mixed raw, either with the "feijao" or black beans, or with molasses; and ingested it produces these parasites. I also have noticed that the children that eat much of this simple granulated cane sugar present the same phenomena.

This case was instructive to me in these particular points: First, the resistance of catgut sutures; secondly, the prompt efficiency of carbolic acid in gum camphor in killing the staphylococci and inhibiting the progress of the infection; thirdly, the good results from free in

jection of the fistula with normal salt solution followed by 1 per cent. carbolic acid solution. The H2O,, which I used for a week, did not do any better, and as it is exceedingly expensive here in Brazil, I was glad to be able to replace it with something a great deal cheaper and yet as effective.

I herewith present a photograph of the patient before operation. She is now like any other woman. For more than a month she has been selling milk on the street. She wears a belt to support her abdomen and prevent any accidental recurrence, as she does hard work. She has come to me several times and enjoys perfect health.

URETERO-INTESTINAL ANASTOMOSIS AND ITS PLACE IN PELVIC SURGERY.*

BY REUBEN PETERSON, M.D., CHICAGO.

In this day of advanced and scientific surgery, it requires more than the mere description of a new surgical procedure to assure its thoughtful consideration by the experienced surgeon. The surgical world is slowing down a bit and is not as apt as formerly to be carried away by those who devise three times a day and at bedtime a new operation or a new technique for an old operation. The burden of proof is now laid heavily upon the advocate of the new procedure and he must show, either by clinical results or experimental work, good and sufficient reasons for the faith that is in him. Especially must those advocating such an intrinsically dangerous operation, as the permanent union of the urinary and digestive tracts show that these dangers can be overcome by perfection of technique, if they hope for the general adoption of their proposed methods of operating.

It so happens that most of the experimental work on uretero-intestinal anastomosis in this country has been performed in Chicago and by members of this society. Hence I have no hesitancy in stating wherein and why my conclusions differ from theirs. It is my hope that they in turn will criticize my views as frankly since oftentimes much more can be brought out by free discussion than by a written communication.

The urinary and digestive tracts below the pelvic brim may be united permanently in three ways:

I. The ureters severed from the bladder may be anastomosed with certain portions of the intestinal tract, preferably some segment of the large bowel.

2. The anastomosis may be accomplished by implanting in the intestine the vesical trigonum with its ureteral orifices.

3. The ureter-intestinal union may be established by the formation of a permanent communication between bladder and rectum in the male and between bladder, vagina and rectum in the female.

Where the last two methods of anastomosis are employed, it is evident that not only are the vesical ureteral orifices preserved, but the natural course of the ureters in the bladder wall remains unchanged. * Read before the Chicago Gynecological Society. June 15, 1900.

On the other hand, where the severed ureters are implanted in the bowel, new ureteral orifices must be formed. These facts must be kept in mind, since they will be found all important in determining the place of uretero-intestinal anastomosis.

I. Intestinal implantation of the severed ureters.

This is a procedure which would be extremely useful to the pelvic surgeon if it could be employed with safety. In primary or secondary malignant disease of the bladder, the entire organ could be removed and the ureters implanted within the colon. It could be employed for enlarging the field of the radical treatment of uterine cancer, which had extended into the broad ligaments. Uretero-uterine or uretero-vaginal fistula where, for any reason the ureter could not be anastomosed with the bladder, could be implanted in the bowel and the patient freed from a most distressing condition. Finally the indications for its employment could be still further extended to the cure of exstrophy of the bladder and to the relief of the distressing sequels of hypertrophied prostate. But can it be employed with safety?

Some two years ago a most interesting case of sarcoma of the bladder in a negress was referred to me for operation. Having under contemplation a total removal of the bladder in order to ascertain the best methods of disposing of the ureters, I began a series of experiments in dogs on bilateral ureteral implanation. These experiments were carried on at intervals for eighteen months and were reported in detail at the last meeting of the American Gynecological Society. In addition to my own experiments I made an extensive study of the literature of uretero-intestinal anastomosis and the conclusions arrived at from this review were included in the article mentioned, which will shortly be published in the Journal of the American Medical Association.

