Surgical treatment of transcapsular rupture of kidney

4ASE

REPORTSf

SURGICAL TREATMENT OF TRANSCAPSULAR RUPTURE OF KIDNEY FOUR CASES R. FRANK JONES, M.D. Instructor

of UroIogy, Howard University

SchooI of Medicine; Chief, Genito-Urinary

Service, Freedmen’s Hospital

WASHINGTON, D. C.

T

cIoseIy the first premeditated remova of RAUMATIC rupture of the kidney was f&t described by GaIen40 in 1561. a kidney by Gustave Simon.15 Czerney’s15 The description of Rayer,41 in 1839, conservative repair of the kidney parenchyma done with five catgut sutures in remains a cIassic. Its occurrence in modern civihzation has been variousIy estimated I 887, initiated a significant era in conservafrom 1 in every Iooo,2,3 to 1 in every tive kidney surgery. The modern attitude toward a ruptured 3ooo4 injuries. Six ruptured kidneys were admitted to kidney is conservative. Keen judgment, as the Freedmen’s HospitaI, a 300 bed unit, to what to do and when, is the primary during the first seven months of this fisca1 requisite, 2o for when radica1 procedures are year, 5 being compIete ruptures, 4 of which necessary, they must be conservative.23,24 were caused by gunshot wounds, and one a This insight cannot be acquired by experisubparieta1 type. Because a severe kidney ence with ruptured kidneys, for the rarity rupture was not seen for ten years of serv- of their incidence in the hands of any one ice in the UroIogic Department, the author surgeon is established. was amazed at this avaIanche of cases and The Iiterature on the subject is so volusought enIightenment from the Iiterature. minous that approximateIy I 300 cases have This study reveaIed that in the “horse been recorded. In spite of this, however, and buggy” days, it was not uncommon to there appears to be a need for a more defibe struck by a faIIing object,ll run over by nite and precise formuIa which may guide a cart wheeI,12-14 kicked by a muIe,13 the proper course of treatment as there has thrown from a horse,16-17 or to faI110J1J1~22been too much uncertainty in the manageand receive a severeIy ruptured kidney, ment of cases of this type.23 waik miIes to reach home or some instituHeterogeneous mortaIity statistics coltion, and in either case, to succumb from Iected by various authors Ieave IittIe choice hemorrhage or infection. MedicaI meetings between expectant treatment and surwere studded with reports and demonstralv2v3 However, statistics compiIed from gery* tions of specimens of fata ruptures due to series which have been anaIyzed eIiminatsevere or trivia1 trauma. ing severe associated injuries, which in a11 No progress was made unti1 the coura- probabiIity caused the mortaIity,25 show geous work of Bremdt,” in x873, in Vienna. a marked improvement in rate when they His successfu1 remova of a stabbed kidney are handled with that keen surgical judgon the fourth day seemed to awaken the ment which “shuflIes and deaIs” the medica worId to surgica1 consciousness. expectant, the immediate and delayed Four years later his surgery foIIowed operations, and the conservative and radi76

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caI procedures according to the patient’s requirement. The presentation of the 4 cases represents the author’s entire experience with transcapsuIar kidney rupture requiring surgery. The foIIowing 2 cases, cIassified as subparieta1 transcapsuIar rupture, are presented.

