Inflammation of the Ureters in the Female. 
BY 
MATTHEW D. MANN, A.M., M.D., 
OF BUFFALO. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 
August, 1894 Extracted from The American Journal of the Medical Sciences, August, 1894. 
INFLAMMATION OF THE URETERS IN THE FEMALE.1 
By Matthew D. Mann, A.M., M.D., 
OF BUFFALO. 
It is for the purpose of calling attention to a disease about which 
little has been said and written, and especially to its causation and 
treatment, that I have prepared this paper. I am convinced that 
ureteritis is common, that it is often overlooked, and that it is mistaken 
for other conditions in no way connected with it except in location. ♦ 
Frequency.—My knowledge of this disease extends over only a few 
years, dating from a paper by Dr. H. A. Kelly,2 in 1888, and a personal 
-visit to him, in which he kindly taught me to recognize the ureters by 
palpation. Since that time I have met with many cases—some of them 
recent, but a larger number of many years’ duration. Some of them I 
have seen only in consultation and have no knowledge of their progress; 
others I have followed for a longer time. 
From the number met with, I am convinced that inflammation and 
irritation of the ureters is exceedingly common, and that its general 
recognition is a matter of great importance. As yet the text-books are 
almost silent on the subject, the latest—Garrigues’ excellent work— 
not mentioning it. In fact, the literature on the subject is exceedingly 
scanty. 
In order to prepare for what I have to say, I must first refresh your 
memories regarding the anatomy of these important ducts. 
Anatomy.—The ureters are two delicate tubes leading from the pelvis 
of the kidney to the bladder. They run nearly parallel as far as the 
brim of the pelvis. After entering the pelvis they run downward, back- 
ward, and outward to the side of the pelvic wall, to a point near the 
spine of the ischium, where they hug the bone closely. Then, reversing 
their course, they come nearly together where they enter the bladder. 
In length they never exceed fifteen inches, averaging between ten and 
twelve inches (Van Hook). The point opening into the bladder is 
about three-quarters of an inch in front of the cervix; the points of 
opening are from one to one and one-half inches apart, and one inch 
from the neck of the bladder. 
Van Hook3 calls attention to the fact that the ureter has three points 
1 Read before the American Gynecological Society, Washington, D. C., May, 1894. 
2 “Relation of the Ureters,” Gynecological Trans., 1888. 
3 W. Van Hook : “ Surgery of the Ureters,” Journ. Amer. Med. Assoc., December, 1893. 2 
MANN: INFLAMMATION OF URETERS IN FEMALE. 
of diminution of calibre, which may give rise to mistakes in the search 
for pathological stenosis. The first is between one and one-half and two 
and one-half inches from the pelvis of the kidney, according to Dr. 
Tangreary’s1 measurements. The second is at the junction of the 
pelvic and vesical portions, and the third (in three out of five) is where 
the ureter curves over the iliac artery. 
It is in the latter part of their course, where they pass under the base 
of the broad ligament and through the bladder wall, that they can best 
be recognized by the examining finger. An exact appreciation of their 
position in the pelvis is, therefore, necessary before we can expect to 
study them. By palpation they can be recognized, especially when 
enlarged by disease, as two cords, running from a point a little in front 
of the uterus and a little to one side of the median line, directed at first 
toward the sides of the pelvis, and then curving somewhat sharply back- 
ward until they go beyond our reach near the spine of the ischium. In 
front of the uterus their ends are separated by an inch or a little more 
of space. Tourneur 2 claims that, when enlarged by disease, they can 
be distinctly palpated through the abdominal wall above the pelvis. 
That the ureters may be the seat of disease has long been recog- 
nized. The causes and nature of their diseases are only now beginning 
to be studied and the diseases to be regarded as independent pathological 
entities. 
Unquestionably the most common disease is inflammation, and I have 
learned by observation to recognize seven causes for this trouble. 
Causes of Inflammation : 
1. Injuries during childbirth. 
2. Previous disease of the bladder. 
3. Gonorrhoea. 
4. Suppuration of the pelvis of the kidney. 
5. Pelvic disease, such as pelvic peritonitis, cellulitis, and tumors. 
6. Abnormal conditions of the urine. 
7. Tuberculosis. 
1. Injuries from childbirth. In our Transactions3 for 1890, Dr. Skene 
called our attention to the first of these causes and the resulting effects. 
During the last winter I met with several cases. In each there was 
a chill, with high fever, pelvic pain, and vesical irritation, coming on 
several days after labor. The labors were none of them especially severe 
or long, but were all in primiparre. A careful pelvic examination 
showed nothing wrong with the uterus, tubes, or pelvic peritoneum; 
but pressure over the lower end of one of the ureters showed great 
tenderness. After the third or fourth day an examination of the urine 
1 Quoted by Van Hook. 
2 C. Tourneur: De 1’Ureterite et de la Peri-ureterite. Paris, 1886. 
3 A. J. C. Skene: “ Injuries of the Ureters during Labor,” Gynecological Transactions. MANN: INFLAMMATION OF URETERS IN FEMALE. 
