URETERIC LESIONS AS A CAUSE OF ABDOMINAL

SYMPTOMS: A CONSIDERATION OF "URETER-

ITIS" OR "URETERAL STRICTURE."*

By DUNCAN M. MORISON, F.R.C.S. Edin.

This is a condition which has only comparatively recently been

recognised as a definite entity. In some quarters, however, scepticism still prevails. This is apparently due to an erroneous

conception of the condition, together with inadequate diagnostic methods which fail to demonstrate its presence. The important role which the ureter plays in many pathological conditions of the urinary tract, and the repercussions it induces in the general system, brings it from its previously obscure position to one of

major importance. The ureter may be regarded as the " dark

horse" in several apparently vague abdominal conditions, particularly those referred to the lower abdomen. It cloaks

its pathological significance by simulating those of the chronic

appendix, the ovary and adhesions. In consequence, many an

exploratory laparotomy has been done to determine the cause of vague pains in the lower abdomen, and many an innocent

appendix, as well as many an ovary showing questionable evi- dence of pathology, sacrificed to assuage the grumblings of a truculent ureter which continues in its quiet retroperitoneal retreat to perpetuate its practices. The owner, temporarily buoyed up by the prospect of relief from the operative pro-

cedure, finds alas only too soon that the status quo ante prevails. Such a patient naturally tends to become somewhat facetious and chiding towards the medical attendant and surgeon. In

the latter a defensive reflex is soon engendered to cover the

acknowledged sense of defeat, and if the stimulus be harassingly maintained, a wise shaking of heads takes place, and the

appellation " neurotic " probably applied.

As you are well aware, the ureter throughout its course from the renal pelvis to the bladder presents normally certain varia- tions in the calibre of its lumen: there are nodes and spindles. The nodes are segments of the ureter where an accentuation occurs of the circular muscle coat. These muscular accentuations practically constitute sphincters. They are found where the ureter leaves the renal pelvis, i.e. pelvo-ureteral junction ; at the level where

* Read ioth June 1931. OBST. I 5 3

Duncan M. Morison

the ureter crosses the iliac vessels; and as the ureter traverses the bladder wall. In women, the association of the broad

ligament provides an additional site of ureteral narrowing. The intramural changes which effect reduction of the ureteral

lumen appear to favour these nodal sites. More than one site

may be involved, or by spread practically the entire length of the ureter.

Types.?(a) Congenital. (b) Acquired?I. Spasmodic or

hypertrophic. 2. Fibro-muscular.

Clinically the condition is bilateral, but in the acquired spasmodic type as well as occasionally in the congenital, only one side may be affected. With bilateral lesions, one side is

commonly found more advanced than the other. Etiology.? Congenital.?Apparently a developmental error.

Occasionally found associated with aberrant vessels. Acquired.?Spasmodic.?Due to repeated muscular exertion,

i.e. hammer throwing. Fibro-vmscular.?Considered to be the result of an inflamma-

tory process secondary to some general systemic infection, or to some site of focal infection, i.e. teeth, tonsils, prostate, cervix, etc. It is commonly associated secondarily with chronic cystitis.

Pathology.?Where opportunity has afforded, early cases

have shown a small-celled submucal infiltration with fibroblastic

changes in the muscular walls. Established lesions reveal local-

ised thickening of the ureteral wall with interstitial fibrosis and marked reduction of the ureteral lumen.

If we attempt to trace the inception of a ureteritis, we find several instances recorded of an apparently acute form occurring in a course of some severe upset, in which anuria was proved to be directly due to oedematous occlusion of both ureters, and the establishment of free drainage by nephrostomy led to ultimate

recovery. Pyelitis of pregnancy is probably mainly due to

ureteral changes of this acute form. A subacute type is not infrequently met with, in which there

is as yet no obvious narrowing, but the mucosa overlying the affected portion of the ureter is hypersensitive, readily inducing spasm.