CASEI. W. J., a sixteen year oId Negro Iad, was admitted to the UroIogic Service about 6~00 o’cIock P.M., September 16, 1932. About noon, the preceding day, the bicycIe which he was riding crashed into a tree and threw him forward against the handIe bars which struck him in the Ieft side about the eighth to tenth ribs in the midcIavicuIar Iine. He remained conscious and waIked home in agonizing pain. He voided bIoody urine after the injury but catheterization was necessary. On examination, he was Iying in bed spIinting his Ieft side. There were Iacerations over the Ieft anterior chest waI1 from the eighth to tenth ribs and a sweIIing of the upper Iip. Tenderness and rigidity of the Ieft flank and abdomen were present and a tympanitic note was eIicited over the entire, sIightIy distended, abdomen. Neither kidney was paIpabIe nor was a mass noted in the Ieft Aank. The temperature was 10 I .6”; puIse I 20; respiration 28; bIood pressure 175/105; red bIood ceIIs 4,370,ooo; hemogIobin 80 per cent; white bIood ceIIs 9,700. The originai impression was rupture of the Ieft kidney and possibiy ihjury to the abdomina1 viscera. A surgica1 consuItation agreed with the urologic opinion and concurred in the expectant form of treatment. The first fifteen days were characterized by a gradual decIine of the puIse rate, a Iow grade remittent fever, continuous, unabated hematuria, and a persistent, painfu1, tender and rigid left Aank. No mass was paIpated. The patient’s genera1 condition remained beIow normai. His bIood pressure was 138/68. The second fifteen day period began with marked dysuria foIlowed by increased hematuria. BIood cIots coIIected in the bIadder causing acute retention on the seventeenth day. The p&e became more rapid, pain in the Ieft kidney region continued, the red bIood ceIIs were reduced to 3,200,000, hemogIobin to 60 per cent, bIood pressure 122/72. His genera1 condition was weaker. Intravenous skiagram

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study on the eighteenth day showed (I) nonfiIIing of the upper caIyx on the Ieft; (2) diIated ureters, up to I cm. in diameter, particuIarIy on the Ieft throughout its entire extent; and (3) the bIadder distended with a blood cIot. The impression was that the Ieft kidney was probabIy ruptured at the upper poIe causing accumuIation of bIood in the bIadder which had obstructed the orifice causing the uretera diIatation. After repeated catheterization, free voIuntary passage of smoky urine with some smaI1 dark cIots was noted on the twenty-second day. The genera1 condition seemed stabiIized at a very Iow ebb. The urine was cIearing, though dysuria and severe abdomina1 pains continued to be an aggravating feature. On the twenty-eight day there was an abrupt recurrence of hematuria and suprapubic pain was observed as a new feature. The red bIood ceIIs were found to be 3,000,000. A genera1 consuItation among the uroIogica1 and surgica1 staffs agreed to surgica1 intervention for the foIIowing reasons: (I) a severe rupture of the Ieft kidney was present; (2) expectant treatment of one month had produced no satisfactory resuIts; (3) the patient’s Iife wouId be in danger if recurrences of bIeeding continued; and (4) it is wise surgery to intervene before it is too Iate. At operation a nephrectomy was done as the Ieft kidney was severeIy Iacerated at its upper poIe, haIf of which was destroyed compIeteIy; the other haIf showed signs of organization. The convaIescence was punctuated by a miId Before discharge on the bronchopneumonia. twenty-ninth postoperative day, a phenolsuIphonphthaIein showed 45 per cent output in the first haIf hour by intravenous method. His recovery was compIete. This patient when seen recentIy, after four years, shows norma deveIopment in every respect. CASE II. As the resuIt of a faI1 from a runaway horse, R. F., a maIe Negro of fourteen years of age, was admitted on JuIy 18, 1935, about IO:OO o’cIock P.M., compIaining of a “pain in his Ieft side and of passing blood instead of water.” At the time of the accident, which occurred about 6~30 o’cIock P.M., JuIy 18, his empIoyer, noticing that simpIe medication was of no avail, brought him for admission. When first observed, he .was unable to take a deep breath without intense pain in the Ieft side; he was in bed with flexed knees to