3 
revealed an acid reaction with a large amount of pus and some blood. 
There was no mucus or other evidence of bladder trouble. As Skene 
points out, bimanual manipulation over the kidney on the affected side 
showed some tenderness. 
In none of these cases was there a history of any pre-existing disease 
of the bladder or kidney. In the first case I gave a grave prognosis; 
but the patient recovered, as did the subsequent cases. Skene met with 
one fatal case. 
Skene considers that the cause is to be found in pressure on, or injury 
of, one or both ureters by the child’s head or the blade of the forceps, 
the pendulum movement of the forceps being particularly prone to pro- 
duce trouble. Especially is it likely to occur if the head pushes down 
an undilated cervix and the bladder with it. 
A most instructive account of an autopsy is to be found in the article 
referred to. 
Besides these more serious lesions, I have noticed an irritation lasting 
a long time, and evidently started by the pressure of the child’s head, 
but kept up by other causes. I will here cite one illustrative case: 
I delivered Mrs. A. of a large child some years ago with forceps. The 
head was R. O. A. Following the labor she had a mild attack of sepsis, 
due to the retention of a small bit of very adherent membrane, from 
which she fully recovered. Soon after the labor she complained of a 
frequent desire to urinate, and it was necessary to pass the catheter quite 
often. This symptom seemed to persist, and her family physician tells 
me that he treated her for “irritable bladder” for a long time. 
A few months after her recovery she was in one of our large cities; 
and, as her bladder began to trouble her again, she consulted one of our 
distinguished Fellows. He sent her back to me, advising that I sew up 
very slight tears in the cervix and perineum in hopes of relieving, as he 
said, the tenderness in the right broad ligament. (Cellulitis?) On 
examination, I found the right ureter very tender, and the urine quite 
acid. I gave her large doses of alkalies, combined with an alkaline 
mineral water, and in a few weeks she was entirely relieved of the 
distressing symptoms. 
Undoubtedly the trouble began in childbed, from the pressure of the 
head (R. O. A.) on the right ureter, and was only relieved when all 
external irritation—the hyper-acid urine—was removed. 
2. Previous bladder disease. In certain deformities of the bladder, 
such as fissure, the ureters are generally greatly dilated. In cystitis, 
except in the gonorrhoeal form, extension to the ureters either does not 
occur or is a late manifestation. If a neoplasm or hypertrophy of the 
bladder obstruct the exit1 of the urine from the ureters, dilatation of the 
ducts gradually takes place. “ When the ureteric openings are dilated 
so that urine regurgitates at each vesical contraction,” infection of the 
ureters is sure to follow with serious results. 
1 Skene : Diseases of the Bladder and Urethra in Women, p. 242. 4 
MANN: INFLAMMATION OF URETERS IN FEMALE. 
Some authors have thought that all diseases of the ureters have their 
origin either iu the bladder or the kidney, the ureteritis being called 
“ ascending ” or “ descending,” as the case may be. It has never been 
my fortune to see a case of ascending ureteritis, except when it has had 
a gonorrhoeal origin. Still it may be possible that an ordinary acute 
septic cystitis may be conveyed to the ureters. But, if this be so, it must 
—in the female, at least—be rare. Coe1 mentions having seen two cases 
of pyelitis follow cystitis. The course of the infection was presumably 
by the ureters. 
3. Gonorrhoea. That gonorrhoea may extend to the bladder is gener- 
ally acknowledged, though gonorrhoeal cystitis in women is either by no 
means common or does not often attract attention. If gonorrhoea once 
reaches the bladder, the inflammation may also extend into the ureters. 
It is possible that after the disease has subsided in the bladder it will 
still lurk in the ureters, either because the conditions are more favorable, 
or because, the bladder symptoms attracting notice, treatment is directed 
to the bladder but does not reach the ureters. 
I have seen several cases in which I am certain that this had occurred. 
There was a direct history of gonorrhoea, and other evidence in the 
presence of inflamed and suppurating Fallopian tubes. I have no 
doubt that many of the failures to obtain entire relief from pain after 
cceliotomy for pus tubes are due to coincident but unrecognized gonor- 
rhoeal ureteritis. 
4. Pyelitis and pyelonephritis. Suppuration of the pelvis of the 
kidney and of the kidney itself is more often, in my belief, due to 
previous disease of the ureters than vice versa. Still, many cases are 
recorded where the disease is supposed to have been due to emboli or 
other trouble starting de novo iu the kidney or pelvis. Unfortunately, 
in the many recorded cases the condition of the ureters is seldom men- 
tioned. A calculus formed in the pelvis of the kidney frequently leads 
to suppuration; and with almost absolute certainty, the ureters will 
then, sooner or later, be involved. This is the so-called descending 
ureteritis. It is my experience that most of the cases where the 
trouble begins in the kidney or its pelvis are either due to calculi or 
tuberculosis. 
5. Pelvie and uterine disease. The relations existing between uterine 
and pelvic diseases and diseases of the ureters have been carefully 
worked out by Engelmann.2 With many of his conclusions I disagree 
in toto. Time fails me to carefully criticise his paper, and I shall only 
allude to a few points of difference, while quoting many points of 
agreement. 
I have very little faith in the extension of inflammation from con- 
1 “ Deaths from Visceral Affections after Ovariotomy,” Gynecological Transactions, 1889. 
2 “ Renal Disease following Utero-ovarian Lesions,” Gynecological Trans., 1889. MANN: INFLAMMATION OF URETERS IN FEMALE. 
5 
tiguous structure, except along surfaces. I do not believe that ureteritis 
ever follows an inflammatory action in the tubes, ovaries, pelvic perito- 
neum or parametrium by direct extension. If the two coexist, I would 
look either for a common cause in a gonorrhoeal infection, or the 
ureteritis may be due to the inflammatory exudation causing pressure 
and obstruction. 
Still less can I believe that an anteflexed fundus can by pressure, 
even for a very long time, and “ under conditions favoring the progress 
of the disease,” induce a ureteritis, pyelitis, and pyelonephritis. 
I wish to enter my protest against what I believe is a common 
mistake. An anteversion or anteflexion is found, and with it a degree 
of vesical irritability, which is attributed to the pressure of the uterine 
body on the bladder. It seems to me to be ridiculous to suppose that 
an organ which weighs only one and one-half dunces, one-half of which 
is supported by the vagina, can produce so much trouble by its weight 
alone. Especially is this so when we see the bladder pushed out of 
place and pressed upon by tumors without any special symptoms of 
this kind. Under such circumstances, I have never failed to find some 
other condition to account for the vesical irritation, usually an abnormal 
condition of the urine. 
Pressure on the ureters is recognized by all writers on this subject 
as a frequent cause of ureteral disease. That a sufficient degree of 
pressure may be made by a firm neoplasm, such as a uterine fibroid or 
ovarian tumor, cannot be doubted. In cancer also the disease itself, or 
the zone of infiltration which surrounds it, may directly press upon and 
even occlude a ureter. Obstruction from any cause may lead to ureter- 
itis, pyelitis, and its consequences. In ulcerating cancer, if the disease 
opens the ureter, direct infection, with all its results, may take 
place. 
Engelmann holds that “ above all, retroflexion and prolapsus uteri ” 
may cause pressure on the ureters. As far as retroflexion is concerned, 
I have never seen any clinical evidence that this may occur; nor does it 
seem likely from the anatomical arrangement of the parts. The ureters 
are so far separated, directly behind the cervix, that there is plenty of 
room for an enormously enlarged retroflexed fundus between them. 
Where they pass over the brim of the pelvis they are well protected by 
the promontory of the sacrum, and are, moreover, too high for a retro- 
verted uterus to reach them. Nor is the weight of the uterus enough. 
In prolapse, the course of the ureters may be interfered with, but in the 
many cases of prolapse and procidentia that I have met with I have 
never seen anything to support this conclusion. 
It is in Engelmann’s third class that it seems to me the most evident 
connection between diseased pelvic viscera and diseases of the ureters is 
to be found. He claims that “ functional derangement and finally 6 
MANN: INFLAMMATION OF URETERS IN FEMALE. 
morbid changes are produced by nervous influences emanating from the 
diseased pelvic viscera.” 
This may be brought about in two ways: “as reflex phenomena,” 
or “ by perverted action of the secretory nerves, due to the intimate 
connection of the uterine and renal plexus.” 
My interpretation of the phenomena would be as follows : 
In the first place, it is well recognized that the stomach and other 
digestive organs bear a very close relationship, as regards their func- 
tional activity, to the sexual organs. Now, if the digestive processes 
are disturbed by primary disturbances in the pelvic viscera, the result- 
ing indigestion will cause abnormal conditions of the urine. It is in 
this way, as I shall explain later, that I believe inflammation of the 
ureters is generally brought about. 
Perverted action of the nerves governing the renal function often 
results in a deficient amount of urinary excretion. This condition, 
generally spoken of as “renal insufficiency,” is, I believe, often a result 
of a stimulation of the inhibitory influence of the nerve centres, due to 
peripheral irritation in the sexual organs. It is often found associated 
with ureteritis, and, I am fully persuaded, often stands in the relation of 
cause and effect. 
