Further, an examination of a number of subjects leads me to believe that the relation of the ureter to that part of the peritoneum which becomes adherent to the spine is within a slight range of variation pretty constant, the ureter lying just outside the line of adhesion. So that if the surgeon has stripped up the peritoneum, and come down to that point where it refuses to strip readily from the spinal column, he will find the ureter upon the stripped up peritoneum at a short distance outside of this point. On the left side the distance from the adherent point to the ureter is from one-half an inch to an inch, while on the right side it is somewhat greater, owing to the ureter being displaced to the outside by the interposition of the vena cava between it and the spine.

After the ureter dips down into the pelvis it is less easily located, because it does not bear any fixed relation with a bony landmark, but fortunately in the cases in which a stone is sought in it, we have a hard body that is readily palpable to guide us to it.

To reach the ureter in the upper part of its course, perhaps no better incision can be chosen than that planned by Israel.

He draws a line from a point on the anterior edge of the sacro-lumbar mass of muscles, a finger's breadth below the twelfth rib, parallel to the rib as far as its tip; then turning down toward the middle of Poupart's ligament till the line of usual incision for tying the iliac artery is reached ; then again turning toward the middle line, and ending on the external border of the rectus muscle. According to the seat of the calculus, the incision will be made on the posterior, middle, or anterior third of this line.

This incision gives us access to the ureter in the abdominal part of its course, and in the upper part of the pelvis. In a very thin subject with lax abdominal walls, or in a child,' it might even be possible to reach it down to within an inch or two of its entrance into the bladder; but even if reached, it would be difficult to operate upon it at such a depth.

Practically, in adults the lower three or four inches of the ureter cannot be reached from in front by an extra-peritoneal incision.

Unfortunately, it is just in this lower part of the ureter that stones are likely to lodge. As the ureter is narrower just where it enters the bladder, the stone is often arrested there, and may remain fixed for a long time.

The plan suggested hitherto for the removal of stones impacted close to the entrance into the bladder has been to approach them through the bladder, by a supra-pubic incision in the male, and by dilatation of the urethra in the female.

If the stone is already projecting well into the vesical cavity, or has

1 Twynam removed a stone from the ureter about two inches from the bladder in a child, by an incision as for tying the iliac artery.

actually passed through the muscular coat and is lying under the mucous membrane, it may be removed easily and successfully through the bladder, and this would certainly be the method of choice. When, however, the stone has not reached the bladder cavity, and an incision of the bladder-wall is therefore necessary to uncover it, this operation is a dangerous one, as urinary infiltration about the base of the bladder is likely to follow it. It would be better then to reach the stone in the vesical end of the ureter by an incision from the outside, which would open a way for the escape of any urine that was afterward extravasated.

As has been said, this part of the ureter cannot be reached from above, and it is necessary, therefore, to seek some approach to it from below. It occurred to me that a modification of the incision employed by Kraske for excision of the rectum would afford the desired access to this lower portion of the ureter, and dissections have confirmed me in this belief.

I find that an incision along the border of the sacrum, on the side upon which it is wished to reach the ureter, stopping just below the point of the coccyx, with a division of the sacro-iliac ligaments and the removal of the coccyx and the lower part of that side of the sacrum, lays open the pelvic cavity in a most satisfactory way, and gives easy access to the lower three or four inches of the ureter. The only difficulty in this dissection is in finding the ureter, which in its collapsed state cannot be easily made out.

The converging lines which the ureters pursue through the pelvis lie pretty closely over the lateral edges of the sacrum, and this relation will help somewhat in fixing their location when approaching them from behind. The peritoneum is very thin, and there is considerable danger of wounding it during a protracted search. Of course, with a stone in the ureter to guide us, this difficulty would largely disappear.

The danger of wounding the rectum may be avoided by introducing into it a large sound, with which its cavity may be mapped out, and which can be used afterward to draw it to one side.

For a stone impacted in the male this would seem a very ready and safe incision for reaching this portion of the ureter. The space afforded is ample for a careful inspection of the parts, and the opening, being dependent, affords good drainage.

In the female we have even readier access to this part of the ureter through the vagina. The ureter for the last two, or even in some cases three, inches of its course runs in the broad ligament in close relation to the upper part of the vault of the vagina, where it can be reached and incised without danger of opening the peritoneum.

That so much of the lower end of the ureter lies within the broad ligament, and is accessible from the vagina, does not seem to be generally understood.

Emmet describes a case in which the stone projected into the bladder

enough to give a click when the steel sound passed over it, and in which he cut down upon it from the vagina. He says: "As soon as I reached the stone, I enlarged the opening forward, toward the neck of the bladder, this being the only safe direction to avoid entering the peritoneal cavity.

From my dissections it would seem that, even had the stone lain an inch, or an inch and a half, higher up in the ureter, it might still have been reached from the vagina without danger of wounding the peri

toneum.

The incision for reaching a stone lying above the vault of the vagina should be outward and backward, in order to keep it within the layers of the broad ligament. After the vaginal wall is divided, the finger pushes up readily into the broad ligament, and the tissues can be pressed aside until the stone is reached.

If then the incision is made through the ureter on its under side, the danger of injuring the peritoneum must be slight. In case it happened that a stone was so lodged in the ureter of a female as to be out of reach from the vagina, and yet not high enough to be accessible from above, the incision over the sacrum might be required for its removal.

That the removal of a stone above the vault of the vagina is feasible by vaginal incision, the following case will show :

The patient was a rather stout woman of thirty-nine years of age, and was seen first by me May 15, 1890. She had for fifteen or sixteen years been subject to attacks of renal colic, always on the left side, and almost always followed by the passage of stones.