With a ureteritis we have to consider not only the discomfort arising directly from the affected portion of the ureter, but since the ureter plays an important part in the active elimination of urine from the renal pelvis, any impairment of its function will tend to impede renal elimination and thus adversely affect the

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general body metabolism. Leaving aside for the meantime the symptoms produced, let us briefly review the mechanical

aspect of a ureteritis. On the proximal side of a ureteral narrowing we shall get

a certain degree of stasis, which, as the condition progresses, will become more obvious and lead to definite changes. The back-

pressure induced will work upwards distending the walls of the

ureter, then those of the renal pelvis, ultimately producing a hydronephrosis. Till the degree of back-pressure is sufficient to cause obvious recession of the renal papillae, the usual renal function tests will reveal little evidence of impairment, yet the

patient may present signs of a mild toxaemia. The degree of renal impairment is not always proportional to the amount of stasis within a renal pelvis. A renal pelvis may contain fully 30 c.c. of residual urine, and yet this kidney may show as good function as its fellow from which no residual can be obtained.

The matter depends on whether we are dealing with an intra- or an extrarenal type of pelvis. With the extrarenal type, the walls of the pelvis being unsupported can continue to distend and thus for a considerable time absorb the stress of back-

pressure, and temporarily conserve the functional activity of the renal parenchyma. The intrarenal pelvis, however, has its walls intimately supported by kidney tissue, and being unable to

expand transmits the back-pressure readily to the renal papillae, forcing them back, and with the resultant increased inter-

parenchymal pressure, function is soon impaired. According to the site of the lesion, the rapidity of the

destructive process will depend. As a general rule, the low ureteritis will take longer to effect renal damage than will one situated at the pelvo-ureteral junction.

In ureteritis, the lumen of the ureter at the affected site rarely shows very marked reduction. Accordingly the term "ureteral stricture" is inapplicable except in a few instances where a definite fibrous stenosis is present, simulating the condition more commonly met with in the urethra. It is

probably partially due to this inappropriate term that so much adverse criticism has arisen regarding this type of ureteric lesion.

Analysis of the Symptoms according to the Site of the Ureteritis.?Pelvo-ureteral junction.?At this site a ureteritis induces back-pressure on, and distention of, the renal pelvis, with consequent increase in quantity of retained urine. This

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Duncan M. Morison

leads to a sense of discomfort especially when the patient is

in the upright position owing to the increased weight of the

kidney. Exercise will naturally augment the discomfort. As

the condition becomes more advanced, the increasing weight of the distended kidney will cause it at times to kink acutely the upper end of the ureter and produce temporary complete obstruction with the attendant symptoms of a lateral epigastric pain associated with nausea and perhaps vomiting. With rest

the pain subsides since drainage of the renal contents is resumed.

During quiescent periods there is apt to be an indefinite aching pain just below and lateral to the umbilicus. This is apparently a referred pain from the site of ureteritis.

Pelvic Brim.?With a ureteritis at the level where the ureter

crosses the iliac vessels, the discomfort experienced is usually referred to the inguinal region somewhat medial to the sites

attributed to a chronic appendix or an ovarian lesion. The

pain commences insidiously and may last for one to three or more hours. There may be intermissions from pain for days or weeks. It may be worse or less evident during the menstrual

period. Exercise does not appear to induce the pain directly but prolonged fatigue tends to bring it on. In character the

pain is usually described as being a dull ache, resembling tooth- ache. Patients very frequently complain that the pain comes on at night and awakes them. By getting out of bed for a short

time, relief is obtained. It may be concluded from this, that in the recumbent position the ureter is relatively more extended, and that the slight tension due to this irritates the localised

inflammatory area within the ureteral wall. With severe and

prolonged attacks of pain it is not unusual to get a referred pain in the corresponding kidney, the explanation probably being that the local spasm is of sufficient degree to cause a damming back of urine on the renal pelvis.