6. Abnormal conditions of the urine. It is my belief that abnormal 
states of the urine cause the great majority of cases of ureteritis. The 
urine which is at the bottom of the trouble is excessively acid, often 
depositing a thick sediment on standing. It is scanty and high-colored ; 
or this condition may alternate with a profusion of pale limpid urine of 
very low specific gravity. The constant passage of this abnormal urine 
irritates the whole urinary tract, and is, I am fully convinced, the most 
common cause of inflammation of the ureters. 
This particular kind of urine will at once be recognized as that char- 
acteristic of the condition often known as lithsemia. To detail the 
causes of lithsemia is beyond my limits. 
One point I must mention again, and that is renal insufficiency. In 
many of these cases I have found the total amount of urine reduced to 
eight or ten ounces in the twenty-four hours. Such urine is often of 
low specific gravity, showing a great deficiency in the total amount of 
solids excreted. It is generally acid and contains a variety of crystals. 
The recognition of this condition—whether we consider it only as one 
factor in lithsemia or as a separate affair—is of the utmost importance 
for the successful treatment of these cases. 
Renal insufficiency being often the result of reflex action, as already 
explained, we must look for the exciting cause; and this we may find 
in the pelvic organs or in some distant organ, as, e. g., in the eye. If 
it be in the pelvis—or wherever it may be—we shall make little pro- 
gress in the management of our case until we recognize the cause. MANN: INFLAMMATION OF URETERS IN FEMALE. 
7 
I have noticed that some kinds of fruit seem to cause a state of the 
urine which is particularly obnoxious to the urinary mucous membranes. 
Strawberries are especially noticeable in this respect. 
7. Tuberculosis. Tuberculosis as a cause of disease of the ureters 
has been occasionally recognized. 
The case of a young girl came under my notice a year or more ago. 
The ureters were enormously enlarged, and there was much pus in the 
urine. I turned her over to Dr. Chas. G. Stockton for general treat- 
ment, and Dr. Bergtold found tubercle bacilli in the urine. She later 
went to New York, where her kidney was opened, and a condition was 
found which was called tubercular pyelitis. A few months ago Dr. 
Roswell Park removed this kidney, finding numerous foci of pus and 
other evidences of tubercular disease. 
It may be questioned whether tubercular disease of the ureters exists 
independently of the same disease in the kidney. 
Pathological Anatomy.—I have had no opportunities of studying 
this disease post-mortem, and have not had access to any work treating 
fully the pathological anatomy of the ureters. Judging from what I 
have observed clinically, and from the reports of cases by other ob- 
servers, I think we may distinguish several forms or stages of ureteritis. 
First, the catarrhal form, in which there is a little swelling of these 
tubes with desquamation of the epithelial lining. It is my belief that 
in slight cases, judging from the evidence gained by examination as well 
as from the symptoms, the force of the disease is first spent on the lower 
end of the ureter, especially the part in front of the broad ligament. 
In other cases the surface of the tubes seems to give forth a plentiful 
purulent secretion, which indicates an ulcerated or granulating condi- 
tion of their lining membranes. Tourneur says that when these ulcer- 
ations occui’ a thickening in the surrounding connective tissue takes 
place with, perhaps, adhesions of the peritoneum, giving an irregular 
outline to the course of the ureters. 
Sometimes the tube is greatly thickened by inflammatory deposits in 
the walls. This may reach a point where the ureters are as large as a 
lead pencil, or even larger. In the case of obstruction, dilatation, even 
to an extreme degree, may take place, accompanied by a certain amount 
of thickening. Tourneur likens these dilated and thickened ureters to 
the arteries in a cadaver. 
I have now under observation a case in which the ureters are greatly 
thickened, and in which the right one seems to be dilated or sacculated 
just behind the broad ligament. 
The pelvis of the kidney is doubtless generally more or less involved 
with the ureters; but that it is always so is not proven. A physical 
examination in several cases of so-called “ pyelitis ” has shown that the 
ureters were the parts chiefly involved. That these conditions may eud 8 
MANN: INFLAMMATION OF URETERS IN FEMALE. 
in involvement of the pelvis and of the kidney itself, I have had clini- 
cal evidence. In several cases perinephritic abscesses have developed ; 
and in two abscess of the kidney has developed, as proven by operation. 
Usually both ureters are involved in the pathological processes; but 
often one side—usually the left—is much more seriously affected than 
the other. 
Coincident Affections of Other Organs.—The bladder is rarely 
directly affected by coincident inflammation; that is, there is seldom a 
general cystitis. But in a case recently examined, in which the pain 
and tenderness are confined to the left side, the surface of the bladder 
around the mouth of the ureter, as shown through a Kelly speculum, 
was quite red and congested. The urethral orifice on this side is only 
half the size of that on the unaffected side. 
In another case there was a patch of granulations around the orifice of 
the right ureter as large as a twenty-five-cent piece. The possible exist- 
ence of stricture at the point of opening is something to be considered. 
It is a matter for future investigation whether the vesical tenesmus 
is not always due to some localized congestion, granulations, or ulcera- 
tion around the mouth of one or both ureters on the bladder wall. In 
consequence of the constant emptying of the bladder its walls may 
become contracted and almost incapable of expansion. This fact must 
be taken into consideration in the treatment, and means taken to over- 
come the contraction. 
Other complications are the various forms of tubal, ovarian, and 
uterine disease. Endometritis is the commonest. Retroversion and 
prolapse are not uncommon. But in a considerable number of the 
cases met with the sexual organs have been only slightly affected. 
It will be at once admitted that some of the conditions described as 
producing ureteritis will also in time produce changes in the kidney, 
especially contracted or granular kidney. This makes the disease a 
more serious one. Whether there be any relation between floating, or 
movable, kidney and ureteritis I am unable to say, never having met 
with a case in which the two conditions coexisted. 
Late in the disease, abscesses, either in or around the kidney, or else 
around the ureter, may form. I have seen several instances of peri- 
nephritic abscess, and one which I think had its origin in the cellular 
tissue around the ureter. It pointed in the iliac fossa. As already 
said, Bright’s disease may come to end the scene. 
Symptoms. — The most constant symptom is frequent micturition, 
which may even become continuous. In only a very few cases with 
which I have met has this symptom been absent. The desire is most 
frequent during the day, but the rest is often broken by calls to empty 
the bladder at night. In the worse case I evei’ saw, when I was sum- 
moned the woman had been sitting on a commode for a month, night MANN: INFLAMMATION OF URETERS IN FEMALE. 
9 
and day, only occasionally snatching a moment’s sleep. The desire to 
urinate was constant. 
In this case the ureters were as large as lead pencils and exquisitely 
tender ; there was pus in the urine, but the bladder seemed to have the 
usual tolerance, that is, there wras no special pain on distending it with 
fluid. Relief was obtained, however, by the establishment of a vesico- 
vaginal fistula. 
The next symptom in importance is pain over the ureters—one or 
both—the left side being more commonly affected than the right. This 
pain is described as burning or boring, and is nearly constant, but is 
almost always greatly aggravated as the menses approach, even becom- 
ing agonizing during the flow. This peculiarity has often led to an 
error in diagnosis, the disease of the ureters being mistaken for ovarian 
disease. Several cases have come to me to have the ovaries removed, 
when all the trouble lay in the ureters. One case in particular has 
been examined by several excellent men, all agreeing that the ovaries 
were the seat of the intolerable menstrual pain, and ought to be removed. 
When I last saw the woman she still possessed her ovaries and was 
perfectly well. 
One curious symptom I have noted as frequently existing in cases 
associated with renal insufficiency, i. e., an absolute distaste for water. 
I have frequently told the patient, without asking her, that she did not 
drink water enough, and she has replied that she did not drink any. 
In some cases water seems actually to produce nausea. This distaste 
for water is often very hard to overcome. 
Should cystitis coexist, the symptoms of this disease may entirely 
mask the other. Again, should the kidneys become affected a new 
train of symptoms will arise. In lithsemic patients other manifesta- 
tions of the condition may develop. Many of these patients are subject 
to bilious attacks and sick headaches. Gastric and intestinal dyspepsias 
are common, and there is often a history of inherited rheumatism or 
gout. Great depression of spirits is not an uncommon symptom. Even 
in the lithaemic cases the symptoms often seem to date from child- 
hood. 
Sometimes the disease is intermittent, attacks coming now and then; 
but usually it runs an essentially chronic course. I have met with cases 
which had lasted for twenty years, gradually getting worse, until life 
was very nearly unendurable. 
The pain is sometimes steady, and again it is spasmodic. It may be 
stationary over the ovarian region, or it may be felt over the hip and 
down through the iliac fossa. In some cases the pain is intensified by 
walking; others are unable to ride in any vehicle, the jar and movement 
causing much pain. 
Attacks of gravel or the passage of small stones from the pelvis of 10 
MANN: INFLAMMATION OF URETERS IN FEMALE. 
the kidney are rather common, and may be distinguished by the usual 
symptoms. In some cases the passage of plugs of inspissated pus pro- 
duces symptoms similar to those of gravel. 
Diagnosis.—This disease may be recognized, first, by the symptoms 
enumerated ; secondarily, by the physical examination ; and, thirdly, 
by an examination of the urine. 
It is needless to go over the symptoms again; only it must be remem- 
bered that they do not give conclusive evidence. As already stated, the 
symptoms may be mistaken for those of ovarian, tubal, and uterine 
disease, on the one hand, and for those of the bladder and kidney on the 
other. It must be borne in mind that frequent micturition is not 
always present. 
It is on the physical examination, then, that we must place the chiei 
reliance. That the ureter is often easily palpable has been clearly 
demonstrated. Pawlik, H. A. Kelly, and others have, by their teach- 
ing and writing, established this fact conclusively. In fact, there is 
nothing easier than the palpation of an enlarged ureter in the pelvis. 
