Eleven Cases of Ruptured Kidney1

ELEVEN CASES OF RUPTURED KIDNEY 1 \VILLIAM R. DELZELL

AND

FRANK W. HARRAH

Jarnes lfochanan Brady Fmmdation of Urology of the New York Hospital

Ruptured kidney is recognized as one of the most important lesions of the abdomen, whether it be traumatic or non-traumatic in origin, because of the serious pathology which may develop from hemorrhage, extravasation and infection, and because of its effect on the future economic welfare of the patient) as it gives rise to a high morbidity, through mistaken diagnosis, and either too conservative or too radical treatment. This report is made to add to the clinical picture of ruptured kidney, to bring the literature on the subject up-to-date and to emphasize the importance of pyelography in the diagnosis and treatment of this condition. It is based upon the records of 11 patients admitted to the New York Hospital, suffering from this lesion. SUMMA:R.Y OF CASES

Case 1. J. S., a boy aged thirteen, fell from a railroad platform, a distance of 5 feet, landing on his left side. Immediate and continuous knife-like pain developed in his left loin. He was nauseated and vmnited twice. He rode home, consulted a physician and was admitted to the Hospital the following day. Examination revealed an abdomen rigid everywhere, especially marked over left kidney. No masses felt. Urine turbid, contained a heavy trace of albumin and bloody in appearance. Temperature ranged between normal and 100° and pulse between 72 and 80. Ho remained in the Hospital ten days. Discharged improved. Urine clear~no operation. D£agnos1:s. Lacerated wound of left kidney, Case 2. F. N., a man aged thirty-three, was thrown from a wagon and rendered unconscious for a short time. He returned home, suffer1 Read at the Annual Meeting of the America,n Urological AssociaJ,ion, Balti-more, Ma.ryland, Ma.y, 1927.

131

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WILLIAM R. DELZELL AND FRANK W. HARRAH

ing some pain. A physician was called and a diagnosis of fracture of. the left tenth rib was first made; then blood appeared in the urine, eight hours following the accident, and was present five days later when the patient was admitted to the Hospital, at which time he developed a sudden, sharp, tearing pain in the left lower abdomen. Straining at stool caused the pain to radiate to the left inguinal region. The pain was sharp and intermittent in character. He had nocturia, hematuria and developed fever. Examination of the abdomen revealed no masses or rigidity. Tenderness was present in the left lower abdomen. An x-ray revealed a fracture of the left 10th rib. Fever ranged between normal and 102° and the pulse between 72 and 90. Urine was a bloody red color; specific gravity 1028; there was a moderate trace of albumin. The blood showed 1,900,000 red blood cells; white blood cells, 13,400; hemoglobin, 65 per cent, polymorphonuclear leucocytes, 65 per cent; small lymphocytes, 35 per cent. The patient was discharged from Hospital improved, six days after admission to the Hospital. No operation. Diagnosis. Lacerated wound of the left kidney-fracture of the tenth left rib. Case 3. J. B., a man, aged twenty-nine, one hour before admission to the Hospital, jumped to the deck of a ship and fell 4 feet, striking his right side against a post, causing great pain in the right lumbar region. Examination revealed a marked tenderness over the eighth and ninth ribs, in the mid axillary line, suggesting costo-chondral separation, however, there was no false motion. Marked tenderness was present in the right upper abdomen extending to the right lumbar region where a swelling existed. There was no distension or evidence of free fluid. The urine presented free blood which persisted for five days. There was microscopic blood for eleven days. .Temperature ranged from 101° on the second day to normal on the tenth day. Pulse ranged between 60 and 80. Blood pressure normal. The patient was discharged from the Hospital improved, eighteen days after admission. No operation. Diagnosis. Rupture of the right kidney. Case 4. L. I., a boy, aged eighteen, was -struck by the bumper of an automobile while crossing the street and was thrown forcibly to the sidewalk. No loss of consciousness. Examination revealed an abrasion of the right thigh and the right

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lateral chest from the fifth to the tenth ribs. There was marked tenderness on compressing the lower ribs on the right side and on percussion over the right lumbar region. There was tenderness and rigidity of the entire right side of abdomen. Temperature ranged between normal and 102°. Pulse between 60 and 100. Urine contained gross blood.

FIG.