Broad Ligament.?The pain arising from this site is similar in nature to that just described in relation to the pelvic brim zone. It is, however, referred more directly to the inguinal region. During the menstrual period the attacks of pain are usually less troublesome or may be absent. If the ureteritis is limited purely to this portion of the ureter, the pain when present does not induce any bladder irritability.

Transvesical Portion.?When that portion of the ureter is

affected which passes through and is incorporated in the bladder

wall, we get symptoms referred to the supra-pubic area, as well

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as attacks of urinary frequency. Since the lowermost portion of the ureter is an extension of the base of the trigone on either

side, and apparently shares a similar nerve supply, any stimulus

arising in this segment is transmitted to the trigone and the

bladder-neck, giving rise to a desire to urinate. Symptomatology.?General.?The patient usually presents

a mild degree of toxaemia, characterised by a sense of lassitude, loss of mental acumen, headaches, irritability, and nervousness, etc.

Local.?(a) If attacks of vague pains are complained of

in either kidney angle, or laterally below the costal margin attended with nausea or sickness, with occasionally a dull

ache just below and lateral to the umbilicus, it is probable that examination will reveal a ureteritis of the pelvo-ureteral junction.

(b) If pains are referred to the inguinal region, a lesion at the

pelvic brim is suggested. (c) Groin pains without bladder symptoms would point to a

broad ligament source.

(id) A supra-pubic ache associated with attacks of urinary frequency usually indicates involvement of the ureter at or near its transvesical portion.

If as frequently occurs, a patient has more than one portion of the ureter affected, there is a consequent grouping of the above symptoms.

As a ureteritis favours the formation of stasis in the higher urinary tract two pathological entities are frequently found

secondary to it, i.e. chronic or relapsing pyelitis, and calculus formation. In the successful treatment accordingly of these two conditions, it is essential that the primary contributing factor be not overlooked.

Diagnosis.?Since the symptoms of a ureteritis may closely simulate those of the chronic appendix and disease of the pelvic organs, the differential diagnosis is not easy. The absence of

bladder symptoms and a completely negative urine tend to put out of supposition the possibility of any pathological lesion of the urinary tract. Where positive data are present in regard to these, however, a cystoscopic examination may be done. In this

event, if ordinary ureteral catheters are employed it may be found that both ureters can be catheterised to their full extent without

difficulty. The impression accordingly is obtained that no

"stricture" of either ureter exists. In such circumstances, obst. 157 n 2

Duncan M. Morison

positive information is frequently missed by not noting if, following the ureteral catheterisation, the patient complains of an acute exacerbation of the old pain.

Physical Examination.?Palpation may or may not reveal any kidney abnormality. A localised area of tenderness may be

elicited on deep palpation over the line of the ureter as it crosses the pelvic brim, should this portion be affected. Examination

accordingly frequently limits itself into the localisation of the

areas to which pain is referred during an attack; and these areas have already been noted.

Urinalysis, as already stated, is usually completely negative. At other times pus cells, coliform bacilli, crystals, etc. may be

present. Cystoscopic Examination.?The findings on which a positive

diagnosis of ureteritis may be placed are :?

(a) The presence of residual urine in the renal pelvis. (b) Calibration of the ureters by

" bulbed " bougies, noting mechanical resistance to the passage of the bulb or "

hang " on its withdrawal, and the local induction of

pain, and its character.

(c) Reaction pain. If following instrumentation there is

a reproduction or an exaggeration of the pain previously complained of.

(a) The presence of residual urine in the renal pelvis usually indicates a ureteral lesion of some duration. In the earlier

stages of a ureteritis the changes are insufficient to impair the ureteral lumen, and consequently such cases present no residual urine. In its absence accordingly greater reliance requires to be placed on actual ureteral calibration.

