Report of a Case of Extirpation 
of a Calculus from the Ureter 
by Combined Abdominal- 
Lumbar Section. 
Recovery. 
BY 
RUFUS B. HALL, M.D., 
CINCINNATI. 
REPRINT FROM TRANSACTIONS, 
1890. REPORT OF A CASE 
OF 
EXTIRPATION OF A CALCULUS FROM THE URETER 
BY 
COMBINED ABDOMINAL-LUMBAR SECTION. 
RECOVERY. 
BY 
RUFUS B. HALL, M.D., 
OF CINCINNATI, OHIO ; 
PROFESSOR OF GYNECOLOGY IN THE CINCINNATI POLYCLINIC ; CLINHCAL^XCTCRER ON 
GYNECOLOGY IN THE MIAMI MEDICAL COLLEGE. 
REPRINTED FROM THE TRANSACTIONS OF 
THE AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS, 
SEPTEMBER, 1890. 
PHILADELPHIA: 
WM. J. DORNAN, PRINTER. 
1890. REPORT OF A CASE OF EXTIRPATION OF A CAIr- 
CULUS FROM THE URETER BY COMBINED 
ABDOMINAL-LUMBAR SECTION. 
RECOVERY. 
By RUFUS B. HALL, M.D., 
CINCINNATI. 
September 2, 1889, I was consulted by Mrs. C., of Columbus, Ohio, who 
was referred to me by her family physician, Dr. J. F. Baldwin, of that city. 
The patient was thirty-six years old, mother of five children, the youngest 
four and one-half years of age. She was a slender woman, never weighing 
more than 120 pounds, and at the time of her visit her weight was about 
100 pounds. She was anemic and very nervous, caused by her suffering. 
She had always enjoyed good health previous to the present illness, which 
dated back to May, 1885, at which time she had an attack of pain that con- 
tinued twelve hours, which was believed to be renal colic by her physician ; 
when this subsided she felt as well as before, except a tenderness for a day 
or two over the region of the left kidney and lower part of the abdomen. 
The physician was so certain that the cause of the pain was the passage of a 
stone from the left kidney that he had careful inspection made of the urine 
for days, expecting to find the calculus ; in that he was disappointed. Ever 
after the first attack she was subject to sudden and severe paroxysms of 
pain, varying in frequency from three to six weeks, for a period of about 
three years. The pain was located in the region of the left kidney at the 
commencement of each attack, but in an hour or so would diffuse itself over 
the whole abdomen. These paroxysms were usually of short duration, vary- 
ing from three to six hours. During the last eighteen months, however, the 
attacks of pain remained longer, usually ten to twelve hours, and the intervals 
became shorter, about ten to fourteen days. Each paroxysm, for a year or 
more, was preceded by an uneasy sensation in the left side of the abdomen for 
two or three hours before the severe pain came on. After trying morphine 
without giving the desired relief, her physician used inhalation of chloro- 
form, keeping the patient under its influence until the paroxysm passed off. 
