No. 241. lst confinement January 24th, 1875, 5 to 6 weeks too early; premature rupture of membranes; forceps delivery by two physicians; immediate involuntary micturition. Longitudinal tear of vesico-vaginal septum, inversion of vesical mucosa. Opening extends from left margin of os ut,eri almost to tubercul. vag. Cicatricial band from left border of orifice goes to ascending ramus of pubis. Also a left uretero-utero vaginal fistula. Operation March 4th, 1876. Freshening of edges of wound Tto inch; same to posterior lip of os. 19 catgut and 1 silk ligature, and 2 tension sutures. Ligatures removed March 18th; save at posterior upper angle, where the ureter is, all is healed. May 30th, the fistula is an inch in front and to left of the left commissure of the os. Funnel.shaped portion excised; much hemorrhage; 5 silk ligatures. R. and L. walls of funnel united by 4 wire and 1 silk suture. At night a considerable hemor rhage from the bladder. June 6th ligatures removed; non-union. July 12th, sent home for 6 weeks. September, and October, 1876, peripheral cauterization of vaginal mucosa around fistula; it became much smaller, and is now bean-sized.
No. 9. Parturient woman with 4 vesico-vaginal fistulce; death from entrance of air into the uterine sinuses.
1874. No. 931. M. 284 years old: 3d pregnancy. Rachitis in child hood. 1st birth easy, 2d a cephalotripsy, and since then involuntary urination. 3d confinement in the institution; high fever post partum; gases of decomposition from vagina. After expulsion of child, dreadfully stinking gases. Death 41 hours p. p. Necropsy: Pelvis 10.4 spina3 11. Conjug. ext. 7.2, oblique 8. Conjugata vera 3.1 inches. Thus pelvic contraction to II or III degree. Absence of greater portion of vesico vaginal wall. A bridge of tissue .6 inch wide is present, dividing on each side into two arms; hence 4 openings, the lowest and largest being twice the size of a dollar. Edges smooth, in places cicatricial. Vesical wall now ulcerated; anterior vaginal wall below fistula moderately prolapsed.
No. 10. Small vesico-vaginal fistula in left vaginal vault ; spontaneous, from pressure ; cure without treatment.
1874. No. 854. Primipara 28 years, 1st confinetnent 32-i hours, 2d 28 hours. Child asphyxiated, 20.8 inches long, weighs 90 ounces, and has numerous pressure marks upon head. On 8th day stillicidium of urine from ulceration in left vaginal vault. Closure during puerperium. Small depressed scar on left side of os on dismissal. May 7, 1876, No. 388, second delivery, normal. Conjugata vera 3.9 inches.
No. 11. Forceps delivery; thin vesico-vaginal fistula cut by R. blade;
cure by one cauterization with lig. fern sesguichlor.
1876. No. 265. Kurt I. primipara, 28 years old. Child died inter par turn. Forceps. Dribbling of urine from 2d day. On anterior vaginal wall high up near cervix a small fissure. Catheter showed bladder containing only a little blood. Cauterization with strong liq. ferri sesquichlor. In voluntary micturition decreased day by day; on 16th day discharged cured. Pelvis was normal, and it was only the long duration of the second delivery and the danger to the child from double coiling of the cord around its body, that formed the indication for forceps.
No. 12. Urethro-vaginal fistula, united by 8 sutures without full resto ration of continence; application of a Schatz pessary.
II., 26 years old, brunette, was rachitic in childhood. Had a dead child at full term May Gth, 1875; turning and forceps to after-coming head. Since then cannot completely control urine. Pelvis: coning. ext. 7.6, spline 8.0, crist.R 9.2, circumference 33.2 inches, a small pelvis. Numer ous scars in lower part of vagina; a transverse urethral fistula .9 inch be hind orif. ut. ext. There was a small opening drawn high up under the sYmphysis and goiug to the bladder; freshened, 8 silver sutures; incision of the lateral cicatricial bands. Complete union; but incomplete power of retaining urine whilst walking and lying. Improved partially by the use of one of Schatz's pe,ssaries.
My father had a very extensive obstetric practice in a district where os teomalacia and rickets are very common, at Gummersbach, in the district of Colog-ne. In 700 artificial and in part very difficult confinements he only observed the two following cases of vesico-vaginal fistula. In many cases he was only called after labor had. been long in progress; and the very small number of cases observed serves to confirm me in the opinion that it is not so much protracted labors and contracted pelves as unskillful and premature use of instruments, that causes the accident.
No. 13. Mrs. M., 24 years old, very small in stature, pelvis rickety and contracted. Conjug. vera circa 4 inches. Pregnancy normal pains began November 29th, 1848. Face presentation. Labor tedious; loud vagitus uterinus; dead child finally extracted with forceps. Pinhead sized vesico-vaginal fistula. January 1st, 1850, 13 months later, delivered by forceps of a small living child. The small fistula could be distinctly seen during labor, as the anterior vaginal wall was driven downwards by the advancing head. Thereupon the fistula closed completely without artificial aid, as was proven repeatedly years later.