extension of a lesion of the renal pelvis, or it may suffer from invasion by way of the bladder. In some severe types of urethral stricture with retention of urine dilation of the ureters occurs. Fig. 104 illustrates such a condition. This principle is applied in the treatment of calculi retained in the ureter, and it has been suggested that the bladder be distended with some warm fluid;

Fig. 104. Showing dilation of the ureters and pelvis, with excavation of the pyramids, caused by long-standing stricture of the membranous urethra (one-third natural size) (specimen from the Museum of Carnegie Laboratory).

the walls of the ureters might thus be increased in diameter, permitting the stone to pass through more easily.

Tuberculosis may attack the ureter as the result of the extension downward of tuberculous disease of the kidney, or by an upward extension from a similarly diseased bladder. The

process is said occasionally to give rise to distention of the ureter or to its obliteration by stricture formation.

Much has been written about kinks in the ureters, particularly in connection with floating kidney. The so-called Dietl's crisis, described elsewhere, is believed to be due to this cause, a belief that is not fully borne out by postmortem findings. The writers explain the occasional occurrence of this symptom-complex as being due to spasmodic contraction of the ureter under certain nervous stimulation similar in nature to like spasmodic contractures of the urethra or esophagus. These contractions are believed to be accelerated or inaugurated by any slight local lesion that exists in the ureter. In some cases the gravid uterus may press so severely on the ureter as to cause obstruction or even serious damage to the tube.

Not infrequently the ureter is the seat of stricture or fistula, the result of injury inflicted on the tube or adjacent tissues during operation or from the passage of stone. The fistula due to injury of the ureter following operative procedures manifests itself by the presence of the perforation either at the site of the original wound, or perhaps in some other structure of the body by the discharge of urine. Wounding of the ureter during the course of an operation is generally made apparent by the immediate presence of urine in the wound. The ureter is occasionally tied during an operation, particularly on the uterus or its appendages. If both ureters have been ligated, there is an immediate cessation of the urinary flow. On attempting to pass a ureteral catheter an obstruction will be encountered, which, together with the total suppression of urine, will generally disclose the condition. Fortunately, in such cases, when the wound is reopened and the ureters are freed, they will ordinarily resume their function even if the constriction has existed for several hours. If only one ureter has been tied, and the condition remains unrecognized, hydronephrosis ensues. If the ureters have been tied off but a little distance from the kidney, this will probably manifest itself in a few days by the occurrence of a swelling, owing to the distention caused by the retained urine in the kidney; or, on the other hand, there may be marked distention of the ureter, giving rise to a tumor that, on being opened, will be found filled with urine.

Wounds of the ureter discovered or inflicted during operation may be immediately sutured, with or without the introduction of a ureteral catheter. In suturing wounds of the ureter that have been made for the removal of calculi, great care should be exercised not to penetrate the mucosa of the tube. Fine silk ligatures, which may afterward be buried in the tissues, or any very rapidly absorbing catgut, may be used. In such cases it is well to leave a drain at the angle of the wound for a few days lest leakage occur. In such a case recently under the writers' care a ureteral catheter was allowed to remain with its extremity in the pelvis of the kidney for thirty-six hours, after which it was removed; no further leakage occurred. The treatment of wounds is again referred to in the chapter on Surgery of the Ureters.

When a stone in the ureter has become impacted and makes no further progress toward the bladder, it may occasionally be pushed up toward the kidney and thus easily reached through a lumbar incision. The various operative procedures for the relief of diseased conditions of the ureters will be described further on; it remains to consider here briefly the methods of inspection of the ureters as an aid to the diagnosis.

Diagnosis. The value of the x-ray and ureter catheterization for diagnostic purposes is so well known as to require nothing but mention here. Palpation of the ureters when carefully practised is occasionally of considerable aid in diagnosis. In the chapter on Diseases of the Kidney the valuable aid that may be obtained from palpation and massage along the course of the ureters in the diagnosis of pyuria has been mentioned. Other things being equal, it follows that a bimanual examination of the ureters may be more easily made in a thin than in a stout subject. Continual practice, however, will increase the skill of the examiner.

It has been claimed that, by the introduction of a finger into the rectum above the prostate, diseased conditions of the ureters can sometimes be detected. The writers have never been able to determine to their satisfaction that a lesion of the ureter could be thus accurately differentiated from an enlarged and diseased seminal vesicle. This method of examination is, however, recommended by some. In a woman it may be possible, with one hand on the abdomen and a finger in the anterior vaginal culdesac, to out

line a swollen ureter, but great care must be observed not to confound this condition with some diseased state of the ovary, tube, appendix, or intestine.

As has been said, the two greatest aids that are at our command in diagnosing diseased conditions of the ureters are ureter catheterization and the x-ray, or a combination of both.

The x-ray, in the hands of one skilled in its use, will sometimes demonstrate the presence of a stone in the ureter very clearly. Some admirable specimens of this work have been made, illustrating the passage of the stone down the ureter into the bladder. The pictures were taken in frequent succession, and showed the stone in many positions in the ureter as it proceeded on its journey. A good illustration of the aid to be obtained from a combination of the two methods was the taking of an x-ray picture of a subject in whom a metal ureteral catheter had been introduced from the bladder into the kidney. The metal catheter was distinctly seen in the picture, and outlined the course of the ureter very clearly. It is doubtful, however, if the adoption of this procedure as a routine practice for the determination of the movability of a kidney, as recommended by some, will ultimately be of great value. Metal catheters, after all, must be used with considerable care in the ureters and are not to be employed in all cases, but, as has been mentioned under the head of Floating Kidney, metal catheters introduced through the ureter into the kidney, followed by the taking of a radiograph, are very helpful in those cases in which it is necessary to differentiate between a floating kidney and a new-growth.

CHAPTER XVIII

SURGERY OF THE URETERS AND FOR THE RELIEF OF HYDRONEPHROSIS

Much has been written in the text-books on surgery regarding the various routes by which the ureters may be reached. For practical purposes, the lumbar inguinal incision, as illustrated in the cut (fig. 105), will enable one to find the ureter in most any portion of its course. The incision may be begun just below the twelfth rib, or further along toward the inguinal region, and may be prolonged as far as necessary, the peritoneum, when met with, being pushed ahead of it. The ureter may also be reached through an abdominal incision, in much the same manner as the kidney is reached; or by finding the posterior wall of the bladder, the ureter may be followed along its course.

Statistics show that the best results are obtained if the ureter

can be reached by the extraperitoneal route. The increasing facility with which ureter catheterization can be performed, being often a comparatively simple procedure, will aid one in finding the canal if a ureteral catheter has been introduced previous to the operation. Gynecologists, in operating on ovarian tumors, will undoubtedly find this of service, since by its use, in certain cases, wounding of the ureter may be avoided.

For purposes of description operations on the ureter may be divided into three principal classes: (1) Operations involving the opening of the ureter into the kidney; (2) operations concerned with the portion of the ureter that opens into the bladder; (3) operations for wounds of the ureter or for the removal of stones from, or for the relief of strictures of, the ureter.

CLASS I. The operations coming in this class are most generally practised for the relief of renal retention of urine. Several of the conditions in which these operations are indicated are shown in the illustrations. In some cases the pelvis of the kidney becomes so greatly distended as the result of hydronephrosis that almost the entire length of the ureter has to be resected