(b) Should a ureteritis be of sufficient degree to reduce

materially the lumen an ordinary straight ureteral catheter may meet with resistance at the site of the lesion and occasion definite

discomfort on passing through the affected portion of the ureter. The majority of cases, however, are less evident and cannot be detected by this method. If there is a localised zone of mild

intramural inflammatory change, it can only be detected by subjecting this zone to some stress or strain, i.e. as by stretching. Since the normal healthy ureter resembles in some respects an elastic tube its lumen can be subjected to an appreciable degree of dilatation before discomfort is registered. When however

a segment of its walls are altered and rendered less elastic and

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more sensitive by inflammatory changes, dilatation of this area will meet with a certain degree of resistance and occasion

discomfort. By employing ureteral catheters or bougies, so constructed as to present a localised bulb towards the extremity, the affected zones of a given ureter can be readily determined.

During the passage of a bulbed bougie up the ureter, and again on its withdrawal, the information imparted by the patient as to the site and character of pain induced is of especial value apart from the sense of resistance met with by the operator on encountering a zone of ureteritis. During such a procedure the location and extent of ureteral involvement can in most instances

be definitely plotted. In doubtful cases, if the pain produced during or following

the examination is not similar in character and location to the

previously experienced pain, the ureter may be dismissed as a possible causal factor.

Treatment.?A course of progressive ureteral dilatation till

a size of bulb bougie No. F12 can be easily tolerated, the

intervals between treatments being ten days to two weeks and

lengthened as the degree of dilatation increases and progress is maintained. In the circumstances it is difficult to assess the

actual local effect of this treatment, but probably dilatation

produces a hyperaemia of the affected area, thus favouring resolution of the inflammatory changes.

Results.?Pain is usually soon alleviated. In cases present- ing upper tract stasis, the treatment in addition effects better renal drainage with consequent general improvement in health. The type referred to as spasmodic or hypertrophic responds less

readily and requires to be dilated further before relief is obtained. Conclusions. ? Abdominal symptoms may arise from a

ureteral source.

In cases presenting apparently obscure pain, the possibility of a ureteral lesion should be considered.

A urological investigation is a simple procedure and may obviate an unsuccessful laparotomy.

Where any doubt may exist regarding an associated lesion, i.e. a chronic appendix, this should be corrected because of its more serious potentialities.

The exact nature of a ureteritis is still problematical. Evidence is chiefly based on clinical findings. Proof of the presence of the lesion is shown by the improve-

ment obtained under treatment.

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Discussion.

The President congratulated Dr Morison on the extraordinary clear and distinct way he had presented his facts to the Society.

Mr Struthers said that in the course of his admirably clear

demonstration Dr Morison had referred to cases in which the

appendix had been erroneously regarded as the cause of right-sided pain and Mr Struthers was glad that Dr Morison had helped to dispel the widely held, but mistaken, view that lesions of the appendix were frequently the cause of chronic right-sided pain in women.

Dr Morison's presentation of his material had been very interesting and apparently convincing, but it was disappointing that he had not shown on the screen the actual lesions in the ureter. If they existed as often as was alleged there should be no difficulty in finding them in the post-mortem room and such a demonstration would help to

convince those who were, rightly, sceptical of the occurrence of

localised ureteritis followed by stricture. There were also considerable

difficulties in the way of accepting such lesions as the cause of

abdominal pain, rather than of pain in the areas well recognised as involved when the ureter was obstructed. Dr Morison's paper was

most interesting and suggestive, but there seemed to be an obligation on him to demonstrate the actual lesions which were said to cause

abdominal pain so often.

