OBSTRUCTION OF THE URETERS.
I have already discussed how a ureter may be obstructed by a cicatrix following upon a wound as happens so frequently in the anal ogous case of the male urethra, the effects that may be thus pro duced in the kidney, and upon what principles the surgeon may pro ceed in the treatment of such a lesion. I will pass on to notice in what other ways the function of these tubes may be interfered with.
That a fatal result may suddenly be brought about by an obstruc tion of the ureter there can be no doubt. Dr. Fuller" records a case of this kind where a pyoneplirotic kidney burst into the abdom inal cavity, causing death by acute peritonitis. The ureter was found impacted with renal calculi.
The question has been raised in a paper by Mr. W. G. Nash," based on a preparation of strictured ureter in the Museum of St. Bar tholomew's Hospital (No. 2361 A), as to whether such a contraction can be caused by the extension of a gonorrhoeal inflammation to these tubes. If it were so, I think that we should meet with instances of this kind more frequently, and consequently that hydronephrbsis and pyonephrosis would oftener require surgical relief. Still, having re gard to the distance that this specific inflammation sometimes travels, as, for instance, in the female, I should not like entirely to put aside its possibility under the circumstances referred to.
That a stricture of a ureter may be caused by the cicatrix resulting from the ulceration produced by its temporary impaction by a stone, as well as by the scar following the healing of a tuberculous abrasion, there can, I think, be no doubt.
Notwithstanding that operations on the vesical openings of the ureters, either for catheterizing these tubes in the male or for drain ing them directly, would no doubt be now done through the medium of a supra-pubic opening, the following observations, which I made some years ago on the dead subject, with the assistance of Dr. Bar ron, may still find a place. Lateral lithotomy was performed on a middle-aged healthy male cadaver; the incision into the bladder was extended in front by opening into the membranous urethra with a probe-pointed bistoury, and behind by cautiously extending the cut into the prostate to almost its extreme boundary. On subsequently removing the parts, it was found that in this way a considerable opening could be made into the bladder without exceeding what I should regard as a safe limit. Though the opening just described permitted a free access to the bladder for the finger, yet no part of the mucous lining of the viscus could be inspected even with the em ployment of retractors. With the latter, aided by forcible pressure
downward with the hand over the pubes, a small portion of the fundus of the bladder could be brought within sight, but the orifices of the ureters could not be seen, nor could any instrument, such as a probe introduced into the bladder through the wound, be made to enter them. The cavity of the abdomen was then opened by a median incision above the pubes sufficient to permit of the introduction of three fin gers over the fundus of the bladder. By thus pressing the bladder down toward the perineal wound, the whole of its mucous surface could be brought into view, including the orifices of the ureters and the trigone. In one subject, by reason of some enlargement of the prostate, the view of the latter was imperfect. With the object of improving this, an endeavor was made to elevate the parts by the introduction of (1) two fingers up the rectum; (2) a lever, (3) the whole hand passed into the rectum. By the first two methods the view of the trigone was not improved, while the hand in the bowel, by occupying the whole space, obscured everything. When, how ever, there was no enlargement of the prostate, it was found possible, with the hand introduced into the abdomen, to bring all parts of the mucous surface of the bladder into sight, including that immediately behind the pubes. It was found easy to catheterize the left ureter, but the right required a little more looking for. By a bilateral sec tion of the prostate the search for the latter was facilitated, but the conclusion we came to was that with a natural prostate this addi tional incision was not necessary. It seemed not only possible to bring the whole of the mucous membrane of the bladder into view and within reach of manipulation, and to catheterize the ureters, but, further, with the hand in the abdomen to command all hemorrhage from the parts through which the deeper incision would probably pass. In a case I saw operated on by Mr. Rushton Parker, where the prostate was incised more freely than is usual, a circumstance which probably arose from the form of the calculus, almost the whole of the mucous membrane of the bladder could be readily seen, includ ing the orifices of the ureters, which might have easily been catheter ized. The patient was a boy, aged about twelve years, who made a good recovery.