1. KIDNEY AFTER REMOVAL SHOWING LACERATION AND PERFORATION O~' THE CAPSULE AND PELVIS WITH ExTRAVASATION OF BLOOD AND URINE

The blood picture presented 4,000,000 red blood cells; 13,000 and later 18,100 white blood cells; hemoglobin 75 and 80 per cent. Operation. Right kidney was explored through a transverse kidney inc1s10n. The peri-renal tissue was distended and infiltrated with blood. Upper pole of kidney was completely shattered and torn. No fresh hemorrhage ensued. Blood clots were removed. Drain was

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WILLIAM R. DELZELL AND FRANK W. HARRAH

inserted to the site of the torn kidney, after several loose fragments of of the kidney had been removed. The wound closed in layers. A profuse, sero-sanguinous discharge persisted for five days. Drain was removed on the fourth day. Eight days after the operation the discharge was foul smelling and became purulent on the thirteenth day. Dakin solution was freely used through drains inserted into the wound. The patient remained in the Hospital thirty-one days and was discharged with a suppurating wound and a temperature of 99°. Wound was dressed regularly and eventually the discharge subsided and the wound healed. Diagnosis. Lacerated wound of the right kidney. Case S. H. A., a man, aged thirty-four, fell off motor truck while it was turning the corner. A heavy case of merchandise fell on top of him, striking the patient over right kidney region. He was admitted to Hospital. Examination revealed a rigid tender right upper abdomen. No signs of free fluid . The left abdomen was soft and not tender. The urine was red in color and contained albumin, but both cleared up on the fifth day. The blood picture showed 5,000,000 red blood cells, 18,000 white blood cells; polymorphonuclear leucocytes 94 per cent. Patient remained in the Hospital nine days. Discharged improved-no operation. Diagnosis. Lacerated wound of the right kidney. Case 6. C. H ., a man, aged forty-six, was kicked in right side by a horse. Pain developed over the crest of the ilium and the patient could not get on his feet for some time. Later that day he was taken to the Hospital in a car. Examination revealed rigidity and tenderness of right upper quadrant of abdomen. The right lumbar region below the last rib and above the crest of the right ilium was quite tender. No masses felt. No limitations. No fractures. The urine was red in appearance but not profusely bloody. No blood in the urine could be found after a period of five days in the Hospital. The temperature ranged between 101 ° on admission and 99°. Pulse between 72 and 88. The blood showed 4,500,000 red blood cells; hemoglobin 90 per cent. The patient was discharged from the Hospital improved. Diagnosis. Lacerated wound of the right kidney. The patient reported a year later and presented no urinary symptoms.

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Case 7. H . K., a man, aged thirty, was knocked down by an automobile which passed over his thorax. He was brought to the Hospital in an ambulance and died on the operating table, before his clothes had been removed. His right kidney was found to be badly ruptured as well as other major injuries detected at autopsy. Case 8. C. C., a man, aged thirty-three, was struck on the right side by a swinging piece of heavy plank. He was unable to walk home and a half hour later was admitted to the Hospital. A catheterized specimen of urine showed free blood. His temperature on admission was 96 and pulse rate 92. He was not actually in shock but in great pain. The right side of his abdomen was rigid from the costal margin to Poupart's ligament. There was extreme tenderness in the right flank. Very slight tenderness in the left abdomen. There was extreme tenderness just below the last rib on the right side. No external marks on abdomen. Operation. An exploratory laparotomy was immediately performed through a four inch mid-right rectus incision. On opening the peritoneum a puddle of water presented no evidence of gas bubbles. No blood or intraperitoneal lesion was found. There was however, a bulging of the colon and the peritoneum beneath it on the right side. Wound closed and a right oblique incision was made to the crest of the ileum from the costovertebral angle. There was a large extra peritoneal collection of blood around the kidney. The kidney was found to be lacerated at the junction of its upper two quarters. Pelvis was not involved. The kidney wound was bleeding freely. The kidney was unusually large and the lower pole was fixed. Edges of the ruptures were sutured satisfactorily and bleeding controlled. Large packing placed around the kidney. Wound closed. Time, fifty minutes. Patient made a good recovery. Temperature rose to 104° on the second day and fluctuated around 101 ° until the seventh day. It rose to 104° on the eighth day and on twenty-second day the temperat ure was 101 °. Pulse ranged between 96 and 100 throughout. Respirations normal. Blood pressure ranged from 96 to 100 systolic and later rose to normal. He was discharged from the Hospital improved on the twenty-ninth day with normal temperature. The urine was free of blood on the ninth day following operation, but contained pus cells which finally cleared up entirely. Diagnosis. Lacerated wound of the right kidney- hematoma of right kidney.