Mr Band said that in a large number of cases, though symptoms point to a lesion in the urinary tract, no organic lesion can be

demonstrated by the ordinary methods of investigation, and it is in

this type of case that the diagnosis of ureteral stricture or non-infective ureteritis has been unduly widely applied. Braasch has pointed out that the strictures of the ureter found in the post-mortem room or in

the operating theatre are those following invasion of the urinary tract by tubercle bacilli or other organisms, or following malignant invasion. Localised stricture of the ureter or ureteritis has been diagnosed in

the absence of infection in the urinary tract in only 4 out of 1000 cases examined at the Mayo Clinic. In the Diagnostic Theatre of the Royal Infirmary, Edinburgh, a diagnosis of ureteral stricture has been made in 4 out of 700 cases during the previous year, and in

all these cases a definite etiological factor of preceding pyelo-nephritis or pelvic cellulitis had been found. As Braasch has pointed out, however, it is common knowledge that the outline of the ureter as seen in the ureterogram varies widely within the limits of normality, and the appearance of the ureterogram varies with the state of

peristaltic activity within the ureter. The wide variation in the outline of the urinary tract during peristalsis has been demonstrated also in the Necker Hospital in Paris, where pyeloscopy is carried out as a

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routine method of examination. The catheterisation of the normal

ureter during active peristalsis may cause pain which is accentuated

if a bulb catheter is used. This type of pain is due to spasm from

the presence of a foreign body?the ureteral catheter?in a sensitive muscular tube. Two of the three common sites of so-called ureteral

stricture, which Dr Morison has described, are found at levels in the ureter at which a congenital form of stricture due to spasm is known to occur. It is well known that narrowing of the pelvi-ureteral junction occurs in the absence of the laying down of fibrous tissue

at that point and the resultant hydronephrosis is due to an achalasia.

Similarly, congenital stricture of the lower end of the ureter has been described by Young and others, though they found that no fibrous tissue formation had occurred which would account for the narrowing. Hurst has recently stated that stricture of the lower end of the ureter as an etiological factor in congenital megalo-ureter is due to an

achalasia or neuromuscular incoordination of the ureter, and when the urinary tract is examined it is found that in addition to an

intrinsic innervation, like the plexus of Auerbach in the intestine, additional motor innervation comes from the parasympathetic and additional inhibiting innervation from the sympathetic. Accordingly stimulation of the sympathetic may delay the emptying of the calyces, the emptying of the renal pelvis or the emptying of the ureter by causing contraction of rings of muscle at the margins of the calyces at the pelvi-ureteral junction or at the uretero-vesical opening. The

parasympathetic and sympathetic oppose one another in their action on the urinary tract, stimulation of the parasympathetic bringing about evacuation from its detrusor function and stimulation of the

sympathetic bringing about collection of secretion within the urinary tract from its relaxor function. For this specialised inhibitory function of the sympathetic two individual nerves are traced; the one is the

superior principal nerve of the ureter from the coeliac ganglion to the pelvi-ureteral junction, and the other is the inferior principal nerve to the ureter from the hypogastric ganglion to the uretero-vesical area. In the recent literature on the subject one finds reports of cases of

hydronephrosis and of alleged stricture of the ureter successfully treated by denervation of the urinary tract with particular reference to these two nerves. A London radiologist has estimated that in

60 per cent, of cases of referred symptoms to the urinary tract

without organic basis, a lesion in the spinal column is found. In

such cases postural defect, visceroptosis, and allied conditions due to faulty anatomical relationships are found. In the treatment of cases

which belong to this type of inorganic ureteral stricture or ureteral

spasm which we have under discussion, three classes may be recognised. In the first, treatment will be directed towards postural defect, general

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visceroptosis and the like. In the second some measure of relief

may be obtained by physiotherapy of the ureter from ureteral

catheterisation or dilatation and pelvic lavage, and in a third class

operative relief will be resorted to by carrying out denervation in the affected areas of the urinary tract.

