there by tying. The only difference in my case was that I did not pass these silk stitches through the mucosa of either bladder or ureter, for fear of causing the formation of calculi on the silk. In Baldy's case, the proximal end of the ureter was too short to go to the bladder without too much tension on the sutures, so he brought the bladder over to that side of the pelvis by two stout catgut sutures. Kelly (Johns Hopkins Bulletin, Feb., 1895) gained one inch in his case by dissecting the bladder from the horizontal rami of the pubis and dropping it back into the pelvis. Boldt (AMERICAN JOURNAL OF OBSTETRICS, 1896, Vol. XXXIII, p. 844) passed a ureteral catheter into the fistula before the operation, which I forgot to do until after I had begun, and thus found the ureter more readily; after cutting the ureter off he left the catheter in the proximal end, and passed it into the bladder through the opening, and out through the urethra, thus running less risk of leakage if his union failed.

Fullerton (Kelly's Operative Gynecology, Vol. I, p. 463) severed a double ureter on right side. As soon as detected she closed the distal end and introduced both proximal ends into the same opening in the bladder, with good result.

Baum, Witzell, Vert and Kelly have performed extraperitoneal implantation into the bladder, and although they were all obliged, as I was, to open the peritoneum for a few minutes to find the ureter, I believe that with a little more experience we could complete the operation extraperitoneally, thereby reducing the small death rate, Kelly having lost but one case, on the seventh day, from sepsis.

Second-My case is interesting because it was due to difficult parturition. Fergman states that of sixty-five cases of ureteral fistula which he collected, twenty-five were due to this cause, and of these twenty-five, in sixteen the forceps were used too soon. and in nine they were used too late. In twelve vaginal hysterectomy was the cause, while two were due to stone in the ureter and ulceration; three to abdominal section; one had a traumatic origin; two from pelvic abscess; one from a pessary, and one from tubercular necrosis of the ureter, as in Krame's case.

Third-It shows the value of urotropine in making the urine aseptic; my patient had a temperature of 103 degrees a week before the operation, which may have been due to infection of the ureter, but if this was so, the urotropine apparently remedied it, for there was no temperature whatever after the operation.

Fourth-Owing to the extensive bruising at the time of the con

finement, and also owing to the four plastic operations, the vagina was reduced to a very small cone of cicatricial tissue, so that repair by this means was out of the question. In a large and capacious vagina I believe that the ureter could be found and repaired by splitting open the vagina and exposing the base of the bladder, as in my method of repairing severe vesicovaginal fistulæ. In no case should we implant the ureter into the bowel, nor tie the ureter so as to cause hydronephrosis. Nephrectomy, even as a last resort, is hardly justifiable, in view of the possibility of there being only one kidney, and the splendid results of transplantation of the ureter.

CASE II, which was also one of transplantation of the ureter, and for which I am indebted to my friend Dr. Reddy, illustrates the second most frequent way in which this accident may happen.

Mrs. H., 29 years of age, Canadian. She began to menstruate at 14 and continued to do so normally till her marriage, at 16. She had one child a year later, which was born dead; this may have been due to syphilis, as she had such a history, but it is more probable that the child was still born because it was dragged out with instruments nineteen hours before the natural termination of labor. Five hours from the first pain the baby was delivered and dead. The reason assigned for this procedure was that the pains had stopped for a while at the end of four hours, and the accoucheur could not wait for them to come on again. She recovered from this labor more or less, but after eleven years she had to consult a physician for pain and leucorrhea. On making an examination he found a moderate laceration of the cervix, which he treated for about three weeks with tampons. She felt much better after this, but a few months later, feeling worse than ever, she consulted Dr. Reddy, who, finding a large cauliflower growth filling the vagina, at once diagnosed cancer of the cervix, and insisted upon her entering the Women's Hospital under my care. This was on Nov. 7, and no time was lost, for the next day I performed vaginal hysterectomy by the clamp method. The cauliflower growth was first removed with the sharp curette and scissors, as is my custom, and the remaining apparently healthy raw surface thoroughly disinfected with bichloride. The two upper clamps were put on the top of the broad ligaments from above, so as to guarantee that the ovarian arteries should not slip out, which is one of the risks of this operation, leading to death by secondary hemorrhage. On the other hand, it causes twisting of the broad. ligament, and some claim that this increases the chances of catch