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ease the pain in the Ieft anterior Iumbar region; he was noticeably drowsy and responded reIuctantIy to questioning. The famiIy history was negative. The sign&ant hndings on physica examination were, (I) a definite spIinting of the muscIes of the Ieft side; (2) tenderness over the Ieft epigastric and Iumbar regions anteriorIy and the Ieft kidney posteriorIy; (3) above the Ieft iIiac crest a mass was outIined with diffrcuIty through the spIinted muscIes; (4) blood pressure 108/78; puIse 88; temperature 98; (5) vomiting of smaI1 amounts of green material and mucus; (6) urine very bIoody; (7) hemogIobin 85; red bIood ceIIs q,rgo,ooo; white bIood ceIIs 13,850; (8) within an hour, the puIse had increased to 108; respiration 24; temperature gg; and at that time, there was no abdomina1 distension. On the morning foIIowing admission, with an average temperature of 99.6, pulse 104, bIoody urine, he feIt somewhat reIieved of pain. On the second day foIIowing admission the drowsiness persisted and his genera1 condition remained unchanged except for increased rigidity of the Ieft abdominal muscIes, associated with more tenderness and IocaI pain. Meteorism was a new symptom. The mass in the Ieft Ioin appeared increased in size. A repetition of white bIood ceIIs showed I 1,800, and hemogIobin 75 per cent At this time an intravenous skiagram series showed that the Ieft kidney was ruptured through its middIe. With the genera1 restIessness and pain prevailing, hematuria continuing unabated, an lincreased puIse rate to 128, some diaphoresis and progressive Ioss of ground, operative interference was deemed advisabIe. At operation, under genera1 anesthesia, there were hematomas of the transversaIis and psoas muscIes which were fixed by an exudate to the perinephritic capsuIe. On opening the fatty capsuIe, there were approximateIy thirty ounces of blood clots. The Ieft kidney was found to be ruptured at the junction of the Iower and middIe thirds through the entire substance of the organ. A tota nephrectomy was performed and two cigarette drains were inserted. Supportive treatment for the operative shock was instituted. The postoperative course was uneventfu1. He was discharged as cured on the twentieth day after admission.

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COMMENT

The injury in each case was due to direct trauma over the kidney region. An anaIysis of the symptoms common in kidney rupture and present in these cases is recorded as fohows : I. Shock was absent in both cases. 2. Pain was present. It bears no direct reIation to the extent of the parenchyma1 tear and is caused by distention of the pelvis. 1 3. Hematuria was immediate in these cases as in upward of g5 per cent of all cases.5l2o 4. Rigidity and spIinting of the muscles of the injured side of the abdomen and Ioin were present. 5. Tympanites, present in each, is known as renaI ileus,25 sometimes caIIed a reflex phenomenon, but actuaIIy it is caused by an irritation of the posterior parietal peritonea1 waI1 .7,2g Vomiting in Case 11 was stimuIated by the same irritation.lg 6. Neither eIevation of temperature nor leukocytosis alone or together is characteristic of infection’ because the absorption of bIood clots and extravasated urine is associated with these reactions. 7. Outline of the mass, usuaIIy a hematoma, is often diffrcuIt because of the tenderness which limits paIpation. In Case II it was observed to increase in size, whereas it was not eIicited in Case I. The mass may be extravasated urine which becomes either infected or encysted, or, in smaller amounts may be absorbed. The course of the mass, whether urine or blood, is aIong the psoas muscIe to the inguinal region or base of the penis.6 CompIete urologic study including direct urography, with the presentation of data to substantiate its rationale, has been advocated as a logical procedure.7~*~1s Intravenous urographic study, invariably negative in shock,4 was reasonably effective in both of the cases presented as the pathoIogy was minimalIy pictured. A direct urographic medium would have Aowed from the superior pole into the

