Finally it is to be noted in connection with page 32, that very lately Lawson Tait ' made an artificial urethra with a trocar in the left vaginal wall in a case Buffering from a largo urethro-vesical fistula. Then he completely restored the old urethra by means of side flaps, and closed the new one after having first restored the vesico-vaginal wall.
No. 1. Large vesico-utero-vaginal-fistula after II-face position with contracted pelvis; easy forceps case. In spite of fistula patient had 3 pre mature childbirths in 31 years.
Mrs. K. , 28 years old, has had 3 living children' born unassisted. At 4th birth (Aug. 1859) waters flowed off one hour after pains began. She now complained of desire to urinate, and the midwife repeatedly tried in vain to introduce a silver catheter. I was called, but could not introduce an elastic instrument, the child being firmly wedged in the second face position in the contracted pelvis. There was considerable swelling of the face, and the heart sounds were inaudible; so I applied the forceps and delivered the head after 1 or 2 attempts at traction. The child had just died. In 3 to 4 days the woman Bent me word that she could no longer retain her water, and when I saw her, on the Eth day, I detected in the anterior vaginal vault a vesico-vaginal fistula half an inch in size, and with uneven, ragged, and tender borders. The patient first wore a sponge, then later a urinal; but this latter gave her so much trouble that she soon discarded it. In August, 1850, hardly a year later, the patient had her fifth confinement, and my father was obliged to use the forceps again.
In 1862 she was confined with a small immature child (footling), and in April, 1863, she had her seventh and last delivery, which passed off fairly well. The child was small, and died at the age of one month.
The patient's pelvis was highly contracted; the distance between the spitue was 9.6 inches, between the cristse 10.8 inches, the external conju gate was 6.9 inches, the diagonal 3.8, and the true conjugate therefore was 3.2 inches, the left oblique diameter was 8 inches, the right 8.2 inches.
In the summer of 1864 I had the patient come to Rostock, so that my colleague Simon might operate upon her. NVe now found a superficial vesico-utero-vaginal fistula, f of an inch long and 1.4 inch broad. Evi
dently the fistula had largely increased in size in the three latter deliveries. Simon healed the posterior lip in the cleft and obtained good union. Since then the patient menstruates through the bladder, and soon fully recov ered her strength.
No. 2. Rachitic contrachon of the pelvis. 3rd pregnancy. Perfora tion, cephalotripsy, gangrene of the vesico-vaginal wall. A vesico-vaginal fistula appeared on the 7th day.
Patient 26 years old, 3 children; abortion at 24 years, prolonged labor and still birth at 25 years old. At 3rd delivery the liquor amnii was lost prematurely, and the dolores praparentes were very painful; dilatation of os very slow. The head was high and the patient exhausted; an ac coucheur who was called tried to turn; he did bring a foot down into the vagina, but could not turn the child. When I arrived the patient was greatly excited, the abdomen very painful; there was high fever and nausea.
The heart sounds were not audible. I perforated through the great fontanelle, at the left, injected the skull several times with water, applied the cephalotryptor a few times, and compressed the skull on all sides. In spite of this extraction was very difficult. It needed long-continued and great traction in the first position, and 'found several times that the anterior edges of the pelvis were too greatly pressed upon by the blades of the instrument. Finally a large boy was extracted. In the first few day-s after delivery, patient was fairly well, save for ischuria and pain upon catheterization; but the discltarge smelled very badly. On the 7th day a portion of vagina the size of a dollar suddenly came away, accompanied by a horrible stench; ilimediately there followed involuntary flow of urine. The fistula was high up in the anterior vaginal vault. In spite of this the patient gradually recovered, and since a large part of the posterior vesical wall was left, she could retain her urine for a time. She was very cleanly, so that there were no excoriations or ulcers. In fact her general condition was so good, six months after confinement, that although there was a hole in her bladder-wall large enough to pass a finger through, I could not persuade her to undergo an operation.