THE IOUBNAL OF UROLOGY, VOL. XIX, NO.

2

136

WILLIAM R. DELZELL AND FRANK W. HARRAH

Case 9. F . R., a man, aged thirty-three, was thrown from an express wagon, five days before admission to the Hospital and rendered partially unconscious. He suffered a little pain but was tender over the left kidney region. He was treated for a fractured left tenth rib for four days, when blood appeared in his urine, associated with a sharp sudden pain in his left abdomen which developed while straining at stool. Tenderness became marked in the left lower quadrant of the abdomen which radiated to the left inguinal region. Pain had to be controlled by the use of morphine. No cough. No hemoptysis. There was frequency of urination, nocturia and hematuria. No edema, no incontinence. The patient was admitted to the Hospital acutely ill, but not in shock and with a sallow complexion. Examination of the abdomen revealed no masses, no rigidity, but tenderness was marked in the left lower quadrant. There was a large area of ecchymosis in the left flank and marked tenderness along course of left tenth rib, with a maximum point of tenderness in post-axillary line. Liver, kidneys and spleen were not felt. Blood examination showed 1,900,000 red blood cells; 13,400 white blood cells; hemoglobin 65 per cent; polymorphonuclear leucocytes 65 per cent. Urine showed macroscopic and microscopic blood. Temperature ranged between normal and 100°. Pulse rate averaged 96. Patient remained · in Hospital for period of six days (eleven days after injury)-was discharged improved. Urine revealed only a few red blood cells per field . Diagnosis. Lacerated wound of left kidney-fracture of left tenth rib. Case 10. H . B ., a man, aged forty-two , was sent to the Hospital in an ambulance. No history of injury. He presented a swelling and discoloration of the entire scrotum extending to the perineum, around the penis and up over the abdomen. He appeared acutely ill. Seven years before he had a right renal colic, which lasted two days. After morphine had been administered he passed a stone in the urine. Four years later he had a similar attack of renal colic which resulted in the passage of another stone. He had been catheterizing himself for a week and he stated that the urine was dark colored but never red or cloudythere was a dull pain on the right side. Examination. The lips and tongue were dry and parched. There was an area of dullness over the right lower part of the chest. The abdomen was flat with a purplish edema covering the lower third. There was very slight edema over the right side of back. The right abdomen was rigid but not extremely tender. There were no masses or

ELEVEN CASES OF RUPTURED KIDNEY

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tenderness on the left side. The abdominal edema was continuous with the edema surrounding most of the penis, the entire scrotum and anterior portion of perineum. No hernia. Scrotum was enlarged to about five times normal size, edematous but not tender. Scrotal contents were not palpable. Rectal examination negative. Extremities normal. A No. 22 F soft rubber catheter passed to the bladder without difficulty. Residual urine 4 ounces. Urine dark yellow and clear and examination of urine negative. Blood urea nitrogen was 25.3 mgm. per 100 cc. of blood. Wassermann reaction negative. Roentgenograms of chest showed fluid in right side. Abdominal roentgenograms were negative. Owing to the patient's critical condition cystoscopy was not done. Diagnosis was made of extravasation of urine without urethral obstruction. Operation. Perinea! section done under gas-oxygen anesthesia in usual manner. Multiple incisions made into the scrotum, perineum and penis and over the suprapubic region, releasing a very foul smelling fluid. He developed hiccoughs the second day after operation which continued until his death three days later. At necropsy there was found: Right renal calculus, above stricture of ureter. Right infected hydronephrosis. Rupture of upper calyx of right kidney. Right peri-nephritic abscess. Purulent infiltration of retroperitoneal tissue and diaphragm on right side. Rupture of fascia and muscles in right inguinal regions with purulent infiltration of soft tissues of the groin, scrotum and perineum. Localized subdiaphragmatic fibrinous peritonitis and peritonitis of small area of ascending colon, without rupture of the peritoneum. Empyema of the right pleura without rupture of diaphragm. Urethral fistula (from operation). Case 11. M. S., a boy, aged fifteen, was kicked in right abdomen, while playing football, eight days before admission to Hospital, after which time a swelling developed in right abdomen and patient commenced to pass bloody urine. This was associated with pain and tenderness in the right kidney region and in right upper quadrant of the abdomen. His family physician advised rest in bed but the mass grew larger in size and the patient began to run a fever. He was then admitted to the Hospital with a temperature of 101°. Examination revealed a swollen mass in right abdomen, rather tender to pressure, but quite firm in consistency. The mass completely filled right upper abdomen and right kidney region. Patient was subjected

