Implantation into the bowel has been performed many times, but infective nephritis has so frequently resulted that the operation is not generally recom mended. Fowler (Amer. Jour. _Med. Sci., Mar., 'OS, vol. cxv, p. 270) describes a new method by which he operated suc cessfully on a boy, 6 years old, for ex strophy of the bladder. After opening the abdomen and isolating the ureters, a longitudinal incision 7 centimetres long was made on the anterior wall of the rec tum through the serous and muscular coats; the coats were dissected back until a diamond-shaped space on the submucous coat was exposed. A tongue shaped flap with its base upward was cut in the mucous membrane of the lower half of the diamond. The flap was doubled up, approximating the submu cons surfaces and secured with sutures; thus, a dap-valve was secured, both sides of which are covered with mucous mem brane. The ureters were then placed in the incision with obliquely-cut ends, pre senting on the external surface of the flap, and were secured by a few stitches in the upper half of the diamond; the flap with the attached ends of the ureters was then pushed into the rectum. The gap in the mucous membrane was closed by catgut sutures and then the original wound in the rectal wall was closed by fine-silk sutures. The valve-flap and compression of the circular muscular fibres of the rectum combine to prevent the passage of freces into the ureter dur ing defecation.
In implantation of the ureters in the rectum the principles of personal method are: I. The ureters empty into the bowel in the direction of its length and from above downward so that the urine is dis charged in the direction taken by the fecal current. 2. The ureters are buried 6— longitudinally in the walls of the rectum for the distance of an inch or more, so that in the act of defecation the faecal mass will squeeze the calibre of the ureters closed by its pressure on the mucous membrane, and so that pressure is exerted from above downward in the direction of the onward flow of the urine. 3. The ureters are further protected by the muscular coat of the intestine, by being surrounded by the circular fibres of the bowel, which hold the ureters closed during defecation. After the pressure of the hecal mass and of the circular muscular coat is removed, urine retained in the ureters will spurt forth with considerable force, acting as its own cleanser. 4. The implantation is in the lower bowel, which is normally empty save during defecation. The operation is performed with the patient in the Tren delenburg position. The ureters are ap proximated by fine-silk sutures and the implantation into the bowel is made when the latter is completely empty and secured above the seat of operation by a clamp. The ureters are secured to the fibrous and mucous coats of the bowel by a number of closely-applied sutures of fine catgut or of silk, great care being necessary not to penetrate to the mucous coat of the ureter or to apply sutures so as to constrict the ureters. F. H. Martin
(Jour. Amer. Med. Assoe., Jan. 25, '99).
Ureter° - intestinal anastomosis: 1. Ureteral implantation into the rectum is always followed by ascending infec tion. The resulting pyelonephritis is caused by the bacillus coli communis. 2. The primary mortality is very large (S4 per cent.), no matter which opera tion is done. 3. Of 120 dogs operated upon. 90 per cent. died of peritonitis due to leakage of urine or general sep sis and pyelonephritis (luring the first ten days. 4. Dogs living a longer time died of pyelonephritis, pyclonephrosis, and pyfemia. 5. Dogs which had fully recovered from the operation and the resulting pyelonephritis, and were, to all appearances, in perfect health and vigor again, all had granular contracted kidneys, due to induration and cicatriza tion of diseased areas. The rectum acts as a fair substitute for the bladder in .07 such cases. 6. Dogs which had fully re covered after unilateral implantation were living by the other kidney. The kidney of the side operated on was atrophic and granular, the result of an early pyelonephritis. The functionally active kidney was of two to eight times the size of the atrophic one. 7. A re view of the literature on uretero-intes tinal anastomosis in man shows that no better results can be expected in man than in animal experiments. S. The ureters are frequently dilated, but show very little or no disease, no matter how extensive a pyelitis or pyelonephritis is present. 9. The bladder is always in fected by way of the urethra, whether it is emptied at the time of operation or not. A purulent cystitis was found in every case, caused by staphylococcus albus and bacillus soli communis. 10. Artificial immunity to infection by the so-called colon group of bacteria is the only hope of making uretero-intestinal anastomosis a feasible operation. R. Zeit (N. Y. Med. Jour., May 18, 1901).
Injuries of the Ureter.—Aside from the wounds which occasionally occur during surgical operations, injuries of the ureter are exceptionally rare. Three classes of injuries have been reported: subcutaneous injuries by indirect vio lence through the unbroken abdominal wall, injuries from penetrating wounds of the abdomen, and wounds inflicted during surgical operations. Morris ("Ori gin and Progress of Penal Surgery," p. 1-1(1, London, 'PS) gives abstracts of eleven cases, out of the twenty-three which have been reported as subcutane ous injuries of the ureter, which he be lieves may he considered well-authenti cated cases.