid and disastrous consequences which ensue when it is effused, often in conjunction with blood, among either normal or damaged tissues. The occurrence of these symptoms is certain and unmistakable so long as no vent is provided for urine which is thus poured out. No exception to this can be brought forward, save in such instances as I shall presently illustrate. Why this immunity from well-recognized consequences should exist in the case of a ruptured ureter, where one would naturally expect an extravasation of urine to follow, is a point of considerable interest and importance.
In the records of a case with remarks by the late Mr. Poland and Dr. Moxon some light, I think, is thrown upon this aspect of the question. Stress is here laid on the condition of the kidneys as ob served in this and other instances, it being stated by Dr. Moxon that the vessels were blocked with ante-mortem clots. It is almost im possible to imagine that a rupture of a ureter could be effected with out the of a considerable amount of violence to the part. Even supposing that the requisite force was limited to the ureter and continued in the form of traction until the tube snapped, this would almost necessarily imply more or less injury to the corresponding kidney. Is it not likely, considering the sympathies existing between the two kidneys, that the infarcted condition of the blood-veSsels of both organs, referred to by Dr. Moxou as of ante-mortem origin, is a provision in the first instance for the substitution of a kind of urine which is incapable of proving destructive to the tissues with which it may come in contact? Thus time is afforded for repair, or to enable the opposite organ by a compensatory hypertrophy to take up the whole work if necessary.
This conclusion suggested itself to me in connection with the fol lowing case. It was one of stricture, with extravasation of urine into the scrotum, occurring in a person suffering from Bright's disease of the kidneys. Though the extravasation had come on suddenly and had existed for twenty-four hours unrelieved, there were no signs of acute inflammatory action and commencing gangrene, such as are usually expected. However, the tension being considerable, the parts involved in the extravasation were incised. As the fluid es caped from the incisions, it was noticed that it had not the strong ammoniacal odor which is so perceptible in such cases. I was some
what puzzled for an explanation, as I felt sure that the case was one of extravasation, and not of acute scrotal oedema. How was it then that extravasated urine failed to create gangrene? I collected some of the fluid as it trickled through the wound, and compared it with that subsequently drawn off by the catheter. They were found to be identical, and in both there was almost a complete absence of urea. This then, to my mind, solved the mystery, and explained that, as there was no urea to decompose, there was no source for the produc tion of the ammonia by which the destruction of tissues in connection with extravasated normal urine is effected. By the absence of urea the urine was rendered chemically harmless to the tissues with which it came in contact.
The view I have ventured to express as explaining certain points connected with the pathology of injuries to the ureter and pelvis of the kidney has some weight given to it by a remark made by Mr. Holmes in connection with this subject: "If it could be shown that a wound of the ureter or a lesion of that organ could suspend the true secreting function of the corresponding kidney, while it left its percolating function intact, or even if any theoretical explanation of such a result could be given, the case would be quite clear, since the opposite kidney would have double secretive work to do, and the urine passed by the urethra would be scanty, with excess of lith ates." The next point to which attention must be given is the fact that, as in the case of the urethra, wounds and lacerations of the ureters are liable to be followed by dense and contractile strictures. In this way the kidney may be destroyed either by a process of hydronephrosis as previously referred to, or by complete atrophy and absorption. Here the law of a compensatory hypertrophy steps in and the life of the individual is preserved, although by the necessary absence of one kid ney it is continued under conditions of living associated with in creased risks, as can readily be understood.
We have now before us the various contingencies the surgeon has to face in connection with the treatment of a rupture of a ureter. Putting aside complications involving neighboring viscera, they may be summed up as collapse, hemorrhage, extravasation of a diluted and comparatively innocuous urine, and the probabilities, so far as the near future is concerned, of a strictured if not an impervious ureter, and a hydronephrotic or atrophied kidney. In view of the treatment that these conditions may require immediately or prospec tively, it will be well to take a glance at some of the more recent ob servations that have been made bearing upon this matter.