sufficient importance to stop his work and have it dressed. Instead of losing a few hours' time in the first place to have it properly attended to he will lose two or three weeks. This and many other instances which I might mention show the necessity of attending to these wounds immediately, and not waiting until more serious results develop.

Dr J. F. Baldwin, Columbus: I have been very much interested in this paper. Those of us who are somewhat gray-haired and graduates from Jefferson, are a little bit more interested than others, because, omitting all scientific knowledge of the germs present, the treatment advocated is precisely that which we had drummed into us at college by old Professor Pancoast, viz., to use what he called the "antiphlogistic touch," which he demonstrated over and over again in his clinics, the free opening up of the infected tissue. We did not know anything of cocci then, and never dreamed of them, but the treatment was just the same as the essayist has advocated today.

It is questionable how much good is accomplished by any applications which are made after the free incision. In only one sense is the peroxid of hydrogen an antiseptic. One of our New York surgeons, as you all know, is very fond of using pure carbolic acid in these cases, followed by alcohol. This is certainly antiseptic treatment, but the mischief in these cases is not going on in the parts which you reach with your antiseptics, but in the deeper tissues. Of course we relieve the tissues locally by free incision and drainage, but after that we must trust to the powers of nature to prevent further advance of the germs which we cannot reach; and nature in these cases usually comes to our relief and accomplishes all that we could wish.

If

I wish that we could condemn effectively the dilly-dallying which we so often see, where pus has already formed, through the use of so-called poultices. When called to see these cases we usually find that poultices have been applied for a number of days, these poultices being of cranberry, slippery elm, flaxseed, bread and water, and what not. they accomplish any good I do not know what it is. There is another preparation against which I think we should lift our voices, and which I know is used quite freely, at least in the central part of Ohio, I allude to a preparation known as antiphlogistin. It has all the disadvantages of any other poultice, and is utterly worthless.

Dr B. Merrill Ricketts, Cincinnati: I do not think that the application of dressing amounts to anything. The moment we apply vaccine virus beneath the skin we have vaccination, and the moment that you are punctured with an infected stick, needle or knife you are infected if you are going to be infected, and it does not make any difference what kind of dressing you put over the wound. Peroxid of hydrogen, formaldeyhd or anything else, does not mitigate the infection which has taken place. If it is in the finger, you might amputate it, but you would have infection just the same, that is if it is going to take place.

Dr J. W. Costolo, Sidney: The last gentleman may be right, but we know that the majority of cases do not suffer from general sepsis after free incision. I think I would consider the life of a patient much safer under this treatment than if left alone until the last minute before amputating a finger, for instance, as advocated by the last speaker.

Dr Thad. A. Reamy, Cincinnati: While sitting here listening to the discussion I have been wondering why the physician does not instruct the laity in reference to these wounds so that they may prevent disastrous results. That would be a far more feasible plan and far more easily accomplished. I could not agree with my friend that every man who has a superficial wound is infected but he is liable to be so.

In 80 or 90% of these cases of superficial injury, contusion or incision, if the laity had been instructed to keep in the house a solution of bichlorid of mercury, 1-1000, or tablets, with instructions for making the solution, and to apply this on the wound and keep it tied up, there would be no need for the attention of the surgeon, or any infection. It is the duty of the physician to tell his patients how to make and apply some such solution, tell them to mark it "poison" and to keep it away from the children. Tie the wounds up with this and let the injured party go about his business. Under no circumstances redress the wound under five to six days from time of injury. Let them put on clean overdressing if appearances demand it. With such practice the lockjaw mortality even from wounds of toy pistols will be much lessened. Hydrophobia (tetanus often) will also grow scarcer.

Dr F. F. Lawrence, Columbus: It is probably true that while every member of this Association believes antisepsis to be good, he also believes asepsis to be better. Wound infection, be the wound large or small, is in almost every case the result of neglected asepsis. One method of infection sometimes overlooked is that which occurs in the changing of the dressings of the wound. It is not an uncommon thing to notice a nurse (and I am sorry to say sometimes a physician) handling soiled dressings with the fingers and then handling the clean dressings which are to replace those removed. They may possibly wash their fingers in bichlorid solution and imagine they are safe from infection. I wish to state here in reference to keeping bichlorid solution in the house as advocated by my distinguished friend from Cincinnati. This practice is one which seems to me to be fraught with as much danger as it contains possibility of good. Particularly would this be true should there be children about the house or in a household whose members would be careless in using it. Corrosive sublimate is a dangerous element to be placed in the hands of those not thoroughly competent to use it. Again I am not sure but much harm might result from a false sense of security gained by its use, however inefficiently.