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WILLIAM R. DELZELL AND FRANK W. HARRAH

to cystoscopy, findings were as follows: Bladder urine contained blood. Interior of bladder normal, except for slight congestion and edema, surrounding right ureteral orifice. No. 6 French catheters passed to both kidney pelves without obstruction. Specimens collected from bladder and both kidney pelves, sent to laboratory for culture, urea and microscopic examination. Urine obtained from right kidney was bloody -that obtained from left kidney clear. P henolsulphonephthalein administered intravenously and appeared on right side in five and one-

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half minutes-on left side in three minutes. Total amount secreted ten minutes 'after first appearance time, 5 per cent right side; 14 per cent left side. Plain x-rays taken with catheters in position. A right pyelogram done after injection of 20 cc. of 20 per cent sodium iodide solution into right kidney pelvis, patient being in prone and erect posture. Catheter being withdrawn in latter position. Catheter then reinserted and sodium iodide siphoned off, after which the pelvis of the kidney lavaged with sterile distilled water. Microscopic findings showed many pus cells, occasional epithelial cell and much blood on

ELEVEN CASES OF RUP'l'URED KIDNEY

right side. Left side showed no blood or pus, The right pyelogram showed: A large mass filling the right loin. Left kidney shadow normal in size and position. No shadows of stone found. There was a shadow signifying an extravasation of sodium iodide outside of lower and middle cavities and kidney pelvis on right side. Upper calyx normal. The

Fm. 3.

CRoss SECTION oF NEPHRECTOMIZED I{rnNEY SHOWING AN Ex'l'ENSIVE

8UBCAPSULAR HEMORRHAGE

UNDERGOING LIQUEFACTION,

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WITH JVIARKED INJURY TO THE KIDNEY

right ureterogram normal except for a slight narrowing below the second lumbar vertebra. :Extravasation of urine and mass in right kidneyregion. Usual kidney incision made down to peri-renal tissue. This structure was hemorrhagic, friable and somewhat disintegTated with old blood clots. This structure was opened and a mass the size

140

WILLIAM R. DELZELL AND FRANK W . HARRAH

of a large grape fruit was found, which apparently contained kidney. With some difficulty this mass was separated from surrounding tissues and at its lowermost pole, below the hilus it was found to contain kidney, which seemed badly torn and lacerated. Active hemorrhage was

FIG.

4.

P YELOGRAM IN A TRAUMATIC RUPTURE OF KIDNEY flHOWING EXTRAVASA• TION OF THE CONTRAST MEDIUM

present. This seemed to be a clot of blood surrounding and involving the kidney, associated with laceration of parenchyma and active hemorrhage. Kidney was removed-cigarette drain placed to kidney pedicle and wound closed. Patient made an uneventful post-operative recovery

ELEVEN CASES OF RUPTURED KIDNEY

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and left Hospital sixteen days after admission. Admission blood urea nitrogen was 24 mgm. per 100 cc. of blood--on day of discharge from Hospital the urea nitrogen was 6 mgm. per 100 cc. Blood pressure 115 systolic and 65 diastolic and again 120 systolic and 62 diastolic. Pulse ranged from 108 to 58. Admission temperature 101 ° and two days before the patient was discharged from Hospital his temperature was normal. Renal function on day of discharge was 65 per cent in two hours. Admission urine was bloody in appearance. Specific gravity 1020-acid reaction- showed a trace of albumin, no sugar, and contained pus, blood and epithelial cells. Urine on discharge from Hospital was clear and straw colored, acid in reaction. Specific gravity 1018, showed no albumin, no sugar, no pui:i, no blood, no casts, no epithelial cells. Blood on admission showed 3,940,000 red blood cells, hemoglobin 74 per cent. White blood cells 14,200. Polymorphonuclear leucocytes 70 per cent. Blood Wassermann negative. An attempt to make a pyelogram of the kidney after it had been removed, failed, because the sodium iodide ran out from laceration in kidney pelvis and cortex of kidney.