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surrounding tissue in Case I, whereas, in Case II, it wouId have reached the perirena1 region through the transverseIy sectioned kidney. This would have hastened surgica1 intervention in Case I. Case II was operated immediately, notwithstanding. The choice of the two procedures is a matter for the judgment of the urologist. Advocates of direct urographic study are increasing. Case I presents a genuine effort directed toward conservative expectant treatment, but was directed toward surgery at the crucial moment. Surgery here was probabIy too radical, yet was dictated by the extent of anemia and genera1 debiIity which warned against infection.20 MechanicaIIy, a resection of the upper poIe was possibIe but it was thought to be unwise. In Case II, there was no aIternative for nephrectomy. In the surgery of ruptured .kidney, conservatism2 is the ruIe; severe hemorrhage and Iate infection being the onIy indications for nephrectomy. Routine nephrectomy is wrong1 for one may be astonished at the reparative ability’,’ of a damaged kidney, as we11 as the return to norma physioIogica1 output. Gunshot wounds of the kidney very rarely are reported in miIitary life; 129 among 170,481 battIe casuaIties in the World War,M not to speak of civilian life. In combination with other visceral injuries, they occasionahy dart the Iiterature. The most comprehensive study of gunshot wounds of the kidney appears in the reports of army surgeons, aIthough severa1 reports in civiIian centers contribute weaIthiIy to the Iiterature.g~24~28 Records of the CiviI War reported by Judkins,27 showed only one of 3 cases of ruptured kidney to be due to a sheI1. Gunshot wounds of the recent WorId War have been reported and anaIyzed criticaIIy. The foIIowing significant data on intraperitonea1 wounds in reIation to the kidney are recorded : I. In Germany, Laewen found that 37 of 42 cases of gunshot wounds of the kidney invoIved the peritoneum. Of a tota of 57 cases coIIected from the German war records, onIy 5 recovered.30

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2. The British found that 155 cases, or 7.3 per cent, of gunshot wounds of the abdomen invoIved the kidney, with a resulting mortaIity of 36.8 per cent.28 3. The French found a much smaIIer percentage of kidney injuries associated with intra-abdomina1 wounds. 31 4. Among the American Expeditionary Forces, 66 cases were found in the records of the MedicaI Department of the United States Army which presented gunshot wounds of the abdomen.26 A mortaIity of 50 per cent resuIted. Gunshot wounds of the kidney in civilian Iife shouid offer a much better prognosis than that of the army in the fieId. The civiIian is in vastIy better genera1 physical condition than the soIdier, worn by battle, hardship and exposure, and, furthermore, the advantage of compIete uroIogic study and timeIy operative intervention is availabIe in civi1 Iife.gf26 To serve the fohowing similar cases within the short period of five months is an unique experience. CASE III. J. W., a we11 developed Negro of twenty-six years of age, was admitted to the surgica1 service in profound shock at I I :30 o’cIock P.M., September 15, 1935, shortIy after he had been shot from behind by a buIIet which passed through his body. His complaint of “pain in the chest when taIking,” and defmite aIcohoIism, made a good history impossibIe. Examination showed that the buIIet entered the back two inches from the midIine in the tenth interspace and made its exit anteriorIy in the eighth interspace on the right midcIavicuIar Iine. There was rigidity of the muscIes of the right Aank and throughout the abdomen. There was such tenderness on the sIightest pressure that the presence of a mass couId not be determined but a duI1 note on percussion was noted in this region. The pulse was weak and thready at 60 per minute. The bIood pressure was 74/o. His brow was coId and bathed in beads of perspiration. Shock was combated by hypodermocIysis and stimulants. By morning, the bIood pressure was go/7a; temperature 98.2; puIse 96; the red blood ceIIs 3,600,000; white bIood ceIIs 6000; hemogIobin 65 per cent. Catheterization yieIded frank hematuria. Vomiting from the aIcohoIic induIgence was noted during the early

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morning. When the surgica1 and uroIogica1 departments conferred, these concIusions warranted immediate surgica1 intervention : (I) the path of buIIet seemed to be through the kidney and Iiver; (2) there was definite indication that the ffuid in the abdomen was bIood for the duI1 area had extended during the night; (3) the frank hematuria shouId be IocaIized from the right kidney by cystoscopy and the presence and function of the Ieft kidney couId be ascertained. Under nitrous oxide and ether anesthesia preoperative cystoscopy reveaIed bIood was being ejected from the right ureter and cIear urine from. the Ieft. No estimate of function was attempted. Through a right rectus incision about IOOOC.C. of cIots and free bIood were removed from the right iIiac fossa and the peIvis. On the postero-IateraI surface of the Iiver was a freeIy bIeeding steIIate puncture. Two mattress sutures in the capsuIe controIIed the hemorrhage compIeteIy. The “other” wound in the Iiver was not located. There was marked discoIoration of the posterior parieta1 peritonea1 waI1 in the region of the right kidney. The peritoneum was cIosed without drainage and the wound was extended IateraIIy under the tweIfth rib. Upon exposure of the fatty renaI capsuIe, a Iarge coIIection of bIood cIots came into view, having dissected away the true capsuIe of the kidney, which, when freed, was found to be shattered in its upper haIf, much Iike a crushed nut. Primary repair of the kidney couId not be effected so it was pIaced in a basket of catgut. The wounds were cIosed and adequateIy drained, but heaIed IargeIy by granuIation because they broke down almost compIeteIy. ConvaIescence was uneventfu1 except for a period of postoperative shock. Before he was discharged, forty days after admission, a cystoscopic note of intravenous indigocarmine reveaIed a two minute appearance time from the injured kidney. CASE IV. G. M., a stockiIy buiIt Negro, thirty-five years of age, arrived at the hospita1 by means of taxicab, immediateIy after he had been shot in the back at II ZOOo’cIock P.M., February 7, 1936. There was some evidence of shock aIthough the patient waIked to and from the taxi. He compIained of sharp severe pains in the hypochondriac and epigastric regions, which became increasingIy aggravating. The

