The results obtained from these operations were bad, the mortality being high, the animals living from one to seven days after the operations, excepting in one instance in which the animal lived for two months. The cause of death in all cases was either peritonitis, ascending infection to the pelvis of kidneys from pulling out of ureters, after implantation, and from intestinal obstruction.

These experiments verify the results of other investigators in this field, as the same results were obtained and practically the same conclusions drawn, i. e., that successful ureteral implantations into the intestine, without the trigonum, by methods heretofore used, is practically impossible. A distinct advance, however, was made and one which we believe with further experimentation and investigation offers prospects of success, i. e., the utilization of the vermiform appendix for the anastomosis. The idea was first suggested by Dr W. J. Gillette after we had made a number of unsuccessful implantations and were somewhat discouraged by the results obtained.

Immediately we began implanting ureters into the appendix, but even here we met with no signal success, excepting in one case in which the right ureter was implanted into the appendix, the dog recovering from the operation and voiding urine from the rectum. The animal lived for about two months when it was killed, the postmortem examination, much to the chagrin of all concerned, revealed complete obliteration of the right kidney with its ureter, as a sequence of ascending infection.

It is a difficult matter to form a just estimate of ureteroappendicular anastomosis, as it cannot be carried out in the dog and other lower animals as it could be done in man.

The appendix of a dog is a short, broad, quadrangular cul-de-sac, about 1⁄2 to 1 inch in length, and of about the same width; this renders infection from the appendix of a dog just as liable as from any part of the intestinal tract. In man the shape and length of the appendix as well as its situation seem to make it an ideal place for the

anastomosis whenever it is necessary to implant one or more ureters into the intestinal tract, without the trigonum of the bladder.

REPORT OF A SUCCESSFUL CASE IN MAN

This case was reported in the Journal of the American Medical Association of January 3, 1903. The patient, a male, aged 29, entered the Lucas County Hospital on April 2, 1902. The father died of Bright's disease; the mother died of so-called "dropsy;" the brothers and sisters are all living. There is no tuberculosis or cancer in the family. The patient relates that since birth he has had no control over his urine; it has always dribbled away, but he did not know what it was. He was operated upon when still a child in Greifswald, Germany, but he cannot give the exact nature of the operation. He has always been obliged to wear some sort of a receptacle to hold the urine; otherwise he has enjoyed the best of health. About one year previous to his entrance to the hospital, he underwent several operations for the relief of his condition. These operations consisted in the endeavor, by means of plastic operations, to cover the defect in the bladder, but they were not successful. At the same time he also underwent an operation for the relief of a large left inguinal hernia, which was thereby cured. He states that previous to these operations, his genitals consisted of a rudimentary penis which was double, and that the urine flowed from one side of the organ.

The rudimentary penis was removed during the plastic operations and examination of the patient at time of entrance revealed a well-nourished, tall, muscular individual, presenting no emaciation; the heart, lungs, liver, and spleen were apparently normal. Above the symphysis pubes is an area of deep red tissue looking like granulation tissue and covered by purulent secretion, which on close inspection proves to be a part of the bladder; from the lower part of the same urine can be seen to spurt at intervals of 30 to 60 seconds; both ureteral orifices can be seen and ureteral catheters can be passed into them. The abdominal wall, as well as the

anterior wall of the bladder, is absent, which permits the posterior wall to prolapse forward.

The diagnosis of exstrophy of the bladder was easily made. Catheterization of the ureters, and examination of the separate urines, gave the following result: Left kidneythe urine runs very freely through the catheter and is of a clear amber color, acid in reaction, highly albuminous; on microscopic examination, epithelial cells, leukocytes, urates, but no casts are found. Right kidney-the urine is of a dirty greyish color, flocculent and opaque, containing albumin, but not so much as is present in the other kidney; on microscopic examination there are found great quantities of pus, red blood-corpuscles, epithelial cells, but no casts. The urine examination reveals mainly the following facts: Both kidneys are the seat of chronic inflammation; the right one more so than the left, which is the result of ascending infection.

