STRICTURE OF THE URETER A POSSIBLE RE- eighths of an inch inside the ureteral orifice. The SULT OF LACKRATION OF THF CERVIX diagnosis was now established of a uroterovaginal fis- UTERI, AND URETEROVAGINAL FISTULA A tula of traumatic origin on the left side and of oblitera- RESULT OF TRACHELORRHAPHY.1 tion of that part of the ureter situated below the fistula. It was evident that one of the sutures or BY E. C. DUDLEY, M.D., CHICAGO, ILL. liga- tures, either ¡it the time of the original operation or FOB purposes of illustration 1 offer the following at the finie of the hemorrhage, had been passed around history of a case. All details not belonging to the sub- this ureter and had slowly cut it off or had so trans- jects under discussion are purposely omitted. The fixed the ureteral wall as to open it. One week after patient was thirty-seven years of age and married. the hemorrhage the sutures were removed. During The oldest child was twenty-one and the youngest one the following four weeks the nurse reported that the and a half years of age. Date of lirst. consultation discharge of urine through the vagina was not con- was March 29, 1899. stant. Urine apparently accumulated in the ureter Subjective symptoms.— In addition to the usual and pelvis of the kidneys and was discharged at, inter- symptoms of menorrhagia, mucopurulent uterine se- vals. Upon speculum examination about three weeks cretions, dysmenorrhea, vesical irritation, headache after the hemorrhage, the injured part of the vagina and nervousness, the patient, since the birth of the being exposed for thirty minutes, no urine was seen to first child, twenty-one years before, had suffered from escape. The patient, however, reported that urine pain referred to the left inguinal region ; this pain had sometimes been retained for three or four hours was of variable intensity, always annoying, often quite and had then escaped in considerable quantities through severe, and was the chief and significant subjective the vagina. symptom. On the 2d of June, thirty-five days after the hem- Examination. Examination of the pelvic organs, orrhage, with the purpose of performing some opera- in so far as it relates— to this discussion, gave the fol- tion to re-establish ¡i free communication between the lowing results: Uterus symmetrically enlarged from injured ureter and the bladder, I again etherized the endometritis and metritis, the canal measuring three patient. For more than three-quarters of an hour and a half inches in length. Position of uterus nor- with uterine tenacilla ¡uni ¡i line probe I sought in mal. Bilateral laceration, great circular enlargement, vain for the, point where the ureter opened into the cystic degeneration, erosion and eversión of the cervix vagina. No urine came through to mark this point, uteri. The cervical laceration on the left side was and even after some rather extensive dissection with extreme; it had extended far into the vaginal wall and the scissors 1 was unable to locate the fistula, nor was paraincfria and had healed by much cicatrization. I able to make out the ureter by palpation. Finally, The perineum was lacerated to the sphincter ani however, a little spurt of urine appeared just to the muscle. Uterine appendages normal. left of the cervix uteri, but I was unable Jit this point Operative treatment. April 20, 189!). The cer- to pass even a very fine probt;. Each attempt only — vix uteri and perineum were closed. The operation resulted in the making of a false passage—a thing on the cervix was that of Emmet, as- modified by difficult to avoid under such conditions. I then made Schroeder, and involved the resection of considerable a colpocystotomy,cutting with the scissors through the I issue from the thickened lips. The denuded surfaces vesicovaginal wall in the median line and in the long- at numerous points were quite hemorrhagic, so that axis of the vagina just in front of the cervix. The both in the cervix and perineum some difficulty was vesicovaginal fistula thus made was ¡in inch long. The experienced in the control of hemorrhage. upper extremity of it terminated close to the ¡interior Nine days after the operation there suddenly ap- wiill of the cervix uteri. With a pair of straight scis- peared dangerous hemorrhage from the vagina, and sors I then extended the incision upward and to the my interne, unable to find me, called one of my col- left as nearly as could be estimated to the point leagues, who promptly etherized the patient, and by whence the urine luid escaped. The object was if pos- the introduction of sutures under the bleeding points, sible to convert the lireterovaginal fistula into a uretero- close to the uterus, arrested the hemorrhage, and, as I vesicovaginal fistula; so'that the ureter si.Id open, think, saved the patient's life. Two days later urine not into the vagina, but into the margin of a vesico- began to pass voluntarily through the vagina. Fur- vaginal fistula. After another long search I again ther observation, however, showed that a part of it failed to lind the tistulous opening into the ureter, also passed normally and voluntarily through the until if was located by another spurt of urine, hut the urethra. This lead to the suspicion that one of the opening was too small to admit even a very line probe ureters was probably discharging urine directly into and therefore could not be entered. I then still fur- the vagina and the other into the bladder. Examina- ther enlarged the vesicovaginal fistula in a direction to tion of the vagina by means of Situs's speculum the left, of the uterus, and by good fortune opened showed ¡it the line of union to the left of the cervix into a very much dilated ureter, from which immedi- where the laceration had been most extensive an oc- ately there gushed two or three ounces of pent-up casional spurt of the urine. The attempt, however, urine. The dilatation