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wound of entrance was Iocated four inches to the right of the midIine in the back at the IeveI of the transverse process of the tweIfth thoracic vertebra. AnteriorIy on the same side the buIIet couId be paIpated at a point four inches from the midline in the tenth interspace just beIow the skin. There was marked rigidity and tenderness over the right flank and entire abdomen. Percussion reveaIed a duI1 note in this area. Upon catheterization bright red bIood was obtained. Temperature 94”; puIse 60; respiration 30; bIood pressure I 10/82. Notation of the bIood pressure Iater in the course of the examination reveaIed a drop to go/68. His entire body was wet from a profuse perspiration. An immediate consuItation with the surgica1 department reveaIed unanimity of opinion as (I) penetrating wound of the right kidney and Iiver with profuse abdomina1 bleeding and (2) immediate exploration of both abdomen and kidney region. Two hours after the wound was inflicted the operation began via a right rectus incision into the peritonea1 cavity where a gush of fresh bIood was emitted from a rent in the postero-IateraI aspect of the Iiver. This huge gap couId not be sutured and the bIeeding was stopped onIy by packing about 5 yards of gauze into it. More than 1500 C.C. of free and cIotted bIood were aspirated from the right iIiac fossa and the pelvis. The rent in the postero-parieta1 peritoneum was sutured. In this position, it was cIear that considerabIe retroperitonea1 hemorrhage was present in this region. The peritoneum was sutured and drained with the packing coming from the Iower angIe. The incision was extended IateraIIy under the tweIfth rib to expose the kidney area. There were handsfu1 of bIood cIots removed from this region before the kidney couId be exposed. The lower poIe not onIy had been shattered and the peIvis penetrated, but a section about one inch cubed was removed compIeteIy, exposing the Iower caIyx. ConsiderabIe free bIeeding was noted. Nephrectomy was accomplished, drainage tubes pIaced and entire wound cIosed. PhIebocIysis and hypodermocIysis of about 3000 C.C. of 5 per cent gIucose were instituted during and folIowing the operation. The packing was removed entireIy in thirty-six hours. HeaIing was by primary intention and recovery was uneventfu1.

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The patient was discharged twenty-four after operation.

days

COMMENT

Each case was shot from behind at cIose range at about I I o’cIock P.M. Guided by the entrance and exit of each buIIet, passage through the kidney and Iiver onIy was reasonabIy outIined. ANALYSIS