Proftssor Johnsto?ie said that after the interesting and erudite

speech by Mr Band, there was practically nothing more that a mere gynaecologist could add. He had had, however, some little experience of cases with vague abdominal pain which had been successfully treated by Dr Morison, and he, personally, felt that Dr Morison was

justified in stating that this condition of ureteral stricture (or whatever name they liked to adopt for it) was a real entity. He did not think

it was fair to put the condition down to neurosis?at any rate not

unless and until the condition of the ureters had been examined with

the type of bougie which alone could demonstrate the presence of the stricture, if it existed. In his cases the pain complained of had been for the most part located laterally to the umbilicus and in the supra- pubic region, which latter was rather an unusual site of pain in

gynaecological affections and one for which he could find no gynaeco- logical cause. Doubtless he had taken out innocent appendices and innocent ovaries, just as Mr Struthers had done, but in these cases

he fortunately decided to have the patients examined by Dr Morison before embarking on operation. A narrowing of the ureter was found at the level at which the patient experienced pain, and he had himself on several occasions passed the bulbous catheter and been forcibly impressed by the way in which, when a certain point was reached, the

patient called out " That's the place," and when the catheter was passed beyond it there was no pain until the bulbous catheter repassed the same area during its withdrawal. The fact that these patients of his had been cured either permanently or at any rate for many months, by dilatation treatment of the ureter, was sufficient for him, and he did not agree with Mr Struthers that one must see the actual stricture

with the naked eye. If the stricture was a functional one its ocular

demonstration might well be impossible, but it was none the less an

actual entity. In this connection he had been very much interested

in Mr Band's description of the nerve supply to the ureter. It seemed

to him that there might prove to be some analogy between a ureteric

spasm arising out of functional disturbance of innervation at a point where the sympathetic and para-sympathetic supplies overlapped each other, and a spasm of the internal os of the uterus causing dysmenor- rhoea. Dr Morison had told him that in some of his cases, women

with ureteral stricture seemed to suffer less pain during menstruation. In a recent paper in the Zentralb. f Gynak., for February 1931, Saitz described his observations after intravenous injection of uroselectan or

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some similar substance. He had found that two out of every three

women showed a dilatation of the ureter during menstruation, which was similar to that found in pregnancy. Dysmenorrhoea was reported by the patients showing this dilatation, and it was found that the

dysmenorrhoea was relieved by the drainage of the ureter by catheter. This seemed to Professor Johnstone a significant finding especially in relation to what Mr Band has described. He thought that on the whole, Mr Band's remarks, based largely on physiological research, confirmed Dr Morison's claims which were based almost exclusively on clinical experience.

Air Leslie Stewart said he had heard Dr Morison before on this

subject of ureteral stricture, a subject which still remained highly controversial in view of the absence of real pathological proof of the existence of a true stricture in the great majority of clinical cases. Chronic right or left sided abdominal pain and tenderness near the umbilicus might be associated with a variety of conditions, for example sacro-iliac strains, and it was interesting to note that Mennell, in a recent work on backache, claims that treatment directed solely towards the sacro-iliac joint in such cases may frequently afford relief. He

mentioned this just as an indication that they were dealing here with a very complex type of case, a type in which a very thorough investiga- tion was often required before they were justified in pronouncing an exact cause for the patient's symptoms. Unfortunately this class of case was very common. In the out-patient departments of the

hospitals they often saw half a dozen or more of such cases in a

morning, the majority in young women, sent in with a diagnosis of appendicitis.

With regard to the question of ureteral stricture itself, it seemed a curious thing that one should commonly meet with a primary stricture of the ureter as a result of a focal infection from a distant

source. This was not in keeping with the pathology of other excretory ducts in the body. Where inflammatory ureteritis did occur, he

considered it much more likely to result from a spread of infection from elsewhere in the urinary tract or from a focus of disease adjoining the ureter. In such cases dilatation of the ureter did good as it

improved the drainage of the urinary system above. Certain cases of so-called stricture of the lower end of the ureter

were congenital, in origin. He agreed with Mr Band that in this

class of case the primary lesion was of the nature of an achalasia. Here one found a marked degree of dilatation of the ureter and

renal pelvis above. Infection was liable to supervene, with a ureteritis and secondary stricture at the lower end of the ureter, sometimes with the production of a pyonephrosis necessitating operation in young children or in later life.

