SYMPTOMS.—In some cases there is limmaturia, which is usually slight and transient. If the rupture has not also torn into the peritoneal cavity. a tumor forms due to the escape of urine into the arenlar tissue. 'Ile fluid aspirated from such tumors has the characteristics, more or less pronounced, of urine. As soon as the urine and blood begin to decom pose, inflammation and suppuration, with their attendant symptoms, occur. When the injury communicates with the peritoneal cavity, symptoms of peritoni tis, which is usually fatal, occur.
If there is at first little or no hTnia hula and no swelling in the loin, and then after three or four weeks, more or less, a swelling forms behind the peri toneum, rupture of the ureter may be suspected. If, many months or even years after an injury in the region of the ureter, a tumor of the kidney is formed, though there has been an absence of symptoms or only slight lyzematuria at the time of the injury, there will be ground for suspecting traumatic contrac tion or occlusion of the ureter.
It is, however, impossible to dis tinguish injured ureter with extravasa tion, from injured renal pelvis with ex travasation; injured ureter with com plete obstruction by clot or recurved ends is equally indistinguishable from injured kidney with clot plugging the renal pelvis or the ureter.
Seine assistance may, perhaps, be ob tained, where an opening in the ureter is believed to exist, by distending the bladder with water. Kammarer found that the water escaped by the defective ureter until the bladder was quite dis tended. and then, doubtless through closure of the valvular entrance in the bladder, the water ceased to flow. Le Fort and Page applied this test in their eases, but without effect.
Tuffier thinks that a constant escape of urine after a wound of the ureter is the leading distinction between these in juries and wounds of the kidney.
In cases of injury of the ureter not complicated with other serious injuries, the immediate effect of these accidents is not to endanger life, if the peritoneum is uninjured. If prompt and decided surgical treatment were adopted, the consequences to the kidney itself Nvould he less unfavorable; and subsequent uephrectomy would probably be less fre qnently required than has been the case hitherto.
sists in implantation of the proximal cud of the ureter into the bladder. Wheu this is not possible, owing to the high situation of the injury. the next resort is extirpation of the kidney on that side. 11. Ffith (Centralb. f. (:yu., July Di, '951.
rnintentional division of the ureter in operations in the abdominal and pelvic cavities is apt to occur in eases in which numerous adhesions exi 1. several methods of dealing with the con dition are available. The kidney on the injured side may be removed: the ureter may he passed into the intestine, colon. or rectum; or into the vagina or through the abdominal wall: the kid ney may be brought down, and the ex tremity of the ureter sutured into the wall of the bladder: an anastomosis may be made between the extremities the divided ureter. This elassideation, while not exhaustive, covers the most important procedures so far devised. I lf
these methods the last two are the most worthy of consideration. Uretero ureteral anastomosis would seem to be the operation of ehoiee. Uretero-ure feral or uretero-nreteros tomy. as the operation is designated by _Kelly. may be performed in various: ways. Henry Morris the following classifications: •nd-to-end by suturing the together in a transverse line: end-to-end :tnastomo sis; lateral implantation: end-to-end anastomosi, by suturin, the ends to gether in an oblique line. The trans verse end-to-end method was used by Sehopf (l586) in the first recorded eases of uretero-ureteral anastomosis. The objections to the operation were so seri ous that the operation has been almost discarded to-day. Pond originated the end-to-end auastomo.is. Lateral im plantation was devised and described by Van Hook in 1893. Kelly was the first to apply this method to the human sub ject. The oblique end-to-cod anastomo sic was first used by The anthor two successful cases in which the Van Hook method was resorted to. Johnson (Amer. Jan. 19, 1903 When the peritoneum is involved the outlook is most serious. Henry Morris (Edinburgh Med. Jour., Jan., '95).
—The ideal treatment is immediate suture or anastomosis, hut unfortunately the exact injury is not usually recognized until some time has elapsed and the peritoneum has become infected or a retroperitoneal cyst has formed. In case a cyst has formed, puncture may be tried, but the result is uncertain. Lumbar incision with evacu ation of the extravasated fluid and age offer the most favorable conditions for repair. Wounds of the ureter usually heal ultimately without suture, although, if the injury be found, it should be re paired. Nephrectomy will he required if there is evidence of extensive sup puration, septic nephritis, or a nent fistula that is a source of intoler able discomfort.
The ideal treatment for subcutaneous rupture, whether in a longitudinal or transverse direction, is immediate suture or anastomosis of the ureter. A free in cision in the ilio-costal space will secure the complete evacuation of the extrava sated fluid; and drainage will obviate the reaccumulation of urine subsequently escaping through the ruptured tube. if the ureter is completely torn asunder, and its ends can be approximated, they should be united by one of the recog nized methods of ureteral anastomosis. If its ends cannot be joined together, then a permanent fistula, opening on the loin, is the result to be expected. Ne phrectomy will be required, if pus in the extravasated fluid, continued high tem perature, or recurring pyrexial attacks, with pain, loss of appetite, and emacia tion, make it clear that the kidney or the retroperitoneal tissue is the seat of extensive suppuration. Nephreetomy may be demanded atso in the absence of suppuration, if a permanent fistula has resulted and is a source of intolerable dis comfort to the patient. Henry Morris (Edinburgh Med. Jour., Jan., '95).
In eases in which the ureter has been cut through, the proper treatment con