OF SYMPTOMS

I. Pain and tenderness were noted in each case. 2. The shock which was evident in each of these cases was characterized by subnorma temperature, sIow puIse of 60 per minute and Iowered bIood pressure. The patients’ bodies were bathed in perspiration. This type of shock, ascribed to soIar plexus injury,l is probabIy a “‘histamine’ traumatic shock.“44,45 It is easiIy differentiated from shock due to hemorrhage which is characterized by rapid puIse and respiration associated with anxiety, Ioss of hemogIobin and red bIood ceIIs. The shock noticed in the cases presented, responds we11 to hypodermocIysis and adrenaIin. Treatment of the shock first is universaIIy accepted. 3. Hematuria was observed on catheterization in each case. 4. Rigidity of the muscIes of the entire abdomen and Ioin was common to each. 5. An advancing duI1 percussion note denoted the presence of bIood in the abdomina1 cavity in both cases. 6. Vomiting was present in Case III onIy. This has been recognized as a positive symptom of abdomina1 viscera1 rupture, and usuaIIy occurs within five hours.28 It is to be noted that Case IV was operated within two hours of the injury. The operative approach differed from that recommended in the ManuaI of the United States Army MedicaI Service and others.28 The fiist incision, which was made over the Iateral border of the right rectus muscIe, permitted the best exposure of the Iiver with simuItaneous exposure of the other abdomina1 viscera and paIpation

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of the Ieft kidney. Subsequent extension of the wound IateraIIy under the tweIfth rib, after peritonea1 cIosure, permitted adequate exposure of the right kidney fossa extraperitoneaIIy. As in subparieta1 rupture, conservative repair of the kidney damaged in Iess than one-third of its extent is mandatory, except where the time consumed in such repair endangers the life of the patient. 26Those who advocate exposure of the kidney first in cases of intraabdomina1 wounds invoIving the kidney, fee1 that (I) Iess shock is attended in changing from the kidney to the Iaparotomy position, than from the reverse order,26 and (2) if there is injury to the hoIIow viscera, contamination of this materia1 into the kidney fossa initiates a vicious infection.28 AI1 condemn transperitonea1 nephrectomy. UroIogic study is indicated in so far as it is practicable. Catheteiization must be done immediateIy if the patient cannot void. At Ieast the presence of the other kidney must be ascertained, even if study of its function and genera1 condition is not practicabIe. The more compIete the uroIogic study, the more accurate the opinion. SUMMARY I. Treatment of a severeIy ruptured kidney became rationa onIy after surgery of the organ was generaIIy practiced. 2. AIthough transcapsuIar rupture of the kidney is not uncommon, few surgeons are caIIed to handIe a Iarge series of cases; yet any surgeon may treat a case. 3. The common symptoms are shock, pain, hematuria, muscular rigidity, tympanites, nausea, vomiting and hematoma. 4. Shock is of two types. The immediate is a diIatation of the vascuIar bed associated with SIOW puIse, Iowered blood pressure, diaphoresis and subnorma temperature. It is reIieved by adrenalin hypodermicaIIy and hypodermocIysis of norma saIine. DeIayed shock is usuaIIy due to hemorrhage and it yieIds best to blood transfusion.

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5. Four cases of transcapsuIar rupture of the kidney are presented, 2 of the subparieta1 type, and 2 gunshot wounds invoIving the peritoneum and Iiver. 6. Urography, direct or intravenous, is indicated where practicabIe. Intravenous urography was empIoyed in the 2 subparieta1 cases with satisfactory resuIts. 7. Treatment of transcapsuIar rupture of the kidney is: (a) expectant, and (b) surgica1, as repair and remova1. 8. SurgicaI treatment was instituted in each case, resuIting in nephrectomy in 3 cases and repair in one, with compIete recovery in aI1. REFERENCES I. WESSON, MILEY B. Treatment of traumatic rupture of kidney. Ann. Surg., 83: 246, 1926. 2. STERLING, W. CALHOUN. TotaI rupture of kidney. Report of Cases. Vu. Med. Monthly, 53: 793, 1931-32. 3. STERLING, W. CALHOUN. SubparietaI traumatism of kidney-four cases. International Clinics, 3:

169, '925.

