There seems very little doubt that, as in the case of the urethra, longitudinal wounds of the ureter, provided only the drainage is sufficient, heal spontaneously without causing subsequent contrac tion. This is evident as the result of experiments on animals as well from what has followed accidental incisions, or those made into these tubes for the removal of calculi. And the same degree of treatment is applicable to those cases where the wound takes a transverse direc tion though it fails in effecting a complete severance of the •ureter; so long as the drainage is free, kindly and complete repair may be an ticipated without interference. In extensive transverse wounds of the ureter involving more than one-third of the thickness of the tube Van Hook concludes "that stricture by subsequent scar contraction should be anticipated by converting the transverse into a longitudinal wound and introducing longitudinal sutures." The technique is thus described: "Make two longitudinal incisions with small scissors in the ureter beginning at the middle of the wound to be closed. These incisions should be equal in combined length to twice the transverse diameter of the tube. Round off the sharp angles of tissue with the scissors and suture longitudinally with the object of producing a very wide instead of a very contracted lumen." The second method of dealing directly with wounds of the ureters is by "implantation," of which there are several varieties arising out of the difference in location of the injury. To implant a ureter into an isolated knuckle of bowel is found to be objectionable on the grounds that the operation is in itself too dangerous and the intes tine is not aseptic. The certainty with which a kidney may be thus infected by means of the intestinal gases has proved an obstacle in at tempts which have been made in cases of extroversion of the bladder to dispose of the urine in this manner. In injuries to the pelvic ureter during laparotomy, where the continuity cannot be restored or temporary vaginal implantation effected in the female, or vesical im plantation in the male, Van Hook advises that the proximal extremity of the duct should be fastened to the skin at the nearest point to the bladder. In injuries to its upper or lower end, the ureter may be implanted into the pelvis of the kidney or into the bladder re spectively.
Dr. Abbe " reports a case of ruptured ureter of an unusual kind. It happened in an instance of an exploratory operation on a man, by means of Kraske's operation, for what was supposed to be either an abscess between the bladder and the rectum, or a vesical pouch. During the manipulation a ureter was torn across. The sac proving to be a vesical pouch the ureter was implanted into the bottom of it and secured by sutures. The wound healed and the pouch shrank.
Dr. Abbe believed the patient would be permanently cured, as in this way the sac was kept flushed by healthy urine. This may further be regarded as a contribution to the treatment of vesical sac culation or pouching.
It should be stated that a case has recently been published which is at variance with the view that the insertion of a ureter into a viscus is objectionable on the ground that the corresponding kidney is likely to become diseased through contact with septic , gases. Chaput " re cords one successful case, as well as a fatal one, where an unilateral uretero-intestinal anastomosis was established in a case of uretero vaginal fistula. The ureter was exposed by an incision in the left iliac fossa and the peritoneal cavity was opened. The paper contains an interesting summary of the literature of this aspect of the subject, though it does not negative the objections to the practice I have stated.
Van Hook thus describes a meth od of dealing with a wounded ureter of a very ingenious character which was first suggested by Ludwig Rydygier. 1 am not, however, aware that it has hitherto been successfully practised: "He advises that in cases of injury to the ureter during surgical operations the two ends of the ureter be brought out through the abdominal wall and the wall be allowed to close about them. He would then prepare for the urine an artificial channel of skin by making two parallel in cisions between the two openings, suturing together the edges of the isolated piece of skin so as to form a tube, and depressing this tube by sewing over it the severed edges of skin drawn from each side." The changes which take place in the kidney conse quent on an impermeable or strictured ureter have already been re ferred to in connection with the subject of surgical disorders of the kidneys.