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left ureter was suspected, but the diagnosis was obscure, and the location of present, uncertain. No abnormality of the urine could be discovered after repeated examinations. The day before the operation a careful exploration had failed to reveal the presence of any tumor whatever. To clear up the diagnosis, an incision in the median line was made and a cyst larger than the doubled fist found immediately below the left kidney. At the lower extremity of the cyst a stone was felt in the ureter. Without removing the left hand from the abdominal cavity, a lumbar incision was made, and the pelvis opened, allowing the contents of the cyst, about a pint of urine, to escape. But it was found impossible to grasp and remove the stone through the pelvis. Accordingly an opening was made through the kidney by means of a longitudinal incision along the convex border, the incision extending to within a half inch of each extremity, and finally, with the left hand still in the abdomen as a guide, the stone was dislodged and removed through this opening. A rubber drainage tube was introduced through the lumbar incision into the kidney. This was retained for eight days, and for four days longer urine passed freely through the lumbar opening. On the twenty-first day the wound was fully healed, the recovery having been uninterrupted.

The stone was found to weigh 3 7-20 grains. It was in the form of a section of a cylinder. It would have perfectly occluded the ureter had it not been for a very small slot at one margin just large enough to allow the urine to trickle through under normal conditions. But if a fragment of mucus were to be caught in this narrow opening, temporary obstruction would be produced with intense pain for a few hours until the obstructing body was dislodged. The reporter was positive that the cyst was not present the day before the operation. Shortly before the patient began taking the anesthetic she told him that if he would wait two hours, an opportunity would be given him to see her in one of her attacks. The rational conclusion is that the slot in the stone had been obstructed by a plug of mucus, between the examination of the previous day and the time of the operation.

This seems to be an admirable method of attack for an obscure case of this kind, since the abdominal incision gives an opportunity to make an exact diagnosis. A hand within the abdomen can render much valuable assistance by making the parts involved more accessible to the lumbar incision. The amount of hemorrhage from an incised kidney is considerable, and why a simple longitudinal incision was not made over the stone, just sufficient to permit of its extraction, and this followed by immediate suture is not clear.

An interesting example of the extraction of a ureteral calculus through the bladder was reported by Prof. Helfinch, of Griefswald, at the last meeting of the Congress of the German Surgical Society. The operation was done primarily for vesical calculus, but after the removal of a very large stone from the bladder by the supra-pubic route, the examining finger felt a small incrusted spot on the posterior wall. More careful investigation showed this to be another stone in a diverticulum. After much labor the stone was dislodged and extracted. Its removal was followed by the dis

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charge of a quantity of ill-smelling pus, and with it three smaller rounded facetted stones. It was then found to have been situated in the dilated lower extremity of the left ureter. Prompt recovery followed the operation, but the patient died 72 months later of a complicating disease of the kidney.

III. STRICTURE OF THE URETER.

The most promising method of dealing with stricture of the ureter seems to be the plan devised by Christian Fenger. It involves the same principle as the Heinecke-Mikulicz operation for simple stricture of the pylorus, longitudinal incision into the ureter through the stricture and suturing so that when the stitches are tied they form a transverse wound.

IV. URETERAL ANASTOMOSIS.

It was nearly three years ago that R. Harvey Reed demonstrated that the ureter can be successfully implanted into the rectum. The criticism against this operation, that it opens the door to an ascending fecal infection, has been proven to be well founded. But in the class of cases in which Reed especially advises the operation, viz: cases in which the bladder has to be removed for disease, or in which constant irritation is caused by the presence of the urine in incurable disease of the bladder, almost any means of relief would be hailed by the sufferer, no matter how great the risk. This is probably the only legitimate field for rectal implantation.

The most notable advance that has been made in the surgery of the ureter recently was contributed by Dr. W. Van Hook, of Chicago. By a series of experiments upon dogs, Van Hook developed a method of suture by which firm union without stricture can almost be assured. It consists of invaginating the proximal end of the ureter into the distal end, through a longitudinal slit in the side, and holding it there with catgut sutures-the distal end having first been ligated.

Already one brilliant case has been reported where the use of this plan of suture was followed by ideal success. The history of Dr. Howard A. Kelly's case is so well known that an extended report of it now would be superfluous. Briefly, while doing a myomectomy, Dr. Kelly accidentally ligated and severed the right ureter. After completing the operation, the two ends were united by the Van Hook method. The patient passed urine on the second day and made an uninterrupted recovery. This is the only case thus far reported, which has come to my knowledge. But this perfect result places this procedure among the recognized methods whenever this accident is confronted.