The husband, who is a very intelligent gentleman, under the direction and 
advice of his physician, soon learned to administer the chloroform to his 
wife during these attacks, keeping her under its influence until they passed 
off. He told me that he had administered it frequently during the last 4 
eighteen months, giving her enough to make her wholly insensible. He 
would then remove the chloroform from her face and apply it again when 
she showed signs of pain, using it much the same as it is used in labor, until 
the attack passed off. In all of the paroxysms the pain would suddenly dis- 
appear, just as it does in renal colic when the stone is forced from the ureter 
into the bladder. The fact that the stone could never be detected only 
served to make the diagnosis more obscure. The paroxysms were so like 
renal colic that her physician would not give up his first diagnosis, yet many 
of the leading symptoms were absent. She never had hematuria ; repeated 
examination of the urine failed to reveal red blood-disks, pus, or anything to 
suggest stone or other serious disease of the kidneys. During her four and 
one-half years' illness she consulted eight or nine prominent physicians, and 
only one of them was willing to admit the possibility of a stone as the cause 
of the pain. I mention this to illustrate the difficulty of diagnosis in the 
case. Her family physician had studied her symptoms so carefully that he 
believed that she had a stone in the kidney, which was the cause of her ill- 
ness, and sent her to me for its removal by lumbar incision. The most care- 
ful examination of the abdomen failed to give any assistance in diagnosis, 
and pelvic examination was also negative in its results. A thorough manipu- 
lation of the left kidney, which was rendered possible by the exceedingly lax 
and thin abdominal wall of the patient, did not cause any pain ; the kidney 
could be plainly felt between the two hands, and was not enlarged. There 
was no hematuria, pain, or any symptoms following the examination sugges- 
tive of stone. After her attacks of pain were over she was perfectly relieved 
except an irritable bladder which followed each one, and continued two or 
three days afterward. The amount of urine passed in twenty-four hours 
was normal, and was free from casts and albumin. The family history7 was 
negative. After carefully considering the case I was at sea regarding a 
diagnosis. That the cause of the attacks of pain was located in the abdomen 
was evident, and that they had some connection with the left kidney or 
obstruction to the flow of urine through the ureter was reasonably certain, 
but the cause and location of this obstruction were not apparent. I was 
strongly inclined to the opinion that there was a stone either in the kidney 
or ureter, but I was not willing to make a lumbar incision when the diagnosis 
was so uncertain. If I should do so I would be subjecting the patient to 
the operation without much hope of relieving her; I therefore advised an 
abdominal section for diagnostic purposes, and be governed in the operation 
by what this revealed. If I detected a stone in the kidney, remove the stone 
by a separate incision through the loin. I was encouraged to perform this 
novel operation by the confidence I possessed, that a simple exploration of 
the peritoneal cavity was free from serious risk, and that the exploration 
would settle the question of diagnosis without a possibility of doubt-the 
very question which had been the bone of contention by the many distin- 
guished consulting physicians preceding me. If in the exploration I should 
find a stone in the kidney, its extraction would not be difficult by the lumbar 
incision after the method of Thornton. By this method we are able to 5 
grasp the kidney with the hand inside of the abdominal cavity, and hold it 
firmly against the loin in the most favorable position for reaching and re- 
moving the stone by the lumbar incision. These were not the only advan- 
tages to be gained by abdominal section in this case, as will be made apparent 
later in its history. The patient was admitted to my " Home" for operation, 
which was made September 4th, at eleven o'clock. At ten A. M. the patient 
told me if I would wait a couple of hours I would see her in one of her par- 
oxysms of pain, for she was certain one was coming on. At eleven o'clock 
she was anesthetized by Dr. C. B. Van Meter, and with the assistance of 
Dr. Samuel Zurmehly, and in the presence of Drs. J. F. Baldwin and C. A. 
L. Reed, the operation was made. After the patient was put upon the 
table, she being then under the influence of chloroform, in palpating the 
abdomen I was surprised to find a small tumor, which appeared to be the 
size of a pint cup, in the region of the left kidney. I was certain that this 
did not exist the day before, and could not account for its presence now. I 
first made median abdominal section four inches in length, and introduced 
my hand into the abdominal cavity. I at once passed the hand to the left 
side and found an elongated, exceedingly thin-walled cyst, somewhat larger 
than the closed hand. Above this I could outline the kidney, which ap- 
peared of normal size. At the lower end of the cyst there was a groove in 
it, and the end overlapped its posterior attachment. Into this groove I passed 
my finger, and could feel a stone some three or more inches below the kidney. 
The diagnosis was perfectly clear to me now. I had to deal with an im- 
pacted stone in the ureter. The left hand was not taken out of the abdomi- 
nal cavity until the stone was removed. As the kidney appeared healthy I 
did not want to sacrifice it; I therefore made the lumbar incision, as planned 
before commencing the operation for the removal of a stone from the kidney. 
