No. 3. In May, 1870, I examined this case, which was one of vesico-va ginal fistula due to violence, with retroversia uteri and atresia orificii ex terni.
Patient a primipara, 23 years old, had pains five weeks before the ex pected time, followed speedily by rupture of the membranes. Six hours later the midwife arrived, and found prolapse of the cord, the head being still high up. She sent for the physician, who is said to have effected ex ternal turning of the head, and to have applied the forceps without success three times during the ensuing night. Then he allowed the patient to re main as she was till next noon; then he again applied the forceps, finally extracting a dead child with the aid of the hook.. After the second op eration there was continuous and involuntary flow of urine. Whenever the patient stood up the water dripped. The pelvis was normal, spinte 10.8, crista 11.6. Conjug. ext. 8.6, obliqux, 10.6 inches.
We found the urethra patent, and in the left side of the fundus vesicle an oval fistula x 1 inch in size, from which a cicatricial band extended to the left commissure of the entirely obliterated os uteri. The uterus itself was left retroverted. She had not yet menstruated again. I beard nothing further of her.
In this case very probably the premature application of the forceps caused rupture of the left commissure, and the left blade cut through the vesico vaginal septum; since there was no mechanical obstacle to delivery.
No. 4. (1871.) Superfici«1 resico-utero-vaginal fistula on the 9th day after confinement. Cure in one sitting.
Mrs. N., 34 years old, 5 children. First 3 confinements normal; an abortion between 3rd and 4th. Fifth pregnancy normal; confinement lasted twenty-four hours. At nightfall forceps were applied effectually. For 8 days she did well, but on the 9th she noticed an involuntary ilow of urine. 4 years later she was normally confined of her 5th child, which is yet living. In the anterior vaginal vault 2 lines from the anterior lip is a hole 1th inch in size. Under chloroform I denuded the anterior lip to the extent of ith inch, and put in 11 silk sutures. (Nov. 28, 1871.)
The 3rd stitch to the left ulcerated out, but the spot soon closed under superficial cauterization. The rest of the wound healed by first intention, and on December 12th the patient was discharged from the Rostock clinic as cured.
In this case the location and shape of the fistula, and the history of the confinement show us that the forceps had nothing to do with its occur rence; the soft parts were contused by the child's head.
No. 5. Urethro- and vesieo-vaginal fistula ; pneumonia. Death 6 months after confinement. (1874.) No. 109. Mrs. A. Kohler, VII p., 31 years old.
After 6 easy and normal deliveries she was confined of her 7th child 3 months ago. Breech presentation, hydrocephalus, forceps to after-com ing head. Slight hemorrhage. 8 days later dripping of urine. Since then is bedridden. Examination shows rupture of the anterior cervical lip, with two urethro-vaginal fistulse. The patient was much emaciated, and died of pneumonia before any operation could be undertaken. The specimen is in the museum of the Royal Maternity Institution. There is a wedge-shaped loss of tissue in the anterior 03, the scar of which is con tinuous with a fistula -flif inch long by Ith inch broad, situated in the middle of the vesico-vaginal wall. The right ureter is 2 lines, the left 3 lines from the opening. The edge of these fistuhe is in places double. Only * of an inch of urethra is left; towards the neck of the bladder there is a hiatus it an inch long by * inch broad, which is united to the left margin of the upper fistula by a scar. The peritoneum is drawn down almost to the level of the anterior hp of the os uteri; the bladder is very gmull, and its walls are hypertrophic. There are no traces of perimetritis. The anterior pelvic diameter is 4 inches, the oblique 41 inches, and the transverse diameter of the brim is 51 inches; no great contraction.
The central location and the enormous size of the opening render it probable that the forceps was at all events a partial cause of the lesion.