The last severe attack was in December, 1888, but since that time she had had a number of slight attacks during which she had passed twenty or more small stones. The attack in which I saw her began five or six weeks before my visit, and had continued ever since, with pain of varying intensity.

The urine was at times much diminished in quantity, and for several days before I saw her had been very scanty (from four to six ounces a day). It had, during this time, been loaded with urates. On the day that I saw her it had become more abundant and less thick.

The patient had a good appearance, with moist tongue, quiet and steady pulse, and normal temperature. She was perspiring rather

freely.

The pain in the region of the left kidney, and running down toward the bladder, was intermittent and spasmodic in character.

In the left lumbar region was a distinct tumor about as large as two fists, which was sensitive to pressure. There was also a point of tenderness deep in the left side of the pelvis. By vaginal examination, a little hard mass was found in the left broad ligament close to the cervix uteri. This felt about as large as the last joint of the forefinger, and it was very sensitive to pressure. The palpation of it during the examination started a spasmodic pain in the left side that had a bearingdown or expulsive character.

A sound introduced into the bladder could be carried to within about

three-quarters of an inch of this little, hard mass, but could not be brought in contact with it by the most careful bimanual manipulation. On July 1st, I saw her again, and the calculus could be felt in exactly the same place where it had been detected by the examination in May.

On July 4th the patient was etherized for operation. An incision was made over the calculus through the vault of the vagina just to the left of the cervix uteri. The calculus was easily reached, the grating of the knife upon it being distinctly felt during the first incision.

After the end which presented had been thoroughly uncovered, it was found that the rest of the calculus was so tightly grasped by the tissues above that it could not be easily extracted. In fact, the presenting end broke to pieces under the grasp of the forceps with which extraction was being attempted. After trying many manipulations in vain, a blunt hook was passed up alongside of the calculus into the ureter behind, then turned and hooked over the upper end, and traction with this, aided with the finger pressing the tissues aside, finally accomplished the removal of the stone.

The moment it came out there was a rush of pus from above. This pus was of ordinary thickness, apparently not much thinned by urine. Probably from ten to twelve ounces escaped. A rubber tube was introduced into the ureter through the opening made. After the pus had fully escaped, the tumor in the abdomen was found to have disappeared. The patient made a good recovery, and the urine, which was very scanty just after the operation, gradually increased in quantity until it became sufficiently abundant. Drainage through the fistula was kept up for some time, and finally, when the drainage-tube was removed, there seemed to be no tendency for the opening to close, there being a constant, moderate discharge of pus through it. She recovered strength slowly, as is usual in those cases where the kidneys are seriously involved. She left the hospital on the 25th of July. She continued to gain strength after getting home, and finally was able to be about as usual, doing her ordinary work.

This patient was last heard from in November, 1890, and at that time there was still an opening in the vagina, discharging a small amount of pus. No urine ever came through the fistula, showing that the long distention of the kidney during the complete stoppage of the ureter had sufficiently destroyed the cortex to stop excretion. If at any time the escape of pus into the vagina becomes a serious annoyance, it can be stopped by the removal of what remains of the kidney.

The stone that was removed weighed one hundred and ninety grains. It was elongated, and evidently made up of two stones which had become attached together, as there were two nuclei, one at each end of it.

I have endeavored in this brief communication to point out the ways in which the ureter can be safely cut down upon in different parts of its course for the purpose of removing calculi impacted in it; and my dissections have led me to think that by a properly selected operation a stone can be removed from any part of this canal by an extra-peritoneal incision.

In order now to select the proper incision for each case, it is neces

sary to be able to locate the stone exactly, and this is often a matter of great difficulty.

A rectal or vaginal examination will ordinarily reach a stone of any size impacted in the lower end of the ureter, but throughout the rest of its course this canal lies so deeply that palpation of it is very unsatisfactory.

Occasionally, the position of the stone may be suspected if in the presence of symptoms pointing to an obstruction of the ureter there is a constant spot of great tenderness somewhere in the course of the canal. The writer in one instance cut down over such a painful spot in the loin, and successfully removed a stone.

When indications do not, however, point with sufficient directness to one spot, more exact information must be sought, and within the past eighteen months two operators,' seeking a solution of this question, have made use of an opening into the abdomen, and palpation of the ureter through that opening with brilliant results.

In both of these cases the stones, though small, were readily felt through the abdominal incision; and after an opening had been made in the lumbar region, the hand in the abdomen greatly aided in the removal of the calculus-in one case by steadying it and guiding the instruments to it, and in the other case by actually lifting the calculus out of the pelvis to a point where it could be easily reached above the crest of the ilium.

This last case suggests that it might be possible by manipulations through an abdominal incision to work a calculus back along the ureter from deep in the pelvis to a point where it could be reached from the loin, and thus to avoid the necessity of the more severe sacral wound.

It may also occasionally happen that a friable calculus can be crumbled between the fingers without injury to the ureter, and thus reduced to sand, which will pass along the canal into the bladder.

Whether it would ever be wise to employ a needle to break up a calculus in the ureter, as Mr. Thornton has done with calculi in the biliary ducts, seems to me very doubtful. The urine is a thin fluid as compared with the bile, and there would, therefore, be more danger of its escaping even through the minute punctures of a needle.

Lastly, in regard to the proper treatment of the ureter after the removal of the calculus.

Mr. Arbuthnot Lane closed the wound in the ureter by a continuous silk suture, and had no leakage from it; Mr. Twynam also sutured the urethral wound, but had considerable leakage from it, and the silk gave rise to some suppuration.

1 Hall: New York Medical Record, October 18, 1890. Arbuthnot Lane: Lancet, November 8, 1890.