within outwards, at a distance of about one-half inch below the edge of the opening. The ends of the threads are now dragged on, and the ureter pulled into the lumen of the bowel. The threads are then knotted firmly, thus fixing the ureters in their new position. The opening in the gut is then closed firmly around the ureters, and one or two Lembert's sutures are placed over the knot retaining the ureter in position. (In performing the typical Maydl operation the retaining thread must not be passed into the lumen of the ureter, but either through the wall of the ureter not entering the lumen, or through the substance of the trigone.) Much stress has been laid on the advisability of allowing the open end of the ureter to lie free in the cavity of the bowel (Tuffier, Beck). Fowler, on the contrary, in his successful case, attached the end of the ureter to the apex of a flap of mucous membrane with the idea of making a valvular opening. As a matter of fact, it seems, from a view of cases operated upon, both in dogs and in man, that the position of the ureteral orifice has nothing to do with preventing ascending infection.

Another point in technique that is of the greatest importance is how to place the sutures between the intestine and the ureter along the intestinal tunnel (if one may use the expression). One suture should be placed uniting the ureter and the edge of the opening in mucous membrane. The finest needles and the finest silk should be employed and care should be taken not to penetrate the lumen of the ureter. Then with the same care the intestinal flap should be fastened down; and if necessary an omental graft placed over the line of incision, or the suturing reinforced by tucking it in by a few Lembert's sutures.

The cases of exstrophy that have been under my treatment are three in number. The histories of the cases are briefly as follows:

Case No. 1.-M. O'K., aged 6 years, female, white. Came under my care in November, 1898. The case was one of complete exstrophy. The pubic bones were ununited and two inches apart. The external genitals were divided into two homologous halves. The vagina was fully developed, the external opening being guarded by well-developed hymen having an oval hole in the center large

enough to admit a pair of artery forceps. A sharp ridge divided the vagina from the bladder. Immediately above the ridge the apex of a rudimentary trigone commenced, at the basal angles of which the slit-like orifices of the ureters presented. The orifices were surrounded by tuberculated projections of mucous membrane and the left orifice was a little higher than the right. The mucous membrane of the bladder was completely prolapsed when the patient cried, but could be reduced with ease between the edges of the separated recti muscles until it formed a cavity as large as a mandarin orange. When the patient was given an anesthetic the reduction was so complete that the edges of the fissure were quite near together and the bladder was reproduced. This suggested a possibility of forming the urinary bladder, which was attempted at the first operation.

First Operation.-The edges of the bladder were dissected from the skin all around the upper and lateral aspects, and from the deeper connections for a distance of about one-half inch. The mucous membrane was then inverted and the raw surface of the muscular coat united by sutures applied in the same way as Lembert's intestinal stitches. Flaps were then cut from the groin and abdominal wall, as in Thiersch's operation, and they were superimposed at once on the raw surface of the bladder. A large catheter was passed under the lower edge of the united bladder walls to drain off the urine. The operation was a failure. The bladder walls parted company and the flaps separated also. Second Operation.-(Three weeks after the first.) Ureteral catheters were passed into the ureteral orifices and temporarily tied there. The bladder wall was now systematically dissected away leaving a portion of mucous membrane around the ureteral papillæ. This was tedious and bloody, but was accomplished without opening the peritoneal cavity. The ureters were now dissected from their beds, and a puncture made between the wound and the vagina just above the hymen, through which the ureters were drawn. They were secured by sutures in this position. The operation was attended by considerable hemorrhage and followed by much shock. For a few days the child was in a critical state,

suffering from nausea, vomiting, quick pulse and high temperature, with a facies that suggested some peritoneal complications. Eventually, however, the child recovered. For one year after the operation trouble ensued at the ureteral orifices. Calculi formed in the vagina, which were removed with difficulty. Since that time none have formed. (The method of operating in the case was essentially unsatisfactory. I wished to try a Maydl's operation, but after discussing the possible dangers with the parents they declined.) The vagina does not form a receptacle capable of holding much urine, and the utmost that was done in this case was to make the wearing of a receptacle easier for the child and to remove the ulcerating vesical mucous membrane.

Case No. 2.-B. S., female, colored, aged 26 years. Operation March 29, 1901. Also a case of complete exstrophy, like case 1. The recti muscles were wide apart. The pubic bones were ununited. The external genital organs were divided. The hymen was intact, an oval opening leading into a well-developed vagina. The trigone was poorly developed and the ureteral orifices were asymmetrically placed, the right one being placed lower than the left and almost hidden from view underneath a button of hypertrophied mucous membrane. The operation was performed on March 29, 1901. The ureters were catheterized and the catheters temporarily tied in by ligatures passed around the ends of the ureters. The bladder was now dissected away, with the exception of an oval piece of trigone which was left attached to the ureteral orifices. The ureters with the attached piece of trigone were now lifted out of their bed, and dissected back into the broad ligaments until the uterine vessels were reached. Then the peritoneal cavity was opened and the ureters still further liberated. A length of each ureter of about two inches was now available. The uterus with its appendages was now inspected. It was infantile and the ovaries were small, but otherwise all were normal. It was found that a greater length of ureter could not be obtained without division of the broad ligaments; and, as this, to be safe, would probably have necessitated a hysterectomy, the idea was given up.

The sigmoid flexure was now brought into view and was found

to have a very short mesentery; so short as to render further manipulations very difficult and unsafe. Clamps were applied above and below the site for implantation and the gut opened on its convex surface. Attempts to suture the ureters in the bowel were so unsatisfactory, owing to the impossibility of applying the stitches without tension, that I decided to abandon the operation. So the ureters were withdrawn, and the opening in the intestine closed with Lembert's sutures. The ends of the ureters were then stitched to the margin of the hymen and the abdominal cavity closed without drainage. The patient suffered from severe shock but eventually recovered without serious symptoms. It was a source of much regret that the operation had to be abandoned. Owing, however, to the impossibility of coaptating the ends of the ureters and sigmoid without tension, accurate suturing was a physical impossibility. I feel certain that, if I had trusted to the sutures, leaking would have occurred and the case would have terminated fatally. This shortness of the sigmoid mesentery was encountered by Park in his case and was the cause of deficient suturing followed by leaking with death from peritonitis (Medical News, May 29, 1897, LXX, page 702). The patient refused further operative procedures.

Case No. 3.-L. R., female, white, aged 3 years. This was a case of complete extroversion not differing from cases 1 or 2 except that there was more protrusion of the posterior bladder wall. There was no sign of the navel. The recti muscles and pubic bones were wide apart. There was the same irregularity in the position of the orifices of the ureters, that of the left side being so narrow that it admitted the ureteral catheter with some difficulty. Urine was collected from each ureter and was found normal in every particular. A Maydl's operation was decided upon and it was thought better to divide it into two stages. 1. Excision of the bladder with the exception of the ureteral orifices. 2. Transplantation of the ureters into the sigmoid.

First Operation.-This was performed on April 16, 1903. It was tedious and bloody; but the patient rallied from it satisfactorily. The peritoneal cavity was not opened. The ureters were

dissected out of their beds for about one inch and a half, and the ends sutured to the margin of the hymen. The patient rallied well. The raw surface granulated in a clean manner. Second Operation. This was performed on May 1st. The ureters were liberated and it was found that a small portion of the trigone

Anterior
muscular

band

-Retaining
thread

uniting the two ureters had sloughed. The mucous membrane surrounding the orifices was intact. The ureters were then separated from one another and catheterized, the catheters being fastened in by temporary ligatures. The peritoneal cavity was now opened in the median line and the sigmoid flexure brought out by the abdominal wound. It was long and easily manipulated. Two