From an experimental standpoint the operation of bilateral ureteral implantation is a dismal failure. The primary mortality is over 85 per cent. in 68 dogs subjected to this operation by different experimenters. My own results were but slightly better, since I was able to save but 5 dogs out of 28 operated upon. The animals died from acute peritonitis from a giving way of the stitches at the site of the anastomosis or from renal infection of an acute ascending type. There is absolutely no proof that a single dog who survived the operation escaped infection of the kidneys. Dr. Martin and I have been fortunate in having the benefit of Dr. Zeit's careful bacteriologic and microscopic work. This has shown infection in all cases whatever the technique employed. The animals surviving the operation died from an acute suppurative pyelonephritis

or from a pyemia from secondary infection. In a few cases the animal was able to overcome its infection with resulting contracted kidneys.

I fail to understand how any one can see any place whatever for the operation of bilateral ureteral implantation in human surgery, if his opinion be based upon experimental results-which may be summarized as follows:

I. The vast majority of the animals operated upon die from the operation itself, either from acute general peritonitis or an acute septic nephritis.

2. The animals surviving the operation usually die from an acute ascending pyelonephritis, or from pyæmia from secondary infection.

3. In a very few instances, they overcome the infection and survive with resulting contracted kidneys.

4. As one could expect when a small compressible tube like the ureter is implanted into a large muscular tube like the intestine contraction at the uretero-intestinal junction results, to be followed by dilatation of the ureter and hydronephrosis.

Those who argue for uretero-intestinal anastomosis in the human being are prone to brush aside the unfavorable results of their experimental work by arguments which a little consideration would have shown to be utterly valueless. For instance, Dr. Martin, in a recent article advocating removal of the bladder and uretero-intestinal implantation in order to extend the limits of the radical treatment of malignant disease of the pelvis, thinks that the upright position in man and the possibility of keeping the latter's rectum relatively clean will prove important factors in preventing infection. A septic cavity like the lower bowel can not be rendered clean by irrigations or the force of gravity. Do the best we can in these directions and myriads of bacteria remain, which could infect thousands of ureters and kidneys-if the former emptied into the intestine. The plea for flushing the kidneys by the employment of diuretics as a preventive of infection would prove of little avail in the presence of such active germs as inhabit the intestine. The endeavor to show that the ureters will take on rapidly increased resistance to infection by pointing out that many cases of exstrophy of the bladder survive at all ages, in spite of the contamination of the ureteral orifices, is unfortunate, since it has been shown that these unfortunate beings on the average only survive a little over 20 years. This in spite of the fact that the course of the ureters in the bladder wall remain intact and the ureteral orifices are not disturbed.

What about the improved technique by which so much was to be accomplished in the way of prevention of infection? The records of the

experimental work on uretero-intestinal anastomosis reveal many different kinds of operations to guard against infection from the mucous flap to the burying the ureters in the muscularis in order that the urine be milked down and germs prevented from going up. Yet the animals were all infected wherever the method was employed. Then having failed to prove what they started out to, the advocates of the operation are driven to the statement that while it seems to be a failure in animals, ureterointestinal anastomosis will no doubt prove much more successful in man, because of the greater resistance of the human ureter to infection and in order to prove this they cite certain cases where the patient has survived with a single or both ureters implanted in the bowel. But do the recorded cases place the operation in a more favorable light?

I have been able to collect 33 cases of uretero-intestinal implantations with a primary mortality of 37 per cent. If to these be added the cases dying later of kidney infection the mortality would be increased to 52 per cent., not a promising mortality for these days of aseptic surgery. For obvious reasons the supreme test of ureteral-implantation. must come when both ureters are implanted simultaneously, where the unilateral operation is performed, the implanted ureter and corresponding kidney may be entirely destroyed yet life be well sustained by the other kidney. If then we consider the bilateral ureteral implantations we find a primary mortality of 41 per cent. If to the cases dying from the immediate effects of the operation be added those succumbing subsequently to ascending pyelonephritis we are confronted with a total mortality of 59 per cent. Of the six cases surviving bilateral implantation, only one (Fowler's) has lived longer than a year. All the autopsies. in the cases of uretero-intestinal implantations have shown well marked lesions of pyelonephritis and there is absolutely no more proof that the survivors have escaped infection than there was proof that in animals any kidney escaped infection after implantation of its ureter in the bowel.

The objection may be raised to these statistics that they include all the cases operated upon and that now the percentage of the recoveries. would be greater. To this I would reply that I can not see that proportionately more cases are being saved to-day than formerly. Dr. Martin who has had an unusual experience in experimental ureteral surgery, in 1899 performed three bilateral implantation operations with three deaths and in only one case was death ascribed to shock. The failures are due to the intrinsic dangers of the operation, principally dangers of an ascending infection and no perfection of technique, I believe, will ever be able to eradicate these dangers.