When it is not enlarged the matter is not so easy; and I am convinced 
that it is not possible to perfectly and clearly distinguish the ureters in 
all women. If, however, we know their anatomical position, and pres- 
sure over these points—and over these points alone—elicits pain, we 
may, if the symptoms are corroboratory, safely infer that we are press- 
ing upon the ureters, and that they are diseased. Care must be taken 
not to confound tender spots in the other structures of the pelvis, so 
frequently discoverable, for the ureters. 
Method of Palpation.—Pelvic. The palpation of the ureter in 
the pelvis is done as follows: The finger is carried along the anterior 
vaginal wall upward and outward near the brim of the pelvis to one side 
of the uterus. It is then passed forward, stroking the pelvic wall and 
carefully feeling for a cord-like body under it. Sometimes a bimanual 
examination will greatly aid in discovering the ureters. Anybody who 
has once distinguished an enlarged ureter will be astonished at the ease 
with which it may be done. 
In every case that I have seen, tenderness on pressure was present, 
and sometimes to an extreme degree. A feeling of a desire to urinate 
is often complained of on touching the ureters; and Kelly describes a 
case in which micturition took place over his hand while examining. 
By tracing the course of the ureters carefully with the finger-tips, 
disease of the bladder and urethra may be excluded. Should bladder 
tenderness coexist it will be hard to distinguish the ureteritic disease, 
unless the ureters are enlarged, or at least distinctly palpable. 
Abdominal palpation. As already mentioned, Tourneur1 lays great 
stress on the palpation of the ureter through the abdominal wall. He 
1 Loc. cit. MANN : INFLAMMATION OF URETERS IN FEMALE. 
11 
says: “At the level of the superior strait the ureter can be found at 
one-third the distance which separates the anterior superior spines of 
the ilium.” 
In women who have borne children and have, in consequence, a 
relaxed abdominal wall, he claims that it is astonishingly easy to palpate 
the enlarged and thickened ureters. If there be a peri-ureteritis, the 
investigation is further facilitated ; and in some cases irregularities or 
swellings are noted along the course of the ureters. If there be simple 
dilatation without hypertrophy, palpation is more difficult. He con- 
siders this as the principal method of determining changes in the form 
and consistence of the ureters, and consequently of the utmost impor- 
tance. He cautions us to be careful not to mistake a chain of enlarged 
glands (the ilio-lumbar) for the enlarged and irregular ureters. These 
glands are especially likely to be affected in tubercular disease. 
His method would seem to supplement the pelvic palpation. For its 
performance it is necessary that the bowels should be thoroughly emptied, 
and that the patient should lie on a hard table with the knees drawn up 
to relax the abdominal walls. 
I have never practised abdominal palpation of the ureters. 
Examination of the Urine.—This is an absolute necessity, both 
for diagnosis and as giving important indications for treatment. No 
examination can be considered as complete unless it embraces an estima- 
tion of the amount of urine passed in twenty-four hours, as well as a 
careful chemical and microscopical examination. Many practitioners 
consider that when they have tested for albumin they have done their 
whole duty. Such a test is practically useless, showing nothing regard- 
ing the abnormalities to be met with in ureteritis. 
The urine will often be scanty—I have seen it as low as six ounces in 
twenty-four hours; always acid in reaction, often hyper-acid, unless 
cystitis coexists, and often of low specific gravity, 1010 to 1015. 
The sediment will consist of urates, uric acid, calcic oxalate, often 
pus, and a little epithelium. All attempts to locate the seat of the 
disease by the presence of peculiar types of epithelial cells will fail. In 
old cases, where pus is present in large amounts, no epithelium will be 
found. Blood-cells in greater or less proportion will often be found 
with the pus. 
The amount of mucus in the urine will be very slightly increased. 
There are no mucous follicles in the pelvis of the kidney or ureters. 
As the bladder is abundantly supplied with such follicles, the presence 
or absence of mucus is of much diagnostic value. Urine containing 
pus without mucus and acid in reaction is, I believe, a sure indication 
of inflammation in the urinary tract above the bladder—leaving out, of 
course, the presence of an abscess opening into the bladder. 
On the other hand, alkaline (ammoniacal) urine with mucus and 12 
MANN: INFLAMMATION OF URETERS IN FEMALE. 
pus is a sure sign of cystitis, but does not exclude involvement of the 
ureters or pelvis of the kidney. 
Palpation or catheterization of the ureters is then the resource for de- 
ciding whether the ureters are also involved. The presence or absence 
of albumin may be of some significance. I have never found anything 
more than the faintest trace of albumin in purulent ureteritis; gener- 
ally there is none. 