It seems to me the points the essayist aimed to emphasize were, first, avoid infection of the wound; second, keep the wound from becoming infected during its aftercare; third, if we have an infected wound, promptly provide free drainage.

Dr Sherman Leach, Columbus, closing discussion: In closing I simply wish to thank the gentlemen for the discussion of my paper. I have been very much interested in the different opinions which have been advanced by the various speakers. I wish to impress upon you the importance of drainage in infected wounds; first, external drainage of the wound should be constantly kept up, and also internal drainage, giving patients free catharsis during the whole sickness, and thus unload the circulation. I also do another kind of drainage, eternal drainage. Thus the three kinds. of drainage used are external, internal, and eternal drainage.

Ureterointestinal Anastomosis, with Report

of a Case

BY JULIUS H. JACOBSON, M. D., TOLEDO

Surgeon to Lucas County Infirmary Hospital

Urinary and intestinal anastomosis is a subject which has interested the medical profession for over half a century. It has long been known that in certain animals, notably birds and reptiles, that the urinary and intestinal tracts have a common exit. It has also long been known, through clinical observations on congenital malformations of the rectum and bladder, and in cases of rectovesical fistula after lithotomy operations and through experiment, that the rectum acts as a suitable urinary receptacle and will tolerate and retain the urine, after a time, almost as well as the natural urinary bladder itself.

There are a certain class of cases, such as extrophy of the bladder, tuberculosis and cancer of the bladder, chronic cystitis, prostatic hypertrophies and injuries of the bladder and ureters, in which conditions and anastomosis between the urinary and intestinal tracts, if successfully accomplished, would be logical and curative. Since John Simon, in 1851, first recommended and performed the operation, much knowledge has been gained from the experimental and practical work which has been done to accomplish the successful anastomosis.

The anastomosis consists mainly in the endeavor to implant the ureters into the intestinal canal, although a method of vesicorectal anastomosis has been recommended. The earlier experiments and operations were on the whole unsuccessful and disappointing and for a time the entire procedure was abandoned.

The principal and main danger of the operation is that of ascending renal infection. Earlier experiments as well as the operations in the human being resulted in pyleonephritis, stricture of the ureter, complete obliteration of the

kidney, from pulling out of the ureters, giving way of sutures and from general peritonitis. Not until the science of bacteriology and the laws of infection were understood was it clearly demonstrated why the operation was attended with such dire results. It was then appreciated that, to implant a normally aseptic ureter into the normally septic intestine would almost invariably be followed by ascending. infection with its consequent pyleonephritis resulting in death.

Efforts to devise some method of preventing this ascending infection were made, and after considerable experimentation with various ingenious methods of ureter suturing, all of which proved useless, Tuffier in 1890 advised the preservation of the normal ureteral orifices in making the anastomosis, thereby preventing ascending infection. In 1894 Maydl, by successfully suturing the entire trigonum with the ureters attached into the sigmoid flexure of the colon, carried Tuffier's idea into effect and thereby placed the operation upon a sound basis. To this operation Peterson in 1901 gave the name ureterotrigonointestinal anastomosis.

It is of interest in this connection to state that the ureters have also been implanted into other structures of the body after injury. They have been implanted into the skin, urethra, vagina, all of which, from the standpoint of infection are less dangerous, but from the inconveniences they produce, are incomplete operations at best, and are not to be recommended.

The operations from urinary and intestinal anastomosis may be divided into (I) ureterointestinal anastomosis; (II) ureterotrigonointestinal anastomosis; (III) vesicorectal anastomosis.

I. URETEROINTESTINAL ANASTOMOSIS

The earlier operations of ureteral implantation were all of this kind. It consisted in the endeavor to implant the ureters into the intestine anywhere in their course between the kidneys and bladder.