Operation: A ureterotrigonointestinal anastomosis, modified after Maydl, was made on April 19, 1902, (Drs Brewer and Steinfeld assisting). A mixture of chloroform and ether was the anesthetic used. The patient was prepared in the usual manner, while special care was given to the sterilization and preparation of the exstrophied portion of the bladder, which was the infected area to be feared. A ureteral catheter was passed into each ureter; the incision made immediately above the bladder about four inches in length, and the peritoneal cavity was opened; the patient was raised to the Trendelenburg position. The intestines. were held back by sponges. The incision was carried downIward to the center of the bladder (between the ureters) dividing it in two. The ureters could be plainly seen running outward, backward, and upward; with the catheters in them, they were surprisingly large and easy to manipulate, which greatly facilitated the work. Each ureter was dissected free by cutting it away from the bladder, leaving a circle of bladder tissue about one-half inch around the vesicoureteral openings thereby leaving the natural ureteral

openings into the bladder unmolested. The peritoneum on the right side was incised and reflected along the course of the ureter, permitting the ureter to be lifted from its bed. The peritoneum was further stripped from the posterior wall of the pelvis around to the rectum. An opening into the right lateral side of the rectum was next made at about the level of the sacral promontory, into which the ureter with bladder-wall attached was sutured; first, mucosa of the bladder to mucosa of the rectum by a continuous silk suture (black iron-dyed silk), then the serosa of bladder to the serosa of the rectum were also applied to make the anastomosis more secure. The reflected peritoneum was finally sutured back into place (by a continuous catgut suture) making the entire anastomosis covered by peritoneum and placed extraperitoneally. About three and one-half inches of the lower part of the ureter was placed in a new position. The same procedure as described for the right side was made on the left side, the anastomosis on the left side being made opposite to the one on the right, a trifle lower. The peritoneal cavity was thoroughly irrigated with salt solution, sponges removed and the patient was lowered to the flat position. All of the remaining portions of the bladder walls were extirpated, hemorrhages being controled by ligatures and cautery.

The incision was closed by interrupted silk-worm-gut sutures supplemented by layer suturing of catgut. In the lower angle of the incision, where tension was great, a few tension sutures were applied. A large drainage-tube was left in the lower angle of the wound and the whole abdomen was supported by broad adhesive strips.

After the operation the patient suffered greatly from the shock, but, under stimulants and salt infusions, recovered. Immediately after the operation the urine seemed to irritate the rectum, the desire to urinate being constant, which gradually disappeared as the rectum became more tolerant, until a tolerance of three to four hours was obtained. The abdominal wound became infected as was anticipated, sup

puration was profuse which ceased after a time, allowing the wound to heal gradually, until at present it is practically closed. A fistula persisted for some time, the result of a suture imbedded deep in the lower angle; after the removal of the suture this fistula closed.

A ventral hernia has developed at the operation site, which is especially noticeable when the patient is in the upright position. His condition now, 13 months after the operation, is good, his occupation is that of a coachman, and he works with no inconvenience, voids urine about every four to six hours, and is able to retain it throughout the night. For a few months after the operation, occasionally, he would pass the urine unconsciously during sleep, but this has gradually disappeared. He gives no evidence of renal infection.

A recent examination of the urine reveals it to be of a greyish white color, flocculent, the specific gravity is 1.010; strongly alkalin, and contains no albumin or casts.

On the Value of Ureteral Catheterization and Urine Separation with Hemo- and Urinocryoscopy in Surgical Diseases of the Kidney

BY WILLIAM E. LOWER, M. D., CLEVELAND

Renal surgery has kept well apace with the rapid strides made in the surgery of other organs. However, the good showing in the surgery of the kidney has not been, as in many of the other instances, due so much to the improved technic of the operation, as to the better methods of diagnosis.

The splendid results in renal surgery which are now being reported from all over the world are encouraging in the extreme, and are splendid monuments to greater precision in diagnosis. To analyze briefly the cause of the high mortality rate of a decade or more ago, we find the principal reasons for the post-operative deaths to be, (1) the