The presence of albumin with pus may mean, then, either that the 
kidneys are affected or that the pus comes from an abscess cavity, the 
liquor puris furnishing the albumin. The further history of the case 
will decide which. 
It is by no means necessary that the ureters should be much thick- 
ened before pus is produced. I have seen it in comparatively recent 
cases where the ureters were not at all enlarged, but only tender. Under 
proper treatment these cases rapidly recover. 
Prognosis.—The prognosis in a given case of inflammation of the 
ureter depends entirely upon the stage in which the disease is met with 
and upon the condition of the ureters as recognized by palpation. If 
the trouble has not lasted very long, and the ureters are not much 
thickened or enlarged, the prognosis is good, though the time necessary 
for a cure will be considerable. In old chronic cases, where great 
thickening of the ureters has taken place, and where large amounts of 
pus are found in the urine, the outlook for the patient is certainly not 
good. It is altogether likely that abscesses will form in or around the 
kidney, and that the patient will succumb from them, or later from 
some form of Bright’s disease. 
Nevertheless, I have seen one case, which I have followed now for 
nine years, and which has apparently recovered. The trouble began, I 
infer, with lithsemia and a mild ureteritis, under my care. This was 
entirely unrecognized and not properly treated. The ureters gradually 
got thicker; and when I examined her again, some four years ago, I 
found them moderately enlarged, the disease having then, judging from 
the symptoms, lasted about five years. Later, she had an abscess of 
the right kidney, which was opened and drained, and which left a sinus. 
Finally the kidney was removed, and the patient is, I understand, now 
perfectly well. The other ureter, however, is slightly thickened, and 
may ultimately give trouble. 
As already stated, I have seen cases which have lasted twenty years, 
judging from the symptoms, in which there was only moderate thicken- 
ing and a small amount of pus in the urine. Other cases run a much 
more rapid course. It will thus be seen that a prompt recognition of 
these cases and a proper treatment is of great importance. 
Treatment.—The treatment may be considered under the heads: MANN: INFLAMMATION OF URETERS IN FEMALE. 
13 
1. Constitutional. 
2. Local. 
a. Through the urine. 
h. Direct local treatment. 
3. Surgical. * 
1. Constitutional. From what has been said regarding the causation 
of this disease, it will be at once seen that constitutional treatment is of 
the utmost importance. Unless this is carefully carried out we cannot 
expect to get a normal condition of the urine, which is absolutely essen- 
tial, not only to prevent the further progress of the disease, but also to 
favor a cure. 
To this end the patient should be put in the best possible environ- 
ment ; have perfect freedom from mental worry and anxiety, in a 
situation where she can have plenty of outdoor air and exercise, and 
where everything shall be done to promote' the general health. A 
careful regulation of the diet is absolutely necessary, even where the 
case be of gonorrhoeal origin ; for the urine must be kept bland and 
unirritating under all circumstances. In many cases sugar and starches 
seem to be very poorly digested. They thus do harm, and are to be 
avoided. Alcoholics, especially wine and beer, must be given up. 
In cases where the kidneys are not acting freely, or where there is 
marked renal insufficiency, the use of hot-air baths—either the regular 
Turkish bath, or, better still, the bath given with an alcohol lamp 
placed under the chair, the patient being swathed in blankets—will 
produce good results. By this means the skin is made to do duty for 
the kidneys, and the poisonous excretions which have been retained in 
the blood are gotten rid of. Moreover, the dry hot-air bath acts as a 
derivative, drawing the blood to the surface, thus lessening the conges- 
tion of the internal organs. Under this treatment the kidneys will 
quickly resume their work, and the amount of urine will be increased 
very markedly, notwithstanding the profuse sweating. 
Massage is also of great use in many of the cases, and can be used 
directly after the hot-air bath. 
Under all circumstances, but especially where there is renal insuffi- 
ciency, I advise the free use of water. The psychical effect is often 
better if we use a mineral water; but I do not believe that any of the 
waters in the market contain a sufficient amount of alkali to do very 
much good. It is the water, and not so much the mineral ingredients 
that it contains, that accomplishes the result. I have very little faith 
in diuretics. 
The use of alkalies is of the utmost importance, and they should be 
used long and persistently, in sufficient quantity to keep the urine alka- 
line, or at least neutral. For this purpose I have used the liquor 14 
MANN : INFLAMMATION OF URETERS IN FEMALE. 
potassee in doses of five drops and more; also the acetate and citrate of 
potassium, and Rochelle salts and bicarbonate of soda. In many in- 
stances the salts of lithium are of great value. Etheridge1 advises 
lithium combined with potash to increase the flow of urine. In some 
cases one agent, and in others another, acts. A little trial will prove 
which has the best effect with each particular patient. 
Agents which act upon the liver, especially where there is constipa- 
tion, are also very useful. To this end I have used podophyllin, 
leptandrin, euonymin, and other agents of this nature. The greatest 
care should be taken to see that the bowels act freely. Where there is 
a history of constipation, flushing of the colon is of inestimable value. 
