ation the lumbar spindle is over-fed by congestion from the arteria ureterica proximal. The The walls of the lumbar ureter hypertrophy and the lumen increases but in cessation of the function of the uteroovarian artery, and consequently the arteria ureterica proximal, the lumbar ureter (especially the spindle) suffers degeneration from lack of nourishment. The ovarian segment of the utero-ovarian artery crosses obliquely ventral to the ureter at slightly different levels, right and left, at the transverse processes of the third to the fifth lumbar vertebræ. The ovarian arterial segments arise from the ventral surface of the aorta at about the same level. ovarian veins arise differently and assume for a part of their course a different route, differing on the right and left side. The right ovarian vein, which terminates at a point in the vena cava distal to the hilus renalis, crosses the ureter at about the same level as the right ovarian artery. The right vein and artery are practically parallel. The ovarian vein of the left side, terminating in the left renal vein, continues almost parallel to the left ureter during its lumbar course. It crosses the ureter near the distal renal pole, generally more proximalward than that of the right. The vein and artery on the left are not so much parallel as that of the right. The relations of the vasa ovarica to the lumbar ureter are extensive, practically remaining externally parallel subsequent to the point of arterio-ureteral crossing. The vasa ovarica course about half an inch external to the lumbar ureter, and send nourishing branches to it for some two inches. This is in the region of the external ends of the transverse processes of the third, fourth and fifth lumbar vertebræ, between which and the ureter the ovarian artery takes its course. The vasa ovarica follow the course of the vasa mesenterica superior, especially on the right side. A septic ureter may infect the left ovarian vein, which is intimately associated with the left ureter. The sepsis may pass through the ureter, infecting the vein, producing thrombosis and finally emboli, from which cause I have noted death. nificance. The position of the tractus intestinalis not being bilaterally symmetrical, the passage of vessels in relation to the ureter will not be bilaterally symmetrical, The uretero-intestinal vessels are complicated in relations, and this is increased by the varying mobility of a large segment of the tractus intestinalis. The vessels of the tractus intestinals have both direct aud indirect relations with the ureter, i.e., they may pass directly in contact with the ventral surface of the ureter or be separated from it by two layers of peri toneum. The vessels of practical medical and surgical importance of the tractus intestinalis in relation to the ureter insinuate themselves between the ventral surface of the ureter and the dorsal surface of the peritoneum. The great curves or anastomoses of Haller, i. e., the anastomoses between the arteria mesenterica superior and inferior, belonging chiefly to the colon transversum, have indirect relations to the ureter. (a) The arteria mesenterica superior has direct relations to the right ureter and direct relations to both right and left. The vasa ileo colica dextra cross directly ventral to the surface of the lumbar ureter about its middle. However, the right colic vessels extend into the iliac fossa subsequent to crossing the ureter. The vasa ovarica dextra cross the ventral surface of the ureter at almost the same level as the right colic vessels, hence here several orders of vessels are superimposed. It would be dangerous surgical procedure to attack the middle of the lumbar ureter from the ventral surface through the peritoneum. The lumbar ureter may be attacked safely from the dorsal surface, as the ureter and peritoneum, with the vessels of the tractus urinarius and tractus intestinalis between them, may be forced ventrally, whence the ureter may be safely manipulated. The vasa ovarica and vasa ileo colica dextra cover almost the entire length of the surface of the right lumbar ureter. The arteria colica dextra and arteria colica media possess only indirect relations to the right lumbar ureter. (b) The arteria mesenterica inferior has direct relations with the ventral surface of the left lumbar ureter and indirect relations with both right and left ureters. The uretero-intestinal vessels are complicated in relation to the left ureter. Practically FIG. 8.