After cutting down to the kidney it was fixed with the left hand and incised, 
making an incision large enough to admit the finger. At once there was a 
gush of about one pint of urine. The cyst in the abdomen had now disap- 
peared, leaving the kidney in its normal position. I could now feel the stone 
about two and one-half inches below the pelvis of the kidney in place of 
three and one-half, as it appeared before the kidney was incised. The most 
difficult part of the operation yet remained, that of the removal of the stone, 
which proved to be an exceedingly trying task. With a pair of forceps, 
introduced through the lumbar incision, guided and aided by the hand inside 
of the abdominal cavity, several attempts were made to dislodge and remove 
the stone. It could not be grasped in the bite of the forceps without, at the 
same time including the surrounding tissues, as could be very easily deter- 
mined by the hand inside of the abdomen. Knowing as we did the exceed- 
ing thinness of the pelvis and ureter forming the collapsed sac, we were 
very careful in our manipulation to avoid injuring that. After convincing 
myself that it was impossible to remove the stone through the lumbar in- 
cision without more room, and finding that I could push the stone with the 
ureter up toward the kidney to a limited extent, I decided to lay the kidney 
reely open, which I did, along the convex border, leaving about half an 6 
inch of kidney tissue at either end of the organ unincised, with the intention 
of first removing the stone, and later the kidney, if the hemorrhage could 
not be controlled. The kidney wound was held aside by retractors in the 
hands of the assistants, and after a tedious effort, by invaginating the sac with 
the hand inside, I was able to reach the stone with the handle of the scalpel, 
and peel the tissues from it. The hemorrhage from the kidney was controlled 
by sponges wrung from hot water. I dressed the wound in the loin by 
placing a rubber drainage-tube in the kidney, but no stitches were placed in 
that organ. The drainage-tube was left long enough to reach over the side 
of the bed to a bottle upon the floor, where the urine was collected from the 
kidney. The wound was sutured carefully around the drainage-tube. As I 
was not certain that I had not injured the thin sac and thus opened the peri- 
toneal cavity from behind, the very thing I wanted to avoid when I planned 
the operation, I placed a glass drainage tube in the abdominal cavity, which 
was removed in eighteen hours, as it was not required. My patient suffered 
very greatly from shock, which I attribute partly to the loss of blood. 
Highest pulse-rate after she rallied was 126, highest temperature 100 8°-for 
one registration only, which was the following day at three P. M. After that 
time the temperature varied from 98.5° to 99.5°. On examination the 
stone, which weighed only 3/^ grains, and measured yV inch long, inch 
wide, and T4ff inch thick, was found to have a most peculiar shape, as you 
will observe from the specimen here presented to you. It represents a section 
of a cylinder with a slot cut in one side, parallel with its long axis, to a little 
The stone-3| times the natural size. 
past the centre. At one end of the stone, and in the slot, it is blackened from 
contact with the urine. This blackened end was presenting toward the 
dilated portion of the ureter and kidney, where it was impacted, with the 
narrow slot spoken of extending parallel with the ureter, making an opening 
about the size of the thickness of an ordinary pin, which was quite sufficient 
to carry off all the urine from the kidney so long as no mucus or other 
solid material interfered with this small opening. But if a little mucus or 
any inflammatory material became deposited over this opening you can 
readily understand how it would close it as perfectly as a ball-valve. With 
the escape of urine from the kidney thus prevented we have a very satis- 
factory explanation of the pain, as well as the cause of the uneasy sensation 
before the attacks of renal colic, and their sudden termination without the 
passage of a stone, as well as why I did not detect the cyst the day before 
the operation, for it is evident that none existed save for a few hours pre- 
ceding and during the attacks of pain. All of that portion of the ureter 7 
above the stone, with the pelvis of the kidney, would be subjected to dila- 
tation until the pressure was strong enough to press the foreign material 
through the small opening, when the patient would get the sudden relief, 
as though a stone had passed ; thus, it is easily explained how the symptoms 
were so misleading to her physicians. The four and one-half years the 
patient suffered from this malady was quite sufficient to dilate the pelvis and 
ureter into a great sac, such as existed in this case and spoken of in describ - 
ing the operation. We have a reason equally as good why the stone was 
not forced on into the bladder when we examine its shape. With its rough 
exterior it would be a difficult stone to pass under favorable circumstances, 
and when it was once impacted with its long axis corresponding with the 
long axis of the ureter, the slot gave exit to the urine, except when blocked 
by mucus or debris, and that would pass through before the pressure was 
long enough continued to have any effect in dislodging or driving the stone 
along the tube. The stitches were removed from the abdominal wound on 
the seventh day. The wound was healed perfectly. On the following day 
the stitches were removed from the lumbar wound. For eight days the 
urine passed from the bladder contained small blood-clots, while that from 
the incised kidney remained clear. 