The same accident happened to Florian Kong while operating for a fibroid, and he anchored the proximal end of the severed ureter into the bladder by an ingenious application of the Van Hook method of doing lateral implantation. The patient's convalescence was without more accident than is to be expected after the extirpation of a fibroid, and she is reported to be in perfect health, and doing hard work. Subsequently a cystoscopic examination proved the patency of the ureter.

The same procedure has been adopted by Penrose, of Philadelphia, and with an equally satisfactory result. The only difference was that in Pen

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rose's case an inch of the ureter was voluntarily excised on account of being involved in a carcinoma extending from the cervix uteri. Judging from these results when the ureter is divided low down so that the proximal end is within reach of the bladder the surgeon has the choice between lateral anastomosis after Van Hook and implanting into the bladder.

When these cases were under discussion by the Philadelphia Obstetrical Society, Dr. Joseph Price stated that he assisted Dr. Cushing, of Boston, to switch a ureter into the bladder. Also, that he had in one case severed a ureter and had a fistula following. In that case he made a triangular flap in the bladder and switched the ureter in. It was a success. In another case he had an accident with both ureters and switched both into the bladder, with success on one side, and had to do a subsequent operation for the other side. He reported the patient in excellent health. It is to be regretted that no more detail is given of the method employed inthese cases.

Dr. Price also reported two cases of suture of the ureter, with one success and one death. His method is to split the divided ends and, by means of a suture, to pull the proximal end into the distal, there to cover over with fine stitches.

V. URETERAL FISTULA.

According to statistics collected by Fenger, out of 34 cases of fistula of ureter whose histories he had been able to collect, the condition was remedied by plastic operation in 11 cases, by kolpo-kleisis in 7, hystero-kleisis in I, and nephrectomy had to be resorted to in 15 cases. Thus it will be seen that 44 per cent of the cases were doomed to nephrectomy with all the immediate dangers and the remote dangers to which the possessor of only one kidney is always subject. The method of Van Hook and the device of Krug and Penrose could be used in almost all cases of uncurable fistula of the ureter. The operation of choice is probably bladder implantation of the proximal end after severing the ureter just above the site of the fistula. If too far from the bladder to comfortably reach excision of the portion of the ureter containing the fistula and uretero-ureterostomy after Van Hook would give excellent promise of cure.

VI.-WOUNDS AND RUPTURE OF THE URETER.

Direct injuries to the ureter are very rare. Fenger states that Tuffier found only five cases in literature. Three of these were incised or punctured wounds and two gun-shot wounds. All occurred before direct treatment by suture had been thought of. I see no reason why such cases should not be amenable to treatment by lateral implantation after excision of the wounded section; or, as Van Hook proposes, when the entire calibre is not involved, by cutting upward and downward longitudinally, trimming off the lacerated corners of the wound, and suturing after Fenger's method for stricture of the ureter.

Ruptures of the ureter, usually caused by a blow upon the abdomen or lumbar region, seem to be much more common than direct wounds. But unfortunately the diagnosis is usually not made until days and weeks have elapsed. Large accumulations of urine at the site of the rupture are often

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the first intimation given of the nature of the injury. To indicate the difficulties attending the diagnosis of these cases as well as to outline the treatment which they have usually received, I cannot do better than to quote briefly from the history of a case reported recently by Herbert W. Page, of London:

A boy of five years was knocked down and run over by a light vehicle. There was nothing to arouse suspicion of the serious nature of the injury until three weeks after the accident, when the temperature rose and abdominal tenderness became marked, with swelling and dullness on percussion in the right iliac region. About ten days later a distinct tumor had developed and, by means of an abdominal incision, forty ounces of a fluid, which proved to be largely urine, were evacuated. It was behind the peritoneum and gave a strong presumption that there was a rupture of the ureter. But the location of the rupture could not be found, and it was vainly hoped that the opening into the ureter would close without further interference. The child's condition grew worse, and at last nephrectomy was resorted to to save the boy's life. The kidney was found to be enlarged to three times its natural size, and the pelvis contained semi-purulent urine. In all such cases, even at so late a stage, if the seat of the rupture can be found, suture would be indicated by the Van Hook method. But unfortunately, the exact location of the rupture is often very difficult to find.