In this series of cases, the age of the patients ranged from thirteen to forty-six years, an average age of thirty years, all of which occurred in male patients. Eight of the cases involved the right kidney and 3 involved the left kidney. Ten were caused by trauma which varied in intensity, from a slight fall to that of being struck by various objects. Four were caused by falls, 3 were struck by automobiles, 1 hit by a swinging plank, 1 kicked by a horse and 1 kicked by an opposing football player. Two were injured by slight falls, 1 falling a distance of 4 feet, and one 5 feet, which shows that seemingly small violence may cause a rupture of the kidney, if it is in a state of hydraulic tension (1). The case of a man rupturing his wife's kidney while waltzing (2), and one caused by indirect violence (3) also bears out this point. Two of the cases were complicated by fractures of left tenth rib. In one of these, the fracture so masked the renal symptoms that rupture of the kidney was not suspected for some time, and the patient was not sent to the Hospital until five days after the injury. Floating ribs may be of importance in the production

142

WILLIAM R. DELZELL AND FRANK W. HARRAH

of renal rupture (4). Kidneys may be caught between the ribs and vertebrae producing laceration or pulpification of the kidney (5).: In one of this series, the kidney seemed to have been crushed between the vertebrae and an opposing football player's knee, and one b_y the kick of a horse in a similar manner, which is like a case previously reported by Reed (6)-. In one of this series the kidney ruptured spontaneously (7) after the patient had , suffered several attacks of renal colic over a period of seven years. This case is extremely rare (only 16 cases of spontaneous rupture were found in 7805 necropsies and only 26 clinical cases have been reported until recently). ~nfection played an important part in the ulceration process, causing this rupture. Ruptured cysts (8):, infected hydronephroses, abscesses, tuberculosis of the kidney (9). Ruptured infarcts and tumors may serve as contributing factors (10). Amberger (8)~ Simmons (4), Szenes (10)-, and Miller (5), have reported cases of rupture occurring in such pathological kidneys. Pathological and distended kidneys rupture as a result of less violence than normal undistended kidneys. Kidney ruptures may be benign or grave. Six of these cases healed under expectant treatment. The hospitalization time averaged nine days-3 being in the Hospital less than a week and only 1 over two weeks. None reported further trouble. However, primarily benign lesions may become serious if followed by infection. Lowsley(12) and Kirwin (12) state that "Infection may take the form of a walled off abscess, but it is often a diffuse cellulitis extending into the surrounding tissues, which in cases seen long after the accident may hinder palliative surgery and require nephrectomy.'' The severity of kidney ruptures may be compared to cerebral injuries; a large injury in the cerebral silent area being less serious than a minute injury in a vital area. A small laceration in the kidney pelvis may allow alarming extravasation, or a small laceration in a large vessel may cause fatal hemorrhage, while a larger tear in the cortex, especially if subcapsular, may be benign. In one reported case (2), the laceration was produced in the cortex only, and though small, caused severe hemorrhage. Thus

ELEVEN CASES OF RUPTURED KIDNEY

143

the situation of the kidney laceration, as well as the degree of the injury determines its gravity. Tuffier's (13) classification of ecchymosis, subcapsular rupture, and total rupture is similar to Shupe's (14), but might well be elaborated to differentiate between infected and non-infected cases, and to include the situation of the laceration. The average hospitalization time of the three operated cases was twentyfour days. One case was inoperable and died five minutes after entering the hospital. Thus, in considering the benign and grave cases in this series, the course was rapid in all. SYMPTOMS

The symptoms complained of in this group were pain, tenderness, blood in the urine, nausea and vomiting, weakness, pallor, abdominal swelling, and ecchymosis (15). The pain was continuous and severe in the majority of cases, but in 1 case the patient had little pain and complained chiefly of tenderness over the kidney area. All patients had some tenderness not only at the site of the injury but also on that side of the abdomen, and over the kidney affected. Blood was present in the urine, in each of these· cases, but this is not pathognomonic nor constant. (Cortical tears may not show hematuria (2).) The hemorrhage was accompanied by pallor in all cases and by shock in two cases. The red blood cell count ranged from 1,900,000 to 4,000,000; the hemoglobin and blood pressure were correspondingly diminished and the pulse rate accelerated. The white blood cell count showed a leucocytosis ranging between 13,000 and 18,000 (except in one case secondarily infected which had a leucocytosis of 41,600); with a preponderance of polymorphonuclear leucocytes. The temperature was not high in non-infected cases, becoming suonormal as a result of the shock, and showed a characteristic elevation as aosorption took place. Nausea and vomiting was present in 3 cases. This, accompanied by other signs of peritoneal irritation, abdominal pain, tenderness and rigidity led to a mistaken diagnosis in 1 case. Rigidity of the abdominal muscles on one side was present in