A. very interesting fact was observed in the secreting power of the incised 
kidney in comparison with the other organ. The drainage-tube must have 
been placed in such a manner as to drain nearly or quite all of the urine 
from the incised kidney into the bottle. For each eight ounces of urine 
passed from the bladder there would be about six and one-half or seven 
ounces deposited in the bottle. It appeared that the incision in the kidney 
did not materially interfere with its secreting power. On the eighth day I 
removed the drainage-tube from the kidney wound ; for four days after that it 
appeared as though all the urine from the left kidney passed through the 
sinus. After the twelfth day only a small quantity escaped occasionally 
This gradually diminished until the sixteenth day, and on the twenty-first 
day the wound was perfectly healed. On the thirty-sixth day she went home 
n perfect health, and has remained so to this day. 
So far as I have been able to examine I cannot find a case of 
removal of a calculus from the ureter by the combined abdominal- 
lumbar operation, and but four cases of removal of a stone from 
the ureter by any other procedure. I find the report of a case by 
Dr. Cullingworth, in the Trans. Path. Soc. of London, 1884 and 
1885, vol. xxxvi. p. 278, of abdominal section and removal of stone 
from the ureter near the bladder; patient died on the fourth day. 
Dr. Terrey's case : in which he was able to remove a stone from the 
ureter near the kidney by the lumbar incision only ; patient recov- 
ered. The case is recorded in the American Journal of the Medical 
Sciences, vol. xcvii. p. 579. A case by Dr. Berg, in Centralblatt 
fur G-ynakologie, January 28, 1890. A female, sick fifteen years, 8 
who had passed about twenty small calculi: Temporary relief fol- 
lowed, and then very severe dysuria set in. By aid of the sound, 
stone in the bladder was detected. The urethra was dilated, the 
finger introduced, and it was found that a calculus was impacted in 
the right ureter, the point projecting into the bladder; the bladder 
was opened from the vagina and the stone extracted without diffi- 
culty. And that of Dr. A. T. Cabot, Boston Medical and Surgical 
Journal, September 11, 1890-removal from ureter by lumbar inci- 
sion only. These cases are so different from mine that they need not 
be considered, so far as the operative procedure is concerned. The 
case of Dr. Cullingworth would probably have recovered if he had, 
at the same time, extirpated the kidney on the affected side. That 
of Dr. Terrey was no more serious than that of removal of a stone 
from the kidney by the lumbar incision; while that of Dr. Berg 
is so different from the others that it has hardly any bearing 
upon .any of them at all, and is only mentioned from the fact that 
it was a case of removal of stone from the ureter. 
The case I report is an interesting one : 
1. On account of the great difficulty of a correct diagnosis before 
abdominal exploration. 
2. The ease with which a correct diagnosis was made after abdo- 
minal exploration in this heretofore troublesome and obscure case. 
3. If the case had been operated upon by the lumbar incision 
only, a correct diagnosis could not have been made, neither could 
the stone have been removed by that method, and the patient would 
have recovered with a fistulous opening in the loin. 
4. It illustrates in a clear and concise manner the possibilities of 
the combined method of operating for extraction of calculi from 
the ureter.