explains the fact that I had been to pass a urétera! bougie from this point failed. Dr. unable to locate this ureter by palpation. A bougie Kolischer, who has great skill in electrocystoscopy, passed without obstruction to the kidney thereby proved kindly saw the patient with me at this time. lie dis- the absence of any constriction above. tended flic bladder with wafer and by means of ¡i Cas- The situation being now much simplified the fol- per cystoscope readily passed a bougie into the right, lowing procedures were adopted : The bladder mucosa ureter. The left ureter, however, was occluded, so was stitched to the vaginal mucosa all around the arti- that the smallest bougie would only pass about live- ficial vesicovaginal fistula. In this way the exposed surfaces were covered and controlled. A 1Read by invitation before the Boston Obstetrical Society, Decem- hemorrhage ber 19, 1899. hemostatio forceps, with handles about four inches

( The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at SAN DIEGO (UCSD) on July 5, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. long and with slender jaws about an inch long, was clamped by pressure forceps. In these cases, however, passed into the vagina and through the fistula. The the ureteral openings were much nearer to the tri- force]) jaws were then passed, one into the ureter and gone, and the lower extremity of the injured ureter the other into the bladder, so that the forceps when therefore was quite «lose to the bladder mucosa. In locked included in their bite, ureteral wall, bladder the case just reported the distance and amount of tis- wall and the connective tissue between. In this way sue between the bladder and ureter was so great that the lower extremity of the cut-oil' ureter was clamped it could hardly have been divided with the scissors into close relations with the bladder. 'The expecta- without danger of uncontrollable hemorrhage or of the tion was that the structures within the bite of the for- exposure, of broad surfaces to reunite, or to cicatrize ceps would be destroyed by pressure necrosis, and that and contract, or to suppurate. These difficulties were ¡i wide free ureterovesical opening would be established obviated by clamping the ureter into close contact ¡it a point somewhat distant from the artificial with the bladder so that when the forceps came off, opening into the bladder, and that in this way the case the exposed surfaces left by the necrosis would, owing would become one of uncomplicated vesicovaginal fis- to the compression, be of small extent. The com- tula. The forceps came off in about three days, pression forceps used in this way, therefore, may make and twelve days later the vesicovaginal fistula was the operation practicable in those regions where the closed by suture in the ordinary way. At the tissue between the ureter and the bladder is too abun time of this operation the new ureteral orifice diint to be safely divided by scissors. Howard Kelly,

was found to be perfectly open and very p.atu- in his recent book, describes an operation of switch- lous. The subsequent history was uncomplicated, ing the ureter into the bladder through an artificial union was complete and in a short time the patient was vesicovaginal fistula. I have proposed the operation discharged (aired. In a letter written about six just described in the hope that it will give the great- months after the filial operation the patient reported est security against subsequent stricture at the new entire freedom from the pain in the left, inguinal region ureteral orifice. from which she had suffered, and which had made Traumatic ureterovaginitl fistula as a result of her a semi-invalid for twenty years. I regret that the trachelorrhaphy is rare, but as a result of vaginal hys- ureter was not explored before the operation, and terrhaphy and other vaginal sections is not of infre- that it has not been practicable to obtain measurements quent occurrence. The operation above described is of it since. applicable to the condition, whatever the cause, .My experience in the surgical treatment of uretero- whether traumatic or congenital. The alternatives to vaginal fistula is limited to only two other cases, one the operation are well known and need not be de- traumatic and one congenital. In these two cases I scribed. To open the abdomen, sever the ureter and operated at St. Luke's Hospital, Chicago, seven or insert it into the bladder wall is an operation of great eight years ago. The operative treatment in each difficulty and danger and sometimes of only transient was like that just described, except the ureteral and value. 'The same may be said of dissecting or strip- vesical walls were divided by scissors instead of being ping the bladder from the pelvic wall, finding the

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at SAN DIEGO (UCSD) on July 5, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. ureter and inserting if into the bladder without invad- animation would be similar to those of measuring the ing the peritoneal cavity. The utilization of vaginal calibre of the male urethra in the diagnosis of Strict- mucosa in a plasiie operation for the purpose of divert- ure. ing the urine from the vagina to the bladder usually Question II: In a case of urétera! stricture due results in failure of union, or, later, in cicatricial to laceration of the cervix uteri, or to ¡my other cause, contraction and consequent stricture al the urétera] and situated within the range of a vaginal operation, orifice. Switching the ureter into the intestine or would not one be warranted in opening the bladder and into the opposite ureter are both questionable proced- then proceeding, as in the case reported, to establish a ures. new urétera] orifice? In other words, should not that As a corollary to the case just described I now condition which in this case was the