should be taken. This is a precaution against disagreeable surprises. Stereoscopic radiographs taken after very thorough evacuation of the bowels may give a fairly good idea of the relation of the stone to surrounding bony structures (Gibbons). Occasionally it happens that ureter-stones not firmly incarcerated change their places, so that some days they are down low and can be palpated, while other days they are higher up and cannot be felt. This fact emphasizes the value of repeated examinations from the rectum or vagina.

Positive evidence of a ureter-stone is at the present time almost generally considered (at least by the surgeons) cause for prompt surgical action. Although, as Deaver says, a calculus may remain lodged in the ureter indefinitely without producing serious symptoms, yet such cases are exceptional, and were such a calculus to be discovered by chance it is questionable whether it would not be the surgeon's duty to remove it as a prophylactic measure. It can, I think, hardly be questioned that the well-known dangers which may ensue from neglect of ureteral calculus are much greater than those which attend its removal by operation. Even the remote possibility of development of cancer at the point of impaction is to be considered. The only exception for surgical interference is the class of cases in which with each attack of kidney colic a larger or smaller calculus is discharged. X-ray pictures between the attacks may, of course, be entirely negative.

It is evident that in cases of this kind the salvation of the patient lies in the proper hygienic and dietetic treatment, combined with urinary antiseptics a treatment which should always be adopted after operations on kidney or ureter.

The operative method for the removal of a stone from the ureter is less agreed upon, if, as is the writer's object in this paper, we consider in particular stones lodged in the ureter during its course through the pelvis (lower ureter).

There are three locations in the ureter where a stone is liable to be arrested:

1. One and one-half to two inches from the pelvis of the kidney as the ureter bends forward over the psoas muscle;

2. In the bend of the ureter about one to

two inches below the pelvic brim (Deaver says, at the brim of the pelvis, where it dips down across the bifurcation of the common iliac artery);

3. In the vesical portion (just before the ureter passes into, or during its course through, the vesical wall.-Morris).

The usual operative route for stones in the vesical portion (3) is intravesically, if the stone is lodged very close to the vesical orifice of the ureter. Where the stone is situated an inch or more from the bladder wall, this method is not safe, and the combined intra- and extra-peritoneal method is to be recommended. Ureterstones lodged near the pelvis of the kidney (1) are best removed extra-peritoneally through incisions as used for exploring the kidney. It is fairly a matter of choice whether the stone be removed by incision through the kidney substance or directly through the pelvis of the kidney or by incising the ureter itself. The danger of urinary fistula from incision into the ureter is extremely slight if the passage to the bladder is free. If drainage is desired, ureterotomy is not advisable. Direct drainage of the pelvis of the kidney is, of course, preferable, just as, in a case of stone in the cystic duct, we prefer to drain the gall-bladder by incising the gall-bladder itself, and do not, unless unavoidable, drain through the cystic duct. And since we believe that most ureter-stones originate in the kidney pelvis, the pelvis of the kidney should be drained in almost all cases, even though conditions for natural drainage may be favorable.

The best operative method for stones in the lower ureter-that is, from the point where the ureter crosses the common iliac artery to the vesical portion-is still under discussion. I believe with most surgeons that ureteral stones are mostly secondary. Primary stones, rare as they may be, must be due to a local cause irritation, foreign body, kinking of the ureter by adhesions, etc. However, we possibly underestimate the frequency of primary ureter-stones since in the vast majority of cases only one stone has been found. If the kidney is the originator of the stones, why do we so frequently find only one? Formerly we believed that ureter-stones near the pelvis of the kidney and near the vesical orifice were much more

frequent than those in the lower ureter. With the aid of the X-ray, we have found that this is not true. They number perhaps 50% or more of all ureteral stones and had simply not been diagnosticated.

The operation must aim (1) to remove the stone or stones in order to avoid the well known dangerous consequences to the kidney, and (2) to prevent the recurrence of stone.