ing the ureter between the jaws of the clamps. There was no shock, and everything went well until the clamps were removed, when it was found that there was some leakage of urine from the vagina, which, on careful examination, was found to be coming from the right ureter. She was allowed to thoroughly regain her strength from the first operation, and a month later preparations were made to transplant the wounded ureter into the bladder. She was given urotropin, as in the previous case, until the urine was thoroughly aseptic, and on December 7, with Dr. Reddy's assistance, the operation was performed. It was a little more difficult than usual, owing to the anatomical changes brought about by the vaginal hysterectomy, and the mass of inflammatory tissue resulting therefrom, which also prevented me from performing the extraperitoneal method. Also the injury was an inch higher up on the ureter than in the first case, so that I was obliged to detach the bladder from the pubis and draw it well up to meet the end. of the ureter, which also had to be drawn down as far as it would come, in order to get it to enter the bladder, to the highest point of which it was attached in the manner already described. The peritoneum was sewed over the ureter and a drainage tube introduced down to the site of the implantation. Owing to an oversight, the glass catheter à demeure was not put in immediately, so that two or three times eight ounces of urine accumulated in the bladder. Whether from this cause, or owing to the tension of the sutures, due to the ureter being too short, about a fourth of the circumference of the ureter pulled out from the bladder, and to our great disappointment, the dressings were soaked with urine. Fortunately, the urine being aseptic, there was no infection and no rise in temperature. Not only did all the urine from the right kidney come out by the abdominal wound, but also a large portion of the urine from the other one. I had arranged the catheter à demeure in the bladder, with a light rubber tube leading into a measuring glass under the bed, and Dr. Reddy ingeniously arranged another catheter with a long tube to bring the urine from the abdominal incision to another jar. The nurse kept a careful table showing exactly how much urine passed through each catheter per twenty-four hours. As the patient was in splendid condition at the end of a month, I reopened the abdomen, found the hole in the bladder from which the ureter was partly pulled out, and stitched it up with much difficulty, owing to the amount of granulation tissue surrounding it. The patient bore this operation well, although there still remained some leakage.

By sitting her up in bed and packing the wound in the abdomen more and more came by the normal opening, until within a month afterwards the fistula was completely cured and the patient went home, looking and feeling very well.

CASE III.-The third case was one of end to end suture of the divided ureter, the accident having happened during the course of an abdominal section for removal of a very large, broad ligament cyst. I was indebted for this case to my friend Dr. Virolle. She was a Mrs. G., 37 years of age, who came under my care on October 17, 1904. Menstruation began at the age of 12, and was always normal. She was married at 32, but was never pregnant. Eight months ago she noticed that she was getting larger in the abdomen. Her bowels were regular and her water was normal. She at first thought she might be pregnant, but on examination, her breasts were found to be those of a virgin. The uterus was small and pressed up against the right side in front. I sent her into the Samaritan Hospital, and a few days later, after being properly prepared, the abdomen was opened and a trocar introduced into the tumor, which extended up to the liver, allowing about two gallons of amber-colored fluid to escape, after which the tumor was easily drawn out; that is to say, the upper half of it. Being a broad ligament cyst, it extended up behind the intestines, which could not, however, be peeled off it. Many broad bands of adhesions had to be tied in segments in order to free the tumor enough to allow it to come out of the abdomen. Several times while tying these segments of peritoneum what was thought to be the ureter was picked up and nearly tied; but each time it was recognized and dropped again. About the sixth or seventh time that it ran this risk it was not recognized, and a clamp being put upon it, it was just being cut through with the scissors. When the latter had gone half way through it diagonally downwards and outwards it was recognized by the mucous membrane showing its nature, which was not evident before, on account of its great size and width, it being nearly three-quarters of an inch wide. However, it was only cut about three-quarters through, so that it was easy, although somewhat tedious, to sew the muscular layer all round, with interrupted sutures, and then another layer of running sutures was put over that. Efforts were made for another half hour to get the sac enucleated, but it was found so densely adherent to the layers of the broad ligament, and extended so deeply down to the pelvis, and lying on the large veins and arteries, that it was thought wiser to adopt the old plan of cutting the cyst

off, leaving enough only to enable one to sew it comfortably to the abdominal peritoneum. Two drainage tubes were then put in, one to the bottom of the remains of the cyst cavity, and the other down to the cut in the ureter, in case that the line of sutures failed to prove water tight.

Notwithstanding the prolonged operation, the patient made an uneventful recovery, without the slightest sign of urinary fistula. The drainage tube leading down to the ureter was removed in three or four days, when it was found that nothing was coming from it; but the other tube, going down to the bottom of the remains of the cyst, was left for several weeks, and there was during that time a watery discharge, which gradually became less and less. When it had quite dried up the tube was removed. The patient is now going around and feeling quite well. I might add that it would have been much easier for me to have removed the tumor by the new method of going down through the broad ligament of the healthy side and across the uterus and up on the other side, taking out both ovaries and tubes and uterus. But the patient begged that I would not remove her ovaries, so that, rather than have her die on the table from injury to the large veins, I thought it wiser to resort to the old method of marsupialization and drainage of that portion, about one-eighth of the cyst, which was so densely attached far down on the floor of the pelvis. The result has proved the wisdom of this course.

248 BISHOP STREET.

REPEATED TUBAL PREGNANCY.*

BY

EDWARD N. LIELL, M.D.,
Jacksonville, Fla.

Formerly Lecturer in Gynecology, New York Polyclinic, and Visiting Gynecologist to St. Elizabeth Hospital, New York, President Florida Medical Association.

(With two illustrations.)

To successfully meet or cope with an emergency is to be prepared for it. The patient upon whom I have operated twice for tubal pregnancy, of which the accompanying specimens are the result, presents a rather unusual history. Age 38; has had two children, at full term. Sterility followed the birth of the second.

*Read at the Thirty-second Annual Meeting of the Florida Medical Association, held at Jacksonville, Fla., April 19-21, 1905.