DOUBLE URETERureter is comparatively uncommon. Out of 726 consecutive autopsies made in the New York Infant Asylum, four cases of " supernumerary ureters" were observed. In another series of autopsies of about one-half this number of cases made in two other institutions only one case of any kind of kidney malformation was seen (Holt). Double ureter proper may be found on both sides or on one side alone, more commonly the left side. When double ureter exists there are two pelves, an upper and a lower, either of which may be the larger, and they do not connect. The ureters either join before reaching the bladder or remain separate and enter the bladder on the same side at two distinct points. I have examined one post-mortem specimen of double ureter on both sides. Each ureter entered the bladder separately on its corresponding side. In fused kidneys most frequently we find two pelves and two ureters which enter the bladder in the usual manner ; there may be only one ureter, and this enter the bladder in the mesial line. Fused kidneys, although usually placed in the middle line, may be situated as a mass upon one side of the spinal column, having two ureters entering the bladder separately on the same side or on opposite sides.
In solitary or unsymmetrical kidney, an extremely rare condition, found once in about 350o post-mortem examinations, the rule is that there is a single ureter which enters the bladder Read before the Missouri Valley Medical Society, September, woo.
on the same side on which the kidney is found. In such an instance there is no evidence of a rudimentery kidney on the other side, and in about io per cent. of these cases the supra renal capsule is wanting. It was my fortune to see a post mortem examination, at the New York Hospital twenty years ago, upon the body of a well-nourished young woman dead of " idiopathic peritonitis." There was found a large solitary kidney on the left side (one ureter), which was in a state of chronic parenchymatous nephritis. There was also a bicor nuate uterus, and the left lung was divided into three lobes and the right lung into four lobes. In another the post-mor tem examination having been made by my preceptor (I missed the autopsy), a large solitary kidney (one ureter) was re moved from the body of a tall, thin man of about fifty years of age, dead of nephritis.
A congenitally atrophic kidney on one side may have a ureter varying from an impervious cord to a practically nor mal tube entering the bladder in the usual way. It is important to observe that a solitary kidney may have two ureters whether there be a true congenital absence or atrophy of the opposite kidney (Henry Morris).
My own case of double ureter on the left side with probably the same anatomical arrangement upon the right side may be briefly stated. A fairly well-nourished delicate female child, two and a half years old, was referred to me, May 26, 19oo, by Dr. W. 0. Bridges. The father is an epileptic, and on the mother's side an aunt had died from pulmonary tuberculosis. The child suffered from irritability of the bladder, wetting the bed, napkins, etc. The urine secured by catheterization was acid, cloudy, and precipitated a whitish purulent deposit. Tubercle bacilli were found in abundance. A tumor, evidently the left kid ney, was easily palpable.
My Harris segregator and instruments for catheterizing the ureters are only intended for adolescents or adults, hence there was no attempt towards determining the condition of each kid ney ; in fact, this was deemed unnecessary. Nephrectomy was advised and carried out in the Clarkson Hospital, May 29, i9oo.
An oblique incision was made and the diagnosis of tuberculous kidney verified. The right kidney was palpated through a button hole opening made in the right side. This kidney was some what enlarged, or rather elongated and lobulated, and at the time I thought it tubercular. We decided that the only hope for the child was the removal of the palpably and visibly diseased left kidney. This I did after being considerably puzzled at first before recognizing that I had two ureters with separate pelves to deal with,—an upper much enlarged tubercular tube, a lower normal tube. The former was followed well down below the pelvic brim, the latter for a short distance only. They were removed together with the kidney. It is my opinion that these ureters entered the bladder alone ; had they joined before entering the bladder, it is probable the lower ureter would have shown some sign of in fection.
Healing was per primani, and the child left the hospital June 18 ; at that time there was still some irritability of the blad der, and tubercle bacilli ( from the stump of the upper ureter prob ably) were to be found in the urine. Since then she has done well, and a few days ago was reported in a good general condition. The after-treatment consisted in the giving of urotropin and methylene blue.
In connection with the subject of double ureter, the writer wishes to draw attention to the fact of the possibility of error in using " segregators" to determine the presence and condition of both kidneys. It is conceivable, also, that mis takes might occur when reliance is placed wholly upon ureteral catheters.
Prior to an extraperitoneal nephrectomy of election, it is wiser, in addition to using all other aids, to palpate through a button-hole opening for the presence of any gross patho logical condition of the opposite kidney.