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In the cases reported by Dr. Ralfe and Mr. Godlee, and by the writer, in which longitudinal incisions were made into the ureter, the slight leakage of urine and the rapid healing of the wounds would seem to show that suturing the wound was an unnecessary prolonging of the operation. Furthermore, owing to Meg Tin Nway Giflie ureter, it must be a matter

wall

, of great difficulty to puerent the stitchies fron entering the calibre of the tube, and if they do 90, tar dikely to serve as nuclei for fresh stones.

It would seem, therefore, bost, not to suture' ile canal, but to provide adequate drainage for the urine escaping from it until the wound in its wall closes.

In the female the lowermost part of the ureter is in intimate relation with the vaginal wall, and it is possible here to get sufficient thickness for the easy application of sutures without encroaching on the cavity of the tube. Emmet thus closed the wound in his case with fortunate result.

In 1889 M. Le Dentu, in his large work,' wrote: “The portion of the canal between the entrance and the floor of the pelvis must, for the present, be regarded as inaccessible," ?

I trust that the considerations that I have offered will show that this is no longer the case.

The following appendix gives a brief account of the important surgical features of all of the more recent cases that the author has been able to find in which calculi have been removed from the ureter. Their almost uniform success, while suggesting the possibility that the less favorable cases have not yet found their way into print, shows, at least, that much may be accomplished in this branch of surgery.

Dr. T. A. Emmet has met with three cases in which a stone was impacted in the lower end of the ureter. In two of these cases he operated : once by opening the bladder, and then with a curette removing the stone from the mouth of the ureter. In the other case he always felt the click of the stone on the sound in the same place. Suspecting that the stone was in the ureter, he made slight backward pressure with a large sound in the bladder, and was then able to feel it with his finger in either the vagina or rectum.

With the patient on the side he operated by an incision through the vaginal wall, while an assistant kept the parts prominent by pressing backward and upward with a sound in the bladder. The stone was

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1 Affections Chirurgicales des Reins, des Uretères, et des Capsules Surrenales.

La portion du conduit intermédiaire au détroit supérieur, et au plancher du bassin doit seule jusqu'à nouvel ordre être considéré comme inaccessible."

3 Principles and Practice of Gynecology, 1884, page 796.

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removed without having entered the bladder or peritoneal cavity. The weight of this stone was 98 grains.

Dr. Cullingworth reported a case in which there were calculi in both ureters.

The patient was a woman of thirty years. The symptoms referring to the kidneys (attacks of pain in back and sides) dated back ten months.

When seen she had fever, pain in loins, frequent micturition. . The urine contained much pus.

Examination showed a smooth, lobulated tumor in the right side of abdomen. Per vaginam, there was detected a mass of stony hardness, about the size of a walnut, to the right of the uterus, and a smaller and equally hard lump to the left.

The diagnosis made was pyonephrosis, with probably independent disease of the ovaries.

An abdominal incision was made, and a stone was found impacted in the right ureter, with great distention of the ureter and pelvis of the kidney above.

This was removed by an incision directly into the ureter, and much pus and urine escaped through the abdominal cavity. The stone weighed 270 grains.

The edges of the incision in the ureter were brought together by means of five interrupted sutures of fine carbolized silk. Drainage of the abdomen was provided by a glass tube.

The patient lived four days, the urine varying in amount from 151 to 24} ounces in the twenty-four hours.

At the autopsy the abdomen contained about 5 fluidounces of thin, dirty fluid. Both kidneys were enlarged, and contained abscesses. The stitches in the ureter had not given way, and there was no evidence of leakage.

It was found that the hard mass felt to the left of the uterus was another calculus in the left ureter, which, though longer than the stone taken from the right side, did not block the passage so completely.

It seems possible from this account that, had the hard masses felt through the vagina been recognized as stones in the ureters, they might have been removed by incision through the vault of the vagina, without entering the abdominal cavity.

Dr. J. M. Richmond reports the case of a woman of forty-two years, in whom he detected a stone in the bladder end of the ureter covered only by mucous membrane.

He dilated the urethra and dislodged it with the finger and a tenaculum.

1 Transactions of the London Pathological Society, vol. xxxvi. p. 278.
• Transactions of the Medical Association of Missouri, St. Louis, 1888.

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Dr. Ralfe and Mr. Godlee. Case of a woman aged twenty-six, who was attacked with nephritic colic on both sides during the same day. The pain in the right side passed off quickly, but on the left side it persisted.

She was seen eight days later, and at that time had had suppression for fifty-three hours.

The left kidney was exposed by lumbar opening and incised, but no stone found in it. Exploration with the finger detected a stone about two inches below the kidney. The ureter was drawn up, opened longitudinally, and the stone removed.

There was an immediate relief of symptoms, and large quantities of urine passed by the wound.

During convalescence from this operation there were several slight attacks of right renal colic, so after the wound was healed, the right kidney was exposed and incised, but only a little mass of gravel was found in it, and no stone in the ureter down to the point where it crossed the iliac vessels. Subsequently there were several slight attacks of pain, and some gravel, and a small stone was passed per urethram. The patient made a good recovery.