144

WILLIAM R. DELZELL AND FRANK W. HARRAH

all cases. In 2 cases the rigidity was generalized. One patient showed a large area of ecchymosis in the left flank and one a large mass in the upper right quadrant, which increased in size and was the most alarming symptom. One patient presented symptoms of perineal urinary extravasation and was operated upon for such, the actual point of leakage not being determined until autopsy showed it to have burrowed from the kidney to the inguinal and perineal regions. -, ... Pu c. 0, ~o3,H•-i1 "·-r C No 8 0

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BRIEF ANALYSIS OF CASES

The symptoms appeared immediately or within one hour in 7 cases, and in six to eight hours in 2 of the traumatic cases, but 3 were able to return home after the injury and came into the Hospital later when the symptoms became more aggravated. One case has been reported that presented no symptoms for ten days after the injury, although the kidney was completely divided (16).

ELEVEN CASES OF RUPTURED KIDNEY

145

TREATMENT

The benign cases were given symptomatic and supportive treatment, and confined to bed. Morphine was given to relieve pain and urinary antiseptics to prevent infection. Subpectoral saline was administered when indicated. In none, was transfusion deemed necessary. Operation was required in 3 traumatic cases. In the first, an exploratory operation revealed that the upper pole of the kidney was completely shattered. No fresh hemorrhage ensued, so the clot and kidney fragments were removed, a drain inserted to the site of the torn kidney and the wound closed. This was the case that became secondarily infected. This kidney was saved by early surgical interference, which might have required nephrectomy, if operated upon after infection had developed. In the second case an intra-peritoneal injury was suspected and an exploratory laparotomy was performed. There was, however, a bulging of the ascending colon and the peritoneum beneath it. The wound was closed and the right kidney exposed through an oblique incision. The kidney was found to be lacerated at the junction of its upper two-quarters. It was bleeding freely, but the pelvis was not involved. The edges of the rupture were sutured satisfactorily and the hemorrhage controlled. Large pieces of gauze packing were placed about the kidney and the wound closed. The patient made a satisfactory recovery. The third case required a nephrectomy, because, it was the opinion of the authors that, since the bleeding was persistent after eight days, it was dangerous to chance further hemorrhage by palliative surgery, and since pyelography revealed a badly damaged kidney. Also, the kidney was so embedded in clot and fibrin that it seemed impossible to locate all the bleeding points which at this time were bleeding to an alarming extent. This patient made an uneventful recovery and left the hospital in sixteen days. The kidney was found on section to have been lacerated in several points, associated with marked injury to the pelvis. There was a very large hemorrhage about the kidney which in places presented evidence of a beginning liquefaction. Three months later the patient

146

WILLIAM R. DELZELL AND FRANK W. HARRAH

returned for observation and his condition and general health was excellent. Cases with persistent decreasing blood pressure and red blood cell count, and with increasing pulse rate, should b'e operated. Those having slight evidence of secondary hemorrhage and but slight pain, and in whom hematuria is the chief symptom, may be treated expectantly but should be hospitalized and carefully observed until the hematuria has subsided. The case having a red blood cell count of 1,900,000; a white blood cell count of 13,400, and a hemoglobin of 65 per cent was treated expectantly with success. This seems too conservative. We believe, that it is safer to inv;estigate doubtful cases under regional anesthesia (which has the advantage of not increasing the blood pressure, thereby producing more hemorrhage and the advantage of a lower mortality in kidney surgery) than to treat them expectantly. Operative procedure is indicated to prevent the danger of exsanguination, extravasation, secondary infection and peritonitis. CONCLUSIONS