-Dorsal abdominal wall demonstrating the relations of the ureter to vessels. On the left the kidney lies within the arc of Treitz and right kidney lies external to all vascular arcs. This kidney demonstrates the safety of approaching the kidney from the dorsal side. This cut illustrates the bilateral ureteral vascular relations in the lumbar segment, due to the ramifications of the arteria mesenterica superior and inferior, and that the lumbar ureter should be approached from the dorsal side. (Author.) its artery, courses between the artery and the ureter. It may pass well median to kidney, describing its terminal cross. The vein courses more irregular than the artery, and sometimes the vein passes on the ventral surface of most of the lumbar ureter-say from the fourth lumbar vertebra. It passes transversely across the distal renal pole. At about the level of the fourth lumbar vertebra the inferior mesenteric artery ter is crossed by the vasa ovarica, the arteria sigmoidea and arteria colica sinistra complicating surgical procedures on the ureter from the ventral or peritoneal surface. In fact, the ureter may be difficult to recognize, and gangrene of the colon or ureter may arise from damaged blood supply to either. The left lumbar ureter may be attacked safely from the dorsal surface, whence the ureter and vessels of the tractus urinarius and tractus intestinalis may FIG. 9.-Dorsal abdominal wall showing the vascular relations to the ureter. The enteron is thrown to the right. This cut demonstrates the relation of the left ureter to the arteria hemorrhoidalis superior (8), arteria sigmoidea (7), and the boundaries of the colica sinistra (6 and 2). Note how dangerous it is to approach the lumbar ureter from the peritoneal or ventral surface. K, kidney. Ur, ureter. 4, origin of arteria mesenterica inferior. Kidney (left) rests in the arc of Treitz. 9 connects the arteria hemorrhoidalis superior to the arteria sigmoidea (7). Figs. 6, 7 and 9, suggestions from W. Waldeyer were employed in the drawings. (Author.) to the lumbar ureter is non-symmetrical. The left lumbar ureter is much nearer the aorta than the right. Surgical relations between the aorta and lumbar ureter are seldom complicated. 5. The relation of the vena cava inferior to the lumbar ureter is intimate and is apt to complicate surgical procedures. The lumbar ureter on the right side is much closer to the vena cava than that of the left side, because the vena cava is situated lateral to median line. In the order: (1) Peritoneum; (2) vasa mesenterica inferior and superior; (3) the arteria colica sinistra et dextra; (4) the vasa ovarica; (5) ureter. The left ureter is easier to expose from the ventral side than the right, because the left colon leaves it more free than the right. However, the complexity of the vascular relations of the left ureter, due to the presence of the vasa mesenterica inferior, can render its exposure difficult and dangerous. Gangrene of the left colon has been reported from damage to the peritoneal relation is almost direct for the colic vessels. IV. THE RELATION OF THE LUMBAR URETER TO THE NERVOUS SYSTEM. The relation of the lumbar ureter to the nervous system involves (a) the sympathetic, and (b) the cerebro-spinal nerves. (a) The sympathetic nerves to the lum bar ureter come from the abdominal brain (ganglion Coelicum). The predominating nervous system is the sympathetic, as the ureter possesses rhythm. They exist as chords and ganglia. The lumbar ureter lies lateral and ventral to the lateral chain of the sympathetic. The left ureter lies near the aorta, which is surrounded by large plexuses of nerves. (b) The relation of the lumbar ureter to the spinal nerves is important clinically and surgically. The psoas muscle separates the lumbar ureter from the ventral branches of the lumbar plexus. The lumbar nerve plexus is imbedded in the substance of the psoas. The ureter is in relation with the (1) external cutaneous nerve, which perforates the psoas near its external border at the fourth lumbar vertebra. The ureter is in intimate relation with (2) the genitocrural nerve, which emerges on the ventral surface of the psoas muscle near the vertebral insertion. It courses along the median border of the ureter. The ureter and genito-crural nerve is important clinically because of its alleged relations to pain in the inguinal and crural region during the crisis of marked cases of nephroptosis. The above two nerves are located dorsal to the iliac. (3) The ureteral relation with the anterior crural nerve is less intimate. (4) The ilco-inguinal nerve, and (5) the ileo-hypogastric nerve have still more distant relations. V.