Various means have been adopted for collecting the urine as it escapes from each ureter into the bladder. One of these consists in the employment of ureteral catheters, and another in the compression of one of the tubes and the examination then of what escapes from the opposite kidney. I cannot say that either of them is generally practical. A reference has been made to this means of diagnosis in the section on the surgery of the kidney.
The most frequent form of obstruction in one or both ureters un doubtedly is that produced by the impaction of calculi in their tran sit from the kidney to the bladder. In cases where the urinary ap paratus is normally disposed, apart from the symptoms indicating this, such an occurrence may bring about, when one ureter is in volved, the ultimate destruction of the corresponding kidney, or when both tubes are similarly implicated, the speedy death of the individ ual from what has been called obstructive or mechanical suppression of urine. In cases of the latter the course of events as gathered from records, as well as from some instances I have met with, is usually this : There is a bygone history of one or more attacks of renal colic, followed, perhaps, by the escape of kidney calculi. The recollection of a paroxysm of nephralgia where no stone was passed may be sig nificant. During one of these occasions, however, a stone becomes impacted in the ureter, and the corresponding kidney is eventually destroyed by absorption or disintegration. In the lapse of time the opposite organ undergoes a compensatory hypertrophy and the entire excretion of urine is thus provided for. So far all this might happen without necessarily exciting much attention; the symptoms of renal colic disappear as the calculus is rendered immobile in the ureter, blood ceases to be found in the urine, and ultimately the fact that the patient has gradually lost a kidney fails to be apparent. In time, however, the enlarged remaining kidney becomes the seat of stone formation as in the former case of the lost organ, and again a renal calculus becomes firmly fixed in its ureter. This of course neces sarily means a more or less complete suppression of urine according to the position occupied by the stone in the ureter. The fact may be briefly stated that one kidney has already been destroyed and the other is now blocked mechanically. When the whole history of a case of this nature is reviewed and summed up, there can be but little difficulty in coming to a conclusion as to what has occurred.
Let me illustrate the pathological details of a case of this kind from some well-authenticated source. Sir William Roberts records the following account of the post-mortem findings in a case where an obstructive suppression of urine had proved fatal in the course of nine clays and a half : That cases of this kind and others which might be mentioned should have directed the attention of surgeons to the matter is not surprising. The occurrence of death from a comparatively slight
and so removable a cause as I have just illustrated would hardly be likely to pass without comment in these days, when so many of the difficulties connected with exploratory surgery are now removed by anesthetics and antiseptics. I will proceed to notice the practical aspect of such a reflection, and will do so more by illustration than by generalizing.
As I have already stated, in the normal disposition of the parts the fact that a stone has become impacted in a ureter and is leading up to the absorption or destruction of the corresponding kidney may easily pass by without recognition. Such a case" is recorded by Mr. Canton. On the other hand, this circumstance may declare it self by symptoms which in themselves are sufficient to demand surgi cal interference for their relief without regard to the important issue at stake so far as the future of the kidney is concerned.
What signs then would lead to the belief that one of the two nor mal ureters is impacted with a stone? Under what circumstances should an attempt be made surgically to effect the removal of the calculus, and lastly, what kinds of procedure may thus be under taken? It may be generally stated that a stone may be impacted in any part of a normal ureter; but by reason of its relations the liability to fixation is greatest where the tube enters the bladder. The diffi culty of determining whether a calculus has left the kidney and is still retained in the ureter is sometimes great. Usually the symp toms of the latter are less urgent. If, after renal colic limited to one side and attended with hoematuria, the pain becomes more fixed, less acute, and pressure with the grasp of the hand refers it to a precise area nearer the groin, while at the same time the presence of blood in the urine either entirely or in a great measure ceases, the prob ability that the calculus is retained in the ureter is considerable. Relative to beematuria, a stone fixed in the ureter will often act the part of a ligature. Of course where one kidney and its ureter are uninvolved in the calculous trouble, the question of suppression can not arise.
Amongst the more remarkable instances of calculus impacted in the ureter is one I had the opportunity of seeing with Dr. Rawdon, where the stone was felt by the finger in the rectum. The following are notes of the case :