PRACTICAL CONSIDERATIONS : THE URETERS. 1899 



These anomalies are readily understood by reference to the embryology of the 

 ure1;er ( page I937)- 



Ureteral calculus is most often arrested (a) at a point from 4-6.5 cm. (1J/2- 

 lYz in.) from the renal pelvis ; ((5) at the point where the ureter crosses the iliac 

 artery ; (r) at the junction of the pelvic and vesical portions ; {d') at its vesical 

 orifice. At these places normal narrowings are found in the majority of subjects. 

 The symptoms of calculus impacted in the ureter are difficult of distinction from those 

 of stone occupying or engaging in the pelvis of the kidney, but it may be said that 

 if, after the usual phenomena of renal colic, vesical symptoms are marked and per- 

 sistent, and especially if they are associated with slight haematuria and no calculus 

 is detected in the bladder, the existence of stone in the ureter should be strongly 

 suspected. The bladder-symptoms — irritability, frequent urination, tenesmus — will 

 be more marked the nearer the situation of the stone to the lower end of the ureter. 

 The relations of the nerve-supply of the ureter with that of the bladder and the geni- 

 talia and with the great intra-abdominal plexuses sufficiently explain the chief sub- 

 jective symptoms of calculus. 



Complete and sudden blocking of the ureter by a calculus often produces an 

 acute hydronephrosis, the symptoms of which may overshadow those directly referri- 

 ble to the region of impaction. The muscular walls of the ureter are capable of 

 strong contraction, and, indeed, the painful "colicky" symptoms attending the 

 passage of a stone along the ureter would better be described as ' ' ureteral' ' rather 

 than ' ' renal. " 



At present the diagnosis of ureteral stone and its localization are to be made with 

 much certainty by the X-rays. 



In an effort to find tenderness which, in the presence of the above symptoms, 

 might locate a stone, or might determine the region of rupture or other ureteral 

 injury, or might confirm a diagnosis of ureteritis or of tuberculous injiltratioyi (as a 

 result of ascending or descending infection), it should be noted that the beginning 

 of the ureter, the lower extremity of the kidney, and the level of origin of the 

 spermatic or ovarian artery are all approximately defined byTourneur's point, which 

 is situated at the intersection of a transverse line between the tips of the twelfth ribs, 

 with a vertical line drawn upward from the junction of the inner and middle thirds of 

 Poupart's ligament ; the course of the abdominal portion of the ureter corresponds 

 to the same vertical line. Tourneur considers its direction vertical from the border 

 of the kidney down to the pelvic brim, over which it passes 4^ cm. (2 in.) from 

 the median line. The exact location of this point is the intersection of a horizontal 

 line drawn between the anterior superior iliac spines and a vertical line passing 

 through the pubic spine. Morris thinks that this point would usually be too low 

 and too far inward, and that the junction of the upper and middle thirds of the line 

 for the iliac arteries (page 819) better indicates the point of crossing of the ureter 

 over the artery. At this point, under favorable circumstances, a dilated or tender 

 ureter may be felt by gentle, steady pressure backward upon the abdominal wall until 

 the resistant brim of the pelvis is reached. The vesical portion of the ureter can be 

 palpated in man through the rectum. Guyon has called attention to the exquisite 

 sensitiveness of this portion of the ureter upon rectal exploration in cases of stone, 

 even when the calculus is located high up. In woman vaginal examination permits 

 the palpation of the ureter to an extent of two or even three inches, as it runs beneath 

 the broad ligament in close relation to the antero-lateral wall of the vagina (Cabot, 

 Fenger). 



Morris gives the following directions for palpating the lower extremity of the 

 ureter : 



(«) Vaginal Palpation. — The part of the ureter which is capable of being felt 

 through the vaginal wall is about three inches or a litde less, or, roughly speaking, 

 about a quarter of the whole length of the duct. It is that part which extends from 

 the vesical orifice of the ureter backward, outward, and upward to the base of the 

 broad ligament and towards the lateral wall of the true pelvis. 



It is in the superior third of the anterior and lateral wall of the vagina that the 

 examination must be made, and it is at the part between the level of the internal 

 orifice of the urethra and the anterior fornix, where the tissues are very lax, that the 