If amemia exists, the use of iron and arsenic will be beneficial. 
It is not necessary for me to enlarge further upon this matter, only 
to insist that everything must be used to restore the patient’s general 
system to normal condition. In several instances of comparatively 
recent cases, other means having failed, I have seen the greatest amount 
of good come from an exclusive milk diet. This must be kept up until 
the symptoms are entirely relieved and the pus disappears from the 
urine. I have seen a number of patients entirely cured in this way. 
2. Local, a. Through the urine. It is well recognized that certain 
agents are excreted through the urine and have an influence upon the 
membranes over which they pass on their way out of the body. The 
various agents ordinarily used in gonorrhoea, such as copaiba and 
sandalwood oil, have in several instances proven beneficial, especially 
where there is a great deal of pus in the urine. Sandalwood I have 
found especially valuable. 
I have also tried carbolic acid, salol, and hydronaphthol, with the 
idea of getting their antiseptic action upon the ureters, or their germi- 
cidal action in the urine as they pass out. I cannot say that I have 
seen any great results from the last-named group ; in fact, we are 
greatly in need of a drug which, w7hen given by the mouth, will pro- 
duce an antiseptic action in the urine. Benzoic acid, perhaps, comes 
as near as anything; but, as it produces an exceedingly acid state of 
the urine—hippuric acid being excreted—it does not seem exactly indi- 
cated. Its beneficial effects in cystitis with alkaline urine is well 
known; but I have not seen the same results in ureteritis. 
Tourneur praises the essence of turpentine in capsules, two to six, or 
even eight, a day. He considers that turpentine renders the urine less 
irritating and at the same time notably increases the amount. 
b. Direct local treatment. The discoveries and inventions of Dr. 
Howard A. Kelly 2 have opened up a new field for the local treatment 
of diseases of the ureter. By his method it is now in the power of 
1 Personal communication. 
2 “ Direct Examination of the Female Bladder, etc.,” Am. Journ. Obstet., January, 1894. MANN : INFLAMMATION OF URETERS IN FEMALE. 
15 
everyone to pass an instrument into the ureters with comparative ease. 
An operation which was formerly considered very difficult, even for an 
expert, is thus brought within the reach of all; and, though sufficient 
time has not yet elapsed for us to have formulated any particular plans 
of treatment, or to have tested any special drugs, still the general 
principles of treatment of inflamed mucous membranes may be applied 
here, I have recently dilated and catheterized the ureters through 
Kelly’s speculum, and am about to institute a series of experiments in 
the action of various drugs. Of course it will be necessary to go 
slowly, as we have no means of knowing as yet what the susceptibility 
of these structures is to the different agents. I propose to try injections 
of boric acid, weak solutions of nitrate of silver and so on, and see what 
can be accomplished in this way. 
3. Surgical treatment. Much has been written lately in regard to the 
surgery of the ureters. As yet, however, very little has been done for 
the application of surgery to their treatment. Personally, I have no 
experience with anything of this nature further than catheterizing and 
dilating the ureters. This I have done a few times, and from it alone 
have never seen any great results, although one case where I dilated 
the ureters with the catheter passed through the bladder was very much 
relieved of her pain for a considerable length of time. After about a 
year the old trouble returned ; and before the patient could come to me 
for a repetition of the operation she died. 
Treatment of the Bladder.—In one case—the one which I noted 
on a previous page as having had almost continuous ardor urince—I 
procured great relief by making a permanent vesico-vaginal fistula. 
After that was done, the patient was able to leave her commode, to lie 
down and sleep well. She died, however, of an abscess which started 
either around the kidney or outside of the ureter, and opened in the 
iliac fossa. 
In another case in which I opened the bladder, the ureteritis being 
at that time unrecognized, no relief followed. The patient afterward 
put herself under the care of a' very distinguished member of the 
American Gynecological Society, but received no benefit, and, I 
think, ultimately committed suicide, owing to the severity of her 
symptoms. 
If the bladder be much contracted and very irritable, benefit can 
often be obtained by distending the bladder with fluids. For this pur- 
pose, weak salt solutions can be used, or solutions of boric acid, or other 
similar agent. If there be granulations around the ureteric openings, 
congested areas or ulcerations, they can be treated topically by the aid 
of Kelly’s speculum. I have recently scored a brilliant success in the 
local treatment of such a case. 16 
MANN: INFLAMMATION OF URETERS IN FEMALE 
From what has already been said, it will be seen that much more 
research is necessary before we can arrive at a truly satisfactory treat- 
ment of this affection. If, however, I can succeed in rousing the atten- 
tion of the profession to its existence and to the necessity of recognizing 
and treating it, I think that the beginning of the end will have been 
reached. $jpericai| Jodrpal 
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