4. ROLNICK, HARRY G. PyeIography in injuries of kidney. Am. Jour. Surg., 20: 40, 1933. 5. PRATT, JOHN G. Traumatic rupture of kidney. So. Medical Jour., 27: 809, 1934. 6. LIVERMORE, GEO. R. Rupture of Kidney-A Case Complete Rupture. So. Surg. Transactions, 44: 434. 1931. 7. DELZELL and HARRAH. Eleven Cases of Ruptured Kidney. Jour. Ural., rg: 131, 1928. 8. HARRIS, AUGUSTUS. Traumatic rupture of Ieft kidney. Jour. Ural., 20: 193, 1928. g. JOPSON, JOHN H. Perforating gunshot wound of the abdomen with invoIvement of Iiver, kidney and secondary infection of pIeura. Ann. Surg., 71: 103. 1920. IO. JESSOP, WALTER H. Rupture of liver and kidney. St. Bartholomew’s Hosnital Report. _ , 17: 24% __. 1881. I I. CHARTERIS. Rupture of ;ight kidney-perinephritic abscess-death. Lancet, I: 91, 1880. 12. FRAZIER, F. Injury to Iiver and kidney from a crush-recovery. Med. Press and Circular, 26: 200, 1878. _ 13, COSKERY, C~CAR J. Three cases probabIe rupture of kidnev. Marvland Med. Jour.. 7: 118. 1880. 14. LUPTON, HARRY. Severe injury to peIvis, right kidney and suprarena1 capsuIe. Lancet, 2: 566, 1882. 15. LEWIS, BRANSFORD. History of Urology, VoI. I, ”

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1933, PP. 291-93. 16. EASTMAN, J. S. Lacerated kidney. St. Louis Courier Med. and Collateral Sciences, 4: 237, 1880.

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17. ISHAM, R. N. Rupture of kidney. Cbi. Med. Jour and Examiner, 45: 365, 1882. 18. BEACH, EDWARD W. Traumatic rupture of the kidney. Col. and Western Med., 33, 1930, 19. SCHENCK, GEORGE F. Traumatic rupture of the kidney. Col. and Western Med., 40, 1934. 20. SIMPSON, CHAS. M. Renal trauma-nine cases. So. Med. Jour., 4, 26: 353, 1935. 21. DAVY, R. B. A case of ruptured kidney-recovery. Cincinnati Lancet and Clinic, 3: 409, 1879. 22. ROWDON, HENRY G. A case of nephrectomy for rupture of kidney where IateraI cystitomy was subsequentIy performed for reIief of cystitis caused by retained bIood clots. Liverpool Med.Cbir. Jour., 59, 1884. 23. PUGH, WINFIELD SCOTT. Rupture of the kidney. Surg. Clin. N. A., 487, 193 I. 24. STRAUS, FRANCIS H. Gunshot wound of kidney. Surg. Clin. N. A., 655, 1928. 25. ROLNICK, HARRY C. Injuries of the kidney. Ill. Med. Jour., 6: 77, 1931. 26. YOUNG, HUGH H. Practice of Urology, II. Chap. 23. 27. JUDKINS, WM. Cincinnati Lancet and Clinic, 3: 41’1 1879. 28. STRAUS, DAVID C. Recent gunshot wounds of kidney-four cases. Surg. Clin. of N. A., 635, 1922. 29. BACKUS, HAROLD S. Traumatic rupture of kidney, etc. New Eng. Jour. Med., 21 I : 563, 1934. 30. LAEWEN, A. Ergebn. d. Cbir. u. Ortb., IO: 611-801, 1918. 31. ROUVILLOIS, H. l?tude cIinique et therapeutique sur Ies DIaies de I’abdomen en chirurzie de guerre. Bull. et mem. Sot. de cbir. de Par., 4;: 708: 1916. 32. GRAVES and CASPER. Complete traumatic rupture of kidney. Kentucky Med. Jour., Ig: 304, 1921. 33. KEEN. Ann. Surg., 26: 138, 1896. 34. WATSON. Boston Med. and Surg. Jour., go: 29, 64, 1903. 35. ADAMS, DONALD S. Traumatic rupture of kidney. New Eng. Jour. Med., 2og. 14: 693. 36. LECOMPTE, R. M. Subcutaneous kidney ruptures. Ural. and Cutan. Rev., 29: 13, 1935. 37. MCKNIGHT, H. A. Perforating wound of kidney with secondary nephrectomy. Ann. Surg., 77: 110,

1923.

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44.