If our sole object were to remove a stone from the ureter during its course through the pelvis, the following extra-peritoneal method would suffice: A straight incision parallel to the external border of the rectus muscle extending from the semi-lunar fold of Douglas to the pubis. The peritoneum is not opened, but pushed toward the middle line and with it, as a rule, the ureter, appearing as a whitish or yellowish-whitish tape. It is surprisingly simple to expose the ureter in this

manner

from the brim of the pelvis to the bladder (about four inches in extent). Instead of mak ing an incision in the linear Spigelii, it may, of course, also be made a little further inward. In that case it exposes and splits the anterior sheath of the rectus muscle, the muscle itself being either cut or pushed aside. In view of the necessary drainage, this incision is, in my opinion, preferable to the low gridiron operation, since it interferes less with the muscular support of the abdominal wall. The removal of the stone is then usually an easy matter. However, as stated, this method takes into consideration only the removal of the stone, and leaves entirely out of question the second point-the prevention of a recurrence of stone formation. It seems evident to me that the mere removal of a stone from the lower ureter does not in any way guarantee the complete cure of the patient, and here, as always, it must be our endeavor to remove not only the effect but the cause (cessante causa, cessat effectus).

Morris attributes lodgment of a ureter-stone in the bend of the ureter to the curve made by the ureter. The ureter-stone near the pelvis of the kidney is also usually found where the ureter bends forward over the psoas muscle. Again, the lodgment of a stone may be due to narrowing or constriction of the ureter, the normal size at the three points where ureter-stones are usually found being one-seventh,

one-fourth and one-tenth of an inch, respectively. I fully agree that the origin of the majority of ureter-stones is in the kidney, and that they are merely arrested in the part of the ureter now under consideration. Some stones, however, are probably formed there. In the former instance, we have to explain the lodging of the stone in this particular place; in the latter, the origin and lodging at this particular place the widest of all three places-just mentioned.

There is, to my mind, nothing more likely than that, in men, an inflammatory condition of the appendix; in women, a like condition or adhesions around tubes and ovaries, or in connection with retroflexion of the uterus, might cause ureteritis or periureteritis, or produce a kink in the ureter, or at least increase the normal bend of the ureter at this point. In this way small stones coming down from the kidney may be retained and increase in size in loco, and in this way a ureter-stone may begin to form about a small nucleus of mucus.

I therefore advocate an operation that permits the examination of these organs and the necessary steps for their reparation or removal. Such an examination can be satisfactorily made only after opening the peritoneal cavity and, in my opinion, it should be made in all cases, especially, however, if the stone is on the right side; for then only can it be ascertained whether the appendix is diseased and whether adhesions around it are not indirectly to blame for the ureter-stone. Before employing this technique I had two cases in each of which I had to remove the appendix after having previously removed a ureter-stone. The intraperitoneal beginning of the operation is of advantage not only for the above reason, but because in a great many cases the finding of the stone is made more easy. After locating the stone, the peritoneum, if infection be feared, may be closed at once, but had better be kept open as advised by Gibbons, to facilitate the removal of the stone with the aid of the finger in the peritoneal cavity. The finger is placed against the stone, the peritoneum pushed off from the abdominal wall and the stone removed extra-peritoneally. The peritoneum is then closed and the rest of the incision sutured in the usual manner down to the

lowest point, through which a drain (no unprotected gauze) is passed to (not into) the small opening in the ureter. A nick in the ureter wall is sufficient to permit the extraction of a good-sized stone. It is advisable to push the stone up a little ways from its lodging place, so that the little cut does not strike the inflamed or ulcerated part of the ureter wall. I have never tried, and do not expect to try (certainly not in men) to push the stone into the bladder, since the opening in the ureter heals very quickly. Frequently hardly any urine is discharged through the drain. It is certainly not advisable to attempt to suture the ureter, which necessitates lifting it from its bed and risking necrosis of its wall. Besides, it is entirely superfluous, since the small incision in the ureter heals, as a rule, very rapidly, usually in less than two weeks, and the drain-opening a few days later. Occasionally the stone in the ureter is only felt and the ureter not distinctly seen. That sewing in such a case is not possible is evident.