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What he felt about Dr Morison's paper was that "the proof of the

pudding was in the eating" and if one could relieve some of these

patients suffering chronic abdominal pain by ureteral dilatation there must be something in it, whether the symptoms were due to an actual

inflammatory ureteritis or whether they were due to a non-inflammatory spasm or some totally extraneous cause.

A great deal of attention was being paid at present to the surgery of the sympathetic system, and though some good results had been obtained from denervation operations on the ureter and renal pelvis, the number of cases thus treated was as yet too small to justify any definite conclusions being drawn from them. In view of the good results claimed by Dr Morison in such a considerable series of cases, he considered that the simpler procedure of ureteral dilatation should have first preference.

Dr Voting said it was interesting and significant to hear the

difference of opinion expressed by surgeons on a matter which had been a source of anxiety to many of us. The remarks which Dr

Morison had made, and the subsequent remarks made by Professor

Johnstone had impressed him as indicating that there did seem to

be evidence of such a ureteral lesion, whatever the cause might be, which could be treated with advantage to the patient. At the same

time he admitted that his own experience in this regard had been largely disappointing. When he first read Hunnder's paper on the

subject he felt that we now had the opportunity of dealing with many of these vague pains which had in the past resisted our treatment, and he had sent a number of these cases to the urologist. He did not

think, however, that he could recall more than three or four cases

that came definitely into the type of condition Dr Morison had

referred to. It might be that because of the difference of opinion which existed amongst urologists on this matter, the gynsecologist had fallen between two stools. He did feel that, with the presentation which had been given to-night, we had renewed hope in regard to

these cases. Mr Band referred to the occasional relationship between orthopaedic lesions in the back and functional disorders of the urinary tract and pelvis. He remembered a case where a young girl of 19 came to him with severe backache, and in whom there was a marked sacro-iliac lesion. She complained of marked dysmenorrhcea and

urinary incontinence. The back was treated and she was fitted with a brace, and the urinary symptoms disappeared though no treatment had been prescribed for them. Regarding cases of sympathectomy, he had had a certain amount of experience of this. A case in point was that of a woman whose life had become one long misery because of constant dysuria and frequency. She had seen many gynaecologists and urologists, and he was constrained to open the abdomen on one

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occasion. A large number of adhesions were found, and a division

of the presacral nerve was carried out. That patient had never shown the slightest improvement. Another point-which had not been touched upon was the relationship between stricture of the ureter and pregnancy. This was the aspect of the matter with which obstetricians were most

closely brought into contact. We knew that in the pyelitis of pregnancy there was a stasis of the ureter. In fact, there was evidence that this stasis was almost an invariable condition in pregnancy. It was possible that the observations on the function of the sympathetic to which

Mr Band had referred might be able to throw light on this matter also.

Dr Joa?i Rose said that Dr Morison had given very little indication as to the general condition of the patient, and she would like to ask if he had found cases of ureteral spasm in otherwise healthy women of good physique and active habits. There was a danger that women who are exposed to successive operations of stretching of the ureter may begin to regard themselves as invalids, and one could not help feeling that cases of spasm, as distinct from stricture, might derive considerable benefit from postural and remedial exercises.

Dr Morison (in reply) said that throughout his paper he had

employed the terms ureteritis and ureteral stricture since these were most commonly used to denote this ureteral lesion, but it was possible that these terms did not furnish any true index of the pathological picture. He fully agreed with Mr Struthers regarding the need of having slides demonstrating the actual pathological changes, but

unfortunately or otherwise no proved clinical case had come to autopsy. The presence of true ureteral stricture was relatively rare. Braasch

concluded from a series of unselected autopsies that definite fibrous stricture of the ureter occurred in only about 2 per cent. Since the

majority of cases had improved by the simple procedure of ureteric dilatation it would seem advisable to carry out this form of treatment

before considering more drastic procedures such as sympathectomy.

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