No. 14. Mrs. D., primipa,ra, 28 years, considerable rachitic narrowing of pelvis. November 16th, 1874, confinement; prolapse of funis and hand along side, the head; perforation; attempted extraction of child with for ceps and hook by physician. My father then tried the cranioclast in vain, and finally succeeded with the cephalotriptor. Puerperium normal. On arising at the Sth day, urine suddenly flowed off, and examination showed a small gangrenous spot at the vesical neck. Rest upon the side was ordered at once, a catheter introduced, and the edges of fistula touched with lapis infernalis. The fistula was entirely closed in 8 days.
Ftve Cases of Vesieo-Clerine Fistulas,.
No. 15. Case 1. Mrs. Bertha R., 27 years old; second child delivered by version and extraction on account of pelvic contraction; child died during the operation. A few days later involuntary urination. On the left side .6 of an inch from the external os is a pea-sized vesico-cervical fistula. The left commissure is ruptured. The right commisaure was then split, and the fistula freshened, and its margins united by 7 silk sutures. Primo intentio. After removing several stitches it was found that the rest were so imbedded in the tissues, that, as their ends had been cut off short, they could not be removed. 6 months later the four that wero left came out through the bladder. The patient.remained cured.
No. 16. Case 2. Mrs. M., 29 years old, farmer's wife, received October 3d, 1879. Six confinements; 1st, 1870, forceps, 2 to 5 normal, 6th March, 1879, 2 physicians, labor of 2 days. Forceps, turning, and extraction attempted. Child dead. Bedridden 14 days. On 31st day post partum sudden involuntary flow of urine, spontaneous evacuation thereafter im possible. Improved, so that while recