1892 HUMAN ANATOMY. 



from a weight falling on the shoulders, may cause compression of the kidney between 

 the lower ribs and the ilium, and is, therefore, not infrequently followed by haema- 

 turia, indicating some degree of rupture of kidney-substance. 



The rupture may be («) incomplete, — i.e., may involve the parenchyma alone, 

 the symptoms in these relatively rare cases being those of excessive renal tension 

 (yvide supra), the constitutional signs of hemorrhage and of toxaemia (usually due to 

 urinary extravasation or to perinephric cellulitis) being moderate or lacking ; (3) 

 complete internally, — into the pelvis of the kidney, — a more common condition, in 

 which haematuria, acute hydronephrosis, from blocking of the ureter with blood- 

 clot, and vesical irritability are prominent symptoms, and the constitutional signs 

 of hemorrhage and toxaemia are more marked ; (<:) complete externally, — extending 

 through the fibrous capsule, — in which, in addition to the immediate indications of 

 hemorrhage and the later symptoms of sepsis, the usually free urino-sanguineous 

 effusion into the loin produces marked lumbar swelling and tenderness ; or {d) com- 

 plete, — running from the pelvis to and through the capsule, — in which, with a com- 

 mingling of the above symptoms, there is often profound shock which may terminate 

 fatally. 



Rupture of the kidney extending through its outer surface may be (<?) transperi- 

 toneal, in which case hemorrhage is apt to be very free, as there is no surrounding 

 pressure to resist and limit the extravasation, and fatal peritonitis will almost surely 

 follow unless the escaped urine is normal, acid, and sterile, and unless both it and 

 the blood-clots are speedily evacuated. 



When, in addition to the laceration of the kidney, a single intraperitoneal organ 

 is also injured, it is always on the same side as the injured kidney (Watson). The 

 liver, for example, or the ascending colon, may be involved in a case of subparietal 

 rupture of the right kidney, but never the spleen or the descending colon. This will 

 readily be understood from a consideration of the frequency with which the cause of 

 rupture is a forcible forward bending of the vertebral column, the kidney being caught 

 in the angle of the bend, any lateral deviation of which may determine the side on 

 which the injury occurs and the involvement of liver or spleen respectively. 



Transperitoneal rupture of the kidney is relatively far more common in children 

 than in adults. Until the age of eight or ten years is reached the kidney lacks its 

 covering of perinephric fat, and its anterior surface lies in contact with, and is closely 

 connected to, the peritoneum. A rupture involving that surface is therefore practi- 

 cally certain to open the peritoneal cavity and is likely to be followed by excessive 

 hemorrhage and septic infection. In children under ten years of age 85 per cent, 

 of subparietal ruptures of the kidney have proved fatal (Maas). 



Wounds of the kidney must, of course, involve the capsule and external surface, 

 so that hemorrhage into the perinephric tissues is an almost constant symptom. If 

 the wound has reached the calyces or the pelvis, urine will be commingled with the 

 blood. Vesical haematuria may be prevented by the presence of a clot in the ureter, 

 or by the actual severance of that tube. If large vessels have been opened, the blood, 

 in addition to reaching the bladder or the perinephric space or the peritoneal cavity, 

 may pass upward to the diaphragm, downward to the iliac fossa, or along the spermatic 

 vessels to the external abdominal ring, or outside of the ureter to the perivesical space, 

 or forward between the two layers of the mesocolon. In a reported case of gunshot 

 wound in which the missile reached the kidney from above downward, injuring 

 pleura and diaphragm en route, the concomitant injury to the lower intercostal nerves 

 caused rigidity and tenderness of the anterior abdominal wall and gave rise to the 

 unfounded suspicion that the wound was transperitoneal. 



Anuria due to reflex effect upon the normal kidney may follow a rupture or 

 wound or even calculous irritation of the other kidney, although, as a rule, calculous 

 anuria indicates a bilateral lesion. Both kidneys are, of course, supplied from the 

 same segments — the tenth, eleventh, and twelfth dorsal and first lumbar — of the 

 spinal cord. Excessive tension from compensatory hyperaemia has been thought to 

 explain this form of anuria, and the theory is supported by the facts that the condi- 

 tion sometimes follows a nephrectomy, the remaining kidney being normal, and that, 

 whatever its cause, it is often relieved by nephrotomy of the hitherto sound kidney. 

 The susceptibility of the kidney to reflex stimulation or inhibition must be admitted, 



