Noble, in 1902, published an interesting series of injuries to the ureter. One of these is of great value, because it proves that a ureter may be accidentally ligatured and give rise to no symptoms.
A woman of thirty-three years of age was submitted to vaginal hysterectomy for cancer of the neck of the uterus, complicated with pregnancy. She died four days after the operation, and at the post-mortem examination the left ureter was found occluded with a ligature. The ureter and pelvis of the kidney were distended with urine.
The urine voided during the four days amounted on the first day to 480 c.c. (16 oz.); second day, 780 c.c. (26 oz.); third day, 1,440 c.c. (48 oz.); fourth day, 960 c.c. (32 oz.). These quantities would lull suspicion in regard to any patient, but the facts of the case are sufficient to raise suspicions of another kind, namely, that it is possible and probable that a ureter has been ligatured in the course of an operation, and the patient has recovered without any one having any suspicion that such an accident has happened.
As soon as the surgeon clearly establishes the existence of a ureteral fistula he is beset with the necessity of deciding which duct is the seat of damage. Some years ago, when it was the practice to remove the kidney for a persistent ureteral fistula, the decision involved the surgeon in a grave responsibility, for the removal of the wrong kidney could only be regarded as a catastrophe for the patient. Morris has recorded a case in which this actually happened. A woman had total hysterectomy performed for a cervix fibroid by a gynæcologist; in the course of the convalescence a ureteral fistula was recognized, and as this failed to close spontaneously, a surgical colleague performed nephrectomy, and next day found to his chagrin that he had removed the kidney belonging to the uninjured ureter. Serious accidents of this kind are less likely to happen now, because the surgeon can avail himself of the cystoscope and ureteral catheter; with these instruments it is possible, not only to decide with certainty which ureter is injured, but also to determine the position and extent of the damage. See also Vol. III.
It is important to remember that every ureteral fistula does not require an operation. It is always advisable, when it has been clearly established that a woman has a leaking ureter, to wait a little, certainly six weeks, for many fistulæ of this kind will gradually close. In describing such a case, Jonas draws attention to a cystoscopic sign of some value. He performed a total hysterectomy for fibroids, and on the tenth day the nurse reported the escape of urine by the vagina. The daily output of urine from the bladder, which had averaged 50 ounces, fell to 25 ounces. On cystoscopic examination, urine could be seen issuing from the right ureteral orifice; at first the left orifice could not be seen, but on careful watching a movement was detected similar to the contraction of a ureter discharging urine, but no fluid came from the opening. This is known as leergehen (empty contraction), and it indicates that there is a lateral opening, but not complete interruption in the continuity of the ureter. Such a case should have an opportunity of healing spontaneously. This happened in Jonas’s patient.
Weibel states that a ureteral fistula due to necrosis after a radical operation for cancer of the uterus usually occurs in the second week. The earliest day is the seventh, and the latest the eighteenth day after operation. The majority of these fistulæ heal in from three to twelve weeks. If a fistula persist for more than three months spontaneous healing is not to be expected. A ureteral fistula is a serious matter for the patient. Blacker has had three cases after total hysterectomy. In one the kidney was removed on account of septic changes. The second had an attack of suppression of urine lasting twenty-four hours; it passed off, the patient recovered and the fistula healed. The third died eight weeks after the hysterectomy with symptoms of pyæmia; a small abscess had formed near the site of the fistula.
The fate of ligatures. When a ligature is satisfactorily applied to a pedicle the tissue on the distal side of the ligature is isolated from the circulation. The fate of this tissue and of the ligature has been the subject of much speculation.
It is a matter of common observation that when animal tissues are cut off from the circulation, they atrophy; but if pathogenic micro-organisms gain access to such parts, suppuration ensues. In due course, through the activity of the living cells, the dead tissues are detached from the living, a process termed sloughing.
When a piece of healthy tissue is removed from the body and immersed in a sterile solution, and absolutely isolated from the atmosphere, decomposition is indefinitely postponed, but as soon as unsterilized air is allowed access to it, putrefactive changes ensue. The pedicle after ovariotomy is in an air-tight chamber, and if the tissues included by the ligature are healthy, and the silk employed for the purpose is absolutely aseptic, this pedicle, when returned into the abdomen, resembles the piece of tissue isolated from contact with the atmosphere. No septic changes occur, but aggressive leucocytes attack the silk and may, in course of time, effect its removal, even the knots. For this desirable result three conditions require to be fulfilled: (1) the ligatured tissue must be aseptic; (2) the ligature should be absolutely sterile; and (3) air or intestinal contents must be excluded.