-RELATIONS OF THE URETER TO THE TRACTUS LYMPHATICUS. The peritoneum (facies peritonei ureteris). In some spare subjects the ureter forms a relief with the peritoneum-a kind of meso-ureteris, seldom visible except in spare subjects. The strong fibers which connect the peritoneum and ureter are dependents of the fascia propria, in the thickness of which the ureter is located. In the female the adipose couch can project itself ventral to the ureter, rendering its separation from the ureter easier. This lumbar ureter only, as in other ureteral segments more organs intervene between ureter and peritoneum. In the lumbar segment the peritoneum is not only extremely mobile on the ureter, but the ureter is extremely mobile in its universal cellular bed, endowing the lumbar ureter with remarkable mobility. However, it is important to know that even with remarkable ureteral mobility the ureter is adherent to the peritoneum by certain fibrous strands which are strong enough to draw the ureter after the stripping peritoneum, and it also has these fibrous strands retain the ureter and peritoneum in relation to blood-vessels for nourishIn surgical exploration the lumbar ureter and peritoneum act as one organ when forced ventral from the dorsal subserous tissue which remains bound together. The extensive range of lumbar ureteral mobility within the zone of health is useful in surgical interventions, as one can draw the lumber ureter through an abdominal incision for inspection, palpation, treatment or surgical repair. The ureter has more intimate topographic relations with the peritoneum than any other viscus. The peritonenm and ureter are connected by a limited number of fibres for the whole course except the proximal and distal extremities. The ureter will cling to the peritoneum while stripping it from the dorsal wall. The ureter is quite intimate as it courses adjacent to the glandular mesenterica, the cysterna lymphatica magna and the lymphatic duct. Occasionally the ureter becomes adherent to a lymph node, and I have observed ureteral kinks and dilatations from this cause. D. Idiotopy (relation to its component segments.)-The idiotopic relations of the lumbar ureter consist mainly in the differences of caliber as the constricted portions obstruct calculi while the dilated portions tolerate, entertain, calculi. The dilated lumbar spindle, from ample wall and liberal lumen, is the location of selection for ureteral surgical intervention. The lumbar ureter consists of (a) fusiform spindle (one-quarter to one-half inch in diameter in its central portion); (b) of an elongated narrower proximal extremity (one-seventh inch diameter); and (c) a shorter, blunter distal extremity. FIG. 10.-Topography of the lumbar ureters with plan of the genital circulation. On the right side the utero-ovarian artery with its two arterio-ureteral crossings may be observed. On the left side the utero ovarian vein is noted. Observe the three ureteral dilatations, the three ureteral constrictions and the three arterio-ureteral crossing on the common iliac on the ovarian and uterine. The author's genital vascular circle is here plainly observed. The proximal extremity, neck or proximal isthmus is in relation with the distal renal pole and ureteral pelvis. It is with the exceptian of the distal ureteral vesical isthmus the narrowest portion of the ureter (one-tenth of an inch in diameter). Calculi lodge at the proximal ureteral ishmus, and at this location ureteral kinks, flexures and torsions are liable to arise, giving obstruction to the urinal stream, resulting in temporary or permanent hydro-nephrosis, pyonephrosis. The neck of the ureter is so narrow that if the ureter be injected with melted paraffin fractures, or ureteral bendings almost always occur at the neck from manipulations. (Author.) The distal extremity of the lumbar ureter consists of a short blunt cone. The uriniferous tubules possess similar irregular dilatations and contractions, as microscopic sections demonstrate. The tubules of the Wolffian body show typical contractions and dilatations. The lumbar spindle is larger in animals which stand or sit erect most of the time, as man, apes, baboons. Hence the large lumbar spindle is a Wolffian body heritage enhanced in size, due to the erect attitude. The iliac arteries kink the ureter and offer obstruction to the urinal stream. Mammal's ureter show distinctly spindles, as my X-ray and paraffin casts clearly demonstrate. The buffalo |