Twynam. This was the case of a boy aged eight, well grown. suffered from pain in the bowels and hæmaturia. This was intermittent. The symptoms seemed to point to the left kidney as the seat of trouble.

Langenbuch's incision was made on the left side. Nothing was found in that kidney, but a small, hard calculus was detected in the right ureter just below the brim of the pelvis. Nothing further was done at the time, and with the exception of one long and serious convulsion, the child made a good recovery.

At the end of three weeks the stone was removed through an extraperitoneal incision in the right hypogastrium. There was difficulty in reaching the stone, but with the aid of an assistant pressing it up, the ureter was incised over it, and it was removed.

The wound in the ureter was sutured with silk, the ends of which were brought out through a drainage-tube. The closure, however, was not complete, and the dressings were soaked with urine.

On the fifth day the urine ceased to come through the wound. The silk kept up some suppuration for a time, but after this was removed the wound quickly closed.

Cabot. This was a case of calculus impacted about two inches below the kidney in a man aged forty. The stone had been fixed in that position for a week, and had caused extreme suffering, with considerable diminution in the amount of urine.

i Transactions of Clinical Society, London, February 22, 1889. ? Ibid., 1890, xxiii. 5 Boston Medical and Surgical Journal, September 11, 1890.

He was seen and operated upon April 22, 1890. The ureter was exposed by an incision along the edge of the quadratus lumborum muscle. A little stone was felt in it about two inches below the kidney at a point where excessive tenderness bad existed during the whole of the attack. It was drawn forward into the wound, and removed by a little longitudinal incision in the ureter. No sutures were applied. There was slight leakage of urine through the wound up to the tenth day, but after that time it ceased. The tube was removed three weeks after the operation, and the patient rapidly recovered; the operation being followed by complete relief.

Hall' reports the case of a woman of thirty-six years who had been troubled with paroxysmal attacks of abdominal pain of obscure origin for five years. Suspecting a calculus in the kidney or ureter, Dr. Hall opened the abdomen, and found the pelvis of the kidney and upper part of the ureter dilated, with a calculus impacted below in the ureter.

The patient was turned on the side, and an opening was made into the kidney through a lumbar incision. The left hand in the abdomen assisted in directing the efforts toward the dislodgment of the stone.

Recovery was complete, the wounds being closed on the twenty-first day. Lane’ records the case of a woman twenty-three years of

age,

who had been troubled intermittently with attacks of pain in tho abdomen since she was three years old.

Shortly before coming under observation she had had more frequent and violent attacks than ever before, coming on two or three times a week.

After each attack the urine contained an excess of pus.

The left kidney was explored by a lumbar incision, and the pelvis was found much dilated; but nothing could be found to explain this beyond a fold across the top of the ureter, which prevented the finger from entering it.

With the finger in the lumbar wound, and afterward in the rectum and vagina, the ureter was examined, except for a short distance in the middle of its course, where it could not be reached from either direction. Nothing could be felt.

The patient recovered well, but the pain, which was at first relieved, soon returned.

In July, 1890, having recruited her strength, she returned for another operation.

The abdomen was opened along the left linea semilunaris, and a stone was easily felt in that middle part of the ureter that had not been explored in the previous operation. With the hand in the abdomen, the stone was pressed upward to the crest of the ilium, and through a small incision in the side the ureter was exposed and the stone removed.

i New York Medical Record, October 18, 1890. 2 London Lancet, November 8, 1890.

The opening in the ureter was closed with a fine continuous silk suture, and the wound quickly closed without any urine leakage.

Cabot. This case is reported in the body of the paper.

MEDICAL GYNECOLOGY.

BY JAMES H. ETHERIDGE, M.D., PROFESSOR OF GYNECOLOGY IN THE RUSH MEDICAL COLLEGE ; PROFESSOR OF GYNECOLOGY IN THE CHICAGO

POLYCLINIC; ATTENDING GYNECOLOGIST TO THE PRESBYTERIAN HOSPITAL

The tendency of to-day is toward specialties in medicine. The specialist is too much inclined to become confined to his branch of study and to ignore the human system as a whole, unless he has been well grounded in general practice of several years' duration.

The most successful specialist is he who is a good general practitioner, from whose practice has grown his special work. The best all-around gynecologist is he who has been and is a good general practitioner. It can be safely laid down as a postulate, that the gynecologist who is incapable of weighing in the balance carefully the necessity for increasing or restraining the organic functions of secretion and excretion with their infinite permutations and combinations incident to disorder and health, is one who will do a great many things that ought not to be done, and will leave undone many things which ought to be done, for the best interests of the patient.

The design of this paper is to enumerate some of the things that can at least interest the gynecologist. How well they will be enumerated remains to be seen. The writer can say, that a careful regard for them added to gynecological treatment has made the practice of gynecology comparatively an easy matter, and that he has seen almost numberless illustrations of failures to treat patients successfully by ignoring the proper use of much needed medicines. No attempt whatever will be made to exhaust this topic. The barest epitome is all that can be expected. It is desired to deal with the symptoms and conditions continually seen in gynecological patients-symptoms and conditions which are perhaps not of gynecological origin, but which are almost inseparable from such patients. The writer is perfectly aware that it is is incon

1 Boston Medical and Surgical Journal, December 25, 1890.

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