No. 6. Large left-sided vesico-vaginal fistula, attached to the left ramus of the pots. .kfter an unsuccessful attempt to secure direct closure, transverse obliteration repeatedly done.
Hrs. B., 26 years old, a small, stout, strongly built brunette, was con ruled April 27th, 1874, after a normal pregnancy and a 4 days' labor, and gave birth to a small full-term dead child. The midwife is said to have raptured the membranes as soon as she arrived, and to have sent for the physician only several hours later. The latter attempted for 2 days, at first alone and then with a colleague, to deliver with the forceps. Finally, perforation was successfully resorted to. Since then the patient has passed urine involuntarily. We found a vesico-vaginal fistula 1 inch in size, the left angle of which was attached by a cicatrical band to the left minus of the pubis.
April 30th she was operated upon, 15 sutures being passed. When they were removed upon the 6th day, it was found that the angle of the wound in the left vaginal vault was not united. Most of the urine passed by the vagina. On July 20th a ring of vaginal tissue inch in breadth was denuded about lir inches from the vaginal entrance, and the wound united vrith 14 silk sutures. On the 7th day, on removing the sutures, the right and middle portion had healed per primam, the left not at all. Patient dismissed at request. She re.entered May 8th, 1876. May 27th V. abortion. 4 months' ftetus; great pain.
The pelvis is generally contracted; spines 9.4, cristre 10.4, conjugata enema 7. Obliqum 8.8 inches. July 4th, 1886, 3rd operation. Fresh ening of posterior vaginal wall for 1+ inches. Then from the left lower corner of the fistula t.re vesico-vaginal wall was split; and after ligature and torsion had been applied to several arteries, and the actual cautery used for the parenchymatous hemorrhage, the vesico-vaginal wall was united to the denuded portion of the recto-vaginal wall by 18 silver wire sutures. July 11th, 8th day, 14 sutures removed. Union complete. Net a drop of urine passes. On the 13th, the 10th day, removal of last 4 sutures. Urine flows from the left corner, though no opening is to be seen. Later, all her urine passed per vaginam. August 3rd, patient
temporarily discharged. October, 1875, transverse obliteration repe,ated; It was successful in a part, a pea-sized opening remaining to be closed.
No. 7. Rupture of entire vesico-vaginal wall by forceps in a pelvis con tracted to the first degree. Cure, save for a lentil-sized opening sealed near the anterior lip of the os uteri, which resisted cauterization for months.
No. 453. May 17, 1876. S., 26 years old; chorea when a child. July 13th, 1875, delivered by forceps after being 4 days in labor. That same day urine passed by vagina. Iu the anterior vaginal wall, somewhat left of the median line, is a tear inch long and an inch broad, through which urine escapes. The vesical mucous membrane projects through it into the vagina. May 20th, denudation begun at lower border of fistula, and made about -3; an inch broad. The end of the freshened area lies about IV, of an inch from the urethral opening. The projecting vesical mucous membrane was cut off. 18 wire sutures were used. May 27th, the 8th day, 16 sutures removed. Union appears to be perfect. June 2d, small fistula found at the upper angle, and cauterized. 2 sutures removed. June 13th, vesico-vaginal fistula entirely cured save for a lentil-sized fistula in front of the os uteri. Ferrum ca,ndens used. June 27th, repeated. July llth cauterization with acid. sulf. concentr. July 14th; only very seldom while standing or walking does a drop of urine escape; none at all passes while lying down. Discharged. Spin. 9.9, Cr. 10, D. obl. sin. 8, dext. 8.6, Conj. ext. 7, diagon. 3.7. In October, Novem ber, and December, 1876, the actual cautery was used 9 times, partly peri fistularly centripetal, partly intrafistularly; but without curing the little fistula.
No. 8. Rupture of entire vesico-vaginal wall, with the stump of the left ureter opening near the anterior lip upon th.e left side.
Union of vesico-vaginal wall with 10 catgut sutures ; a bean-sized fis tula being left, into which the left uret,er opens.