VII.—HYDRO NEPHROSIS AND PYO-NEPHROSIS.

Whenever a surgeon meets with a case of hydro-nephrosis or pyonephrosis, it at once arouses a query. What is the cause? Is there a stricture of the urethra, an enlarged prostate, or atony of the bladder, causing obstruction from below? Had he a case of vesical calculus or cystitis with an ascending infection to deal with? Is the disease caused by a stone in the kidney or pelvis? Or is the condition due to valve formation, stricture or stone in the ureter? He does his duty best as a surgeon who addresses himself most carefully and most intelligently to finding a proper answer to the above questions. Hydro-nephrosis and pyo-nephrosis should not be looked upon as idiopathic diseases any more than peritonitis is now looked upon as an idiopathic disease. They all have their causes, and in the vast majority of cases the cause is removable. It is my opinion that many of these cases would be susceptible of cure after the cause has been searched out and removed, and, if not too far gone, a functionating kidney be left. It is always well to remember that the man or woman with but one kidney has a very uncertain hold upon life. Every thing may go along smoothly for a time, but the slightest accident or the chilling of the body, an inter-current disease, as an acute fever, pneumonia, etc., is very likely to end fatally.

What means shall be employed to arrive at a satisfactory solution of the cause? First the urethra and bladder should be interrogated in the usual manner. If nothing abnormal is found a careful use of the cystoscope may be of incalculable service, especially in arriving at a certain knowledge of the relative condition of the two kidneys. If the patient is a woman the ureteral catheter can be used, and the ureter may be palpated from the vagina or rectum.

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Next where is the seat of the pain, if any; its nature? Is it constant or intermittent? If the symptoms point directly to the kidney itself, an incision over that organ and careful palpation for stone, with aspiration of the fluid would now be in order. If satisfied that the secreting area is entirely gone no hesitancy need be had about its removal.

Now having arrived at the point which it is especially desired to make, and having freed the urethra, bladder, and kidney itself from suspicion, the logical conclusion is that the ureter is the culprit. But where in its course? That is the difficult question to answer. Where careful search has fastened the blame thus upon the ureter, I believe the surgeon is justified in opening. the abdominal cavity by a small incision either in the median line or in the linea semi-lunaris of the side affected, introducing the hand and palpating carefully the course of the ureter from the kidney as far down as possible. If the cause is found to be a stone, valve formation, stricture, a mass of adhesions causing obstruction to the flow of urine, the left hand can remain in the abdominal cavity as a guide, and an incision can be made from behind and the trouble dealt with extra-peritoneally in the manner adopted by Dr. Hall in his case of ureteral stone. By adopting these expedients there is little doubt that many kidneys, such as heretofore have been doomed to extirpation, could be retained with partial or complete secreting. power.

MISSISSIPPI VALLEY MEDICAL ASSOCIATION.

The Twenty-first Annual Meeting of the Mississippi Valley Medical Association will occur in Detroit, Mich., September 3, 4, 5, and 6, 1895. This Association is now in a more prosperous condition than ever before. The membership list shows a large increase annually, and the character of the scientific work accomplished at each meeting is of the very highest. The Officers and Committee of Arrangements are working unceasingly for the success of the Detroit meeting, and, although early, indications are that a meeting of unusual size and interest will be held in September. The profession of Detroit are united in their efforts to have the gathering in their city outshine all previous ones. The social features of the meeting will leave nothing to be desired in that direction.

A meeting of the Officers, Committee of Arrangements and Auxiliary Executive Committee was held in St. Louis in April. The prominent railroads were all represented at this meeting, and the railroad officials present promised a united effort to obtain a half-fare rate to Detroit.

It was decided to make the annual addresses a special feature of the meeting, and Dr. Wm. Pepper, of Philadelphia, will deliver the Address on Medicine. September was chosen as the time of the meeting, for two First, because the medical colleges will not have opened, and opportunity will thus be given those connected with these institutions to be present; second, because this is the most delightful time of the year in which to visit the beautiful City of Detroit.

A cordial invitation to attend is hereby extended to the profession by the Executive Committee. Titles of papers should be presented to the Secretary as early as possible.

W. N. WISHART, M. D.,
President.

Fraternally,

FREDERICK C. WOODBURN, M. D.,
Secretary.