The proper treatment, then, for stone in the lower ureter is, in the writer's opinion, a lap

arotomy which allows a thorough examination into possible causes for the lodging of the stone or for the origin of the stone in situ; removal of the cause, if found, intraperitoneally, and then removal of the stone from the ureter extraperitoneally by pushing away the peritoneum as above described. That this method should, of course, be employed if the diagnosis is doubtful, needs hardly to be mentioned, and that a definite diagnosis cannot always be made needs not to be discussed. In spite of most painstaking examination, some cases remain doubtful. That, furthermore, the combination of appendicitis and ureter-stones is not rare, is proved by cases reported in literature (Gibbons, Deaver, and others), the two cases of mine before mentioned, and two more cases in which I employed this method and removed a badly diseased appendix and ureterstone. In all these cases the ureter-stone was located about one and one-half to two inches from the pelvic brim.

Positive evidence of a ureter-stone, therefore, instead of causing us to exclude other diseased conditions in this locality, should make

us suspicious of them. The only operation which answers all demands is the combined intra- and extra-peritoneal ureterolithotomy.

To summarize: The proper treatment for stone in the lower ureter is the combined intra- and extra-peritoneal ureterolithotomy.

The intra-peritoneal part of the operation serves for exploration and for the removal of conditions which are possible etiological factors in the lodging and formation of stone. It also frequently makes the finding of the stone easier. The extra-peritoneal steps serve for the removal of the stone.

(Stones higher up, at the crossing of the ureter and the iliac vessels can be removed by this combined route, as described and first emphasized by Gibbons. Should it be difficult to push the peritoneum back far enough, it might become necessary to add McBurney's gridiron incision. In this way a flap is formed which gives complete access to the whole ureter from its point of crossing with the iliac vessels to the bladder. The shape of the entire incision is analogous to the cut described by Fowler for the extra-peritoneal removal of ureter-stones in the lower ureter and now frequently advocated for the ligation of the common iliac artery.)

DEGREE OF CARE AND SKILL WITH WHICH A PHYSICIAN OR SURGEON IS LEGALLY CHARGEABLE.

By P. W. HABERMAN, ESQ.

The question of the degree of care and skill which a physician or surgeon must exercise arises in every action for damages on account of alleged malpractice. There are certain standards to which a practitioner must conform. If he does so, of course there is no ele. ment of liability even though the result be unsatisfactory on the part of the patient. If, on the other hand, a practitioner has fallen short of the measure of care and skill which the law requires of him he may be liable in damages. The question of what degree of skill and care should be accepted as the standard in a given case depends always upon the facts and circumstances of the case, and is, like any other question of fact, to be determined by the jury under appropriate instructions of law to be given by the court. The court will apply the appro

priate principles to the facts in hand and instruct the jury accordingly. It then remains for the jury to determine whether the practitioner has been remiss or not.

In view of the fact that many practitioners specialize along certain lines and others undertake to fill the more ancient calling of a general practice, the legal principles applicable to a case of malpractice arising under the one or the other are different.

A physician is said to impliedly hold out as a representation to a patient that he possesses that degree of skill and will exercise that degree of care which is ordinarily possessed and observed by others in like callings and in similar localities. The question of locality necessarily plays an important part, as a physician practicing in a settled community, having readily accessible instrumentalities which would not be available to a practitioner in a rural and sparsely settled community, would be held to a degree of care much higher than the latter. For instance, if it be generally accepted that with regard to a given disease, a certain antitoxin should be used, the failure to use the same by a physician practicing remote from depots where such supplies could be had would not leave him open to the charge of lack of care, whereas a physician practicing within access of such a depot of supplies would be held derelict in his duty in failing to obtain and use the same.