1. Spontaneous rupture is extremely rare and occurs only m pathological kidneys. 2. Seemingly small violence may cause a rupture of the kidney if it is in a state of hydraulic tension. 3. The majority of traumatic ruptures heal without surgical interference, but should be hospitalized and carefully observed until hematuria subsides. 4. Most ruptured kidneys which require operation may be saved by palliative surgery; few require nephrectomy. 5. The symptoms of ruptured kidney are usually definite but may be mistaken for intraperitoneal lesions. 6. Cystoscopy is usually not necessary for diagnosis, but should be done in occasional cases to determine the condition of damaged kidney. 7. Pyelography is an aid to accurate diagnosis, in selected cases. 8. Moderate leucocytosis (13,000 to 18,000) may not indicate

ELEVEN CASES OF RUPTURED KIDNEY

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infection, but may be due to absorption of the blood clot and secondary anemia. 9. It is safer to investigate doubtful cases under regional anesthesia than to treat them expectantly. 10. Operative procedure is indicated to prevent exsanguination, extravasation and infection. 11. The morbidity of kidney rupture is more dependent upon the state of shock and subsequent infection than the amount of secondary hemorrhage. We wish to thank the surgeons of the New York Hospital who have kindly permitted us to include their records in this series. REFERENCES (1) TRoou, G.: Traumatic renal lesions. Policlinico (sez. prat.), 1923, xxx, 1551.

(2) WESSON, MILEY B.: For former bibliography. The treatment of traumatic rupture of the kidney. Ann. Surg., Feb., 1926, lxxxiii, 246. (3) JEFFERSON, R. J. C.: Lacerated kidney due to indirect violence. Brit. Med. Jour., June, 1923, i, 1053. (4) MORRIS, H.: Injuries of the Kidney. In Surgical Diseases of the Kidney and Ureter. Cassell & Co. London, 1901, i, 141- 198. (5) MILLER, C. R.: A case of hydronephrosis with rupture into the peritoneal cavity. U. S. Vet. Bur. Med. Bull., 1926, ii, 500. (6) REED, J. A.: Ruptured kidney; nephrectomy. Brit. Med. Jour., 1924, i, 518. (7) HENLINE, R. B. : Non-traumatic rupture of the kidney. Amer. Med. Assoc., 1924, lxxxiii, 1411- 1414. (8) AMBERGER: Spontaneous rupture of the right kidney. Ztschr. f. Urol., 1926, xx, 561. (9) LE COMTE, R. M.: Spontaneous rupture of hydronephrosis; case report. Jour. Urol., 1926, xv, 517. (10) SzENEs, A. : Spontaneous rupture of the kidney. Ztschr. f. Urol., 1923, xvii, 276. (11) SIMMONS, R. R.: Gonococcal infections of the kidney. Report of a case with traumatic rupture. Jour. Urol., 1922, vii, 113. (12) LowsLEY, 0. S., AND Krnwrn, T. J.: A textbook of urology, 1926. (13) TRIFFIER, T.: Traumatismes du rein; in Traite de Chirurgie . S. Del play and P. Reclus, Par. G. Masson, 1892, vii, 476-493. (14) SHUPE, T . P.: Traumatism of the kidney. Ohio State Med. Jour., Feb., 1923, xix, 104. (15) MARSHAL, V. F.: Traumatic rupture of the kidney. Journal, Lancet, 1923, xliii, 345.

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(16) KEMM, NOEL : Rupture of the kidney; delayed symptoms; operation; recovery. Brit. Med. Jour., 1923, ii, 1218.

In addition to the references already given, the following will be found of interest: WATSON, F. G.: Rupture of kidney, case report. Minnesota Med., 1924, vii, 436. VoNCKEN AND REYNDERS: Indications for operation in traumatic lesions of the kidney. Arch. Med. Beiges., 1924, lxxvii, 95. KELLY, E . C.: Hematuria from traumatic ruptured kidney. Ill. Med. Jour ., 1925, xlviii, 215. STIRLI~G, W. C.: .Subparietal traumatism of the kidney. Internat. Clin. September, 1925, iii, 169. RIESE, H.: Zur Klinik der subcutanen Nierenverletzungen. Archiv. f. klin. chir., 1903, lxxi, 694-725. PAPIN, E.: De la resection des nerfs du rein dans les affections douloureuses de cet organe. J. d'urol. med. et chir., 1921, xii, 126-134. KoLISCHER, G., AND ErsENSTAEDT, J. S.: Traumatic rupture of the kidney. Surg. Clin., Chicago, 1919, iii, 131-134. BAILEY, H. : Injuries to the kidney and ureter. Brit. Jour. Surg., Bristol, 19231924, xi, 609--621.