result of an acci- bring before you an observation that, if well founded, dent be deliberately reproduced in similar cases? may ¡trove to have, some practical significance. It is My own answer to these questions would be in the probable in this case that the laceration having ex- affirmative. tended into the parametria had torn the structures around the ureter. There may also have been injuri- ous of the of the child pressure presenting part against THE RELATIVE HUMIDITY OF OUR HOUSES the ureter. Such lacerated tissues would necessarily heal by cicatrization and contraction, and the cicatrix IN WINTER. thus formed would draw the bruised ureter towards BY ROBERT DE C. WARD, CAMBRIDGE, MASS., Instructor in Climatology in Harvard the uterus, compress it and so give rise to obstruction University. both from stricture and from kinking. This mechan- 1'n discussing with my classes in climatology the ism will account for the facts of the case. The con- various ways in which climatic, conditions affect man, tracting cicatriciel tissue extending from the cervix I have been accustomed to point out that the climate uteri around the ureter would necessarily draw the which we have been able to produce inside of our ureter into closer proximity to the uterus, where a modern houses is an extremely artificial one. We deep suture applied for closure of the cervix or to shut, out the winds, and live in an atmosphere which control bleeding would be apt to injure it and by com- is prevailingly calm. We keep out rain, snow, sleet pression would cause ¡rnarrowing of the lumen of that and hail, and thus spend most of our time where there part lying within its grasp. In this case the. stricture, is no precipitation of any sort. In summer we are extended at least a half-inch on either side of the uré- able to keep the air in our houses cooler than that out- tera! fistula. If was evidently this constricted portion side by closing windows and blinds, and by means of of the ureter that was caught bj' the needle and cut artificial ventilation. In winter our houses are heated, oil' or penetrated by the suture. and we live in an atmosphere which is many degrees It would be quite impossible, without, further ob- warmer, and very much drier, than that out of doors. servation, to estimate the proportion of cases in which This dryness of the air indoors in winter I have been laceration of the cervix uteri causes stricture or kink- in the habit of comparing with that of deserts, although ing of the ureter. In this connection, however, every I have never used any numerical data in making this may revert to a class of cases not small, comparison. In view of the of this matter gynecologistin importance which there is extensive laceration of the cervix from a physiological point of view, and also because- uteri on one or both sides, usually on the left, and in of my desire to present my students with humidity which the localized pain on the corresponding side of data obtained actual observation indoors, I have re- the by pelvis is not readily accounted for by palpable cently made a short series of simple observations along lesions, such as disease of the uterine appendages or of these lines, which may have some interest for the the appendix vermiformis. The continued pain in readers of the Journal. SUchcases dates from the piierperium, is always out of These observations were made in my study by means proportion to the 'palpable pelvic lesions and is not re- of one of II. ,1. Green's ordinary sling psychroineters. lieved in the slightest degree by the repair of the cer- The room in question is heated by hot air, from an ordi- vix. As I look back overall experience of more than nary hot-air furnace, provided with the, usual small — twenty years 1 recall many such cases; the one just, ridiculously small — evaporating pan. Inside the regis- •'' ported apparently belongs to this class. ter there is a vessel holding a little more than half a litre But why, one may ask, if the ureter is often drawn of water. This pan has to be filled about once a day, by cieatricial contraction close to the uterus, is it, not although the rapidity of evaporation depends so directly more frequently injured by operations on the cervix ? upon the amount of heat from the furnace that the 'he answer is that if the sutures of trachelorraphy li. needed to evaporate the water varies considerably. Were not, usually introduced close to the uterus or Observations were made during three weeks of last very superficially in I he vaginal wall more cases of November (November 8d-28d), from two to live times "riierovao'inal fistula would probably be reported. daily, as offered. The hours of observa- opportunity the * "}» ease, was very hcniorrhagic and therefore re- tion necessarily varied. Each record included quired exceptionally deep sutures to control the bleed- readings of wet, and dry bulb thermometers, and a note "'•Í- In view of the fads set forth I desire to as to the condition of the weather outside; the amount _ already Submit two questions, as follows: of ventilation by means of the windows ; the degree of of water Question I: In all cases of extensive laceration heat coming from the furnace, and the amount Of the cervix in which tin; localized is not in the inside the register. uteri, [win evaporating pan and accounted for by palpable lesions, should we not pass A summary of the mean daily temperatures 11 is in «erics of ureferal on the side cor- relative humidities indoors and outdoors given graduated bougies the p6Bponding to tint laceration? This would be for the the table. In the case of the data for following of Purpose (if measuring the calibre of the ureter and of outside air the readings were taken from the sheets at the liar- "eating a possible stricture. The principles of ex- the Richard thermograph and hygrograph

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