The rule is strict against the trying of experiments without the knowledge and consent of the patient. It is necessary that established and accepted forms of treatment be followed and if a physician, whether he be a general practitioner or specialist, undertake an experiment, the same is undertaken by him at his own peril. If the ordinarily and generally ac cepted practice is that a given ailment be treated in a certain manner and some other method is adopted which results in injury to the patient, it is not a matter of any consequence how much skill was possessed by the physician, and his failure to follow the accepted form of treatment would be held to constitute negligence.

The fact that the service is gratuitously rendered does not change the principles applicable for the purpose of determining whether the physician or surgeon is chargeable with mal

practice. The same degree of care and skill is exacted of a physician or surgeon in the performance of gratuitous services as one who expects to receive compensation therefor.

It is elementary to say that a physician does not warrant a cure, and if the practitioner has exercised the degree of skill and care with which he is chargeable under the law, he is under no liability to the patient, even though an unsatisfactory and unfortunate result be attained.

Quite apart from the question of the degree of technical skill required of a physician or surgeon, as the case may be, is the question of lack of care involved in non-attendance to a patient. If a physician answer a call there is an implied contract that he will give the patient that attention which is necessary until such time as the same be no longer necessary or the physician be discharged from attendance. One who leaves a patient at a critical stage of a disease without reason or sufficient notice to enable him to procure another medical attendant, to the patient's damage, is guilty of an actionable wrong. The physician is bound to use not only the ordinary care and skill exacted of men in his class, but is bound to exercise a discriminating judgment as to when his visits may be safely discontinued.

The foregoing comments apply to practitioners generally without undertaking to differentiate between general practitioners and specialists. The degree of care and skill with which a general practitioner is chargeable is, however, different from that standard to which the law holds a specialist.

A general practitioner is said to be "bound to bestow such reasonable, ordinary care, skill and diligence as physicians in the same neighbor hood in the same general line of practice ordin arily have and exercise in like cases." He must keep himself informed of the general advancement in matters pertaining to his profession and is chargeable with negligence if he fails to conform to the requirements of advances in science which are generally understood and fol lowed. He is chargeable with a reasonable de gree of skill as distinct from the very highest degree of skill and with ordinary care as dis tinct from a very high degree of care, but for the absence of such ordinary skill or the failure

to exercise such ordinary care, resulting in damage, the physician is liable at law.

The standard of skill and the degree of care to which a specialist is required to conform is much higer than that required of a general practitioner. One who holds himself out as a specialist impliedly warrants that he possesses a degree of skill and knowledge higher than that possessed by a general practitioner and furthermore that he is the possessor of that degree of skill and knowledge which specialists in his particular department who keep pace with the advancement in such specialty, possess. It has been held in Missouri in an adjudicated case that a specialist will be held to that degree of skill which he holds himself out to possess and that by professing to be a specialist he holds himself out to possess "a degree of skill and diligence as high as that possessed by other good surgeons of the specialty to which defendant belonged." (McMurdock vs. Kimberlin, 23 Missouri Appeals 1. c. 531.)

*

It will thus be seen that the specialist is chargeable with bringing to the aid of his patient a degree of skill and knowledge such as is possessed by physicians who give special study to the specialty, having regard to the state of scientific knowledge at the time of the treat ment.

"The physician is not to be judged by the mere result obtained or for mere errors of judg ment. His negligence is to be determined by resource to the pertinent facts existing at the time of his examination and treatment, of which he knew, or, in the exercise of due care, should have known. It may consist of a failure to ap ply appropriate remedy upon a correct determination of existing physical conditions, or it may precede that and result from a failure properly to inform himself of these conditions." (Rand vs. Twitchell, 71 Atlantic, 1045, Vt.)

The general practitioner in many instances, confessing that he has reached the end of his resources, refers the patient to a specialist. This well illustrates the difference in the degree of skill which may properly be exacted of the one and of the other. The general practi tioner adopts the remedies and treatment most appropriate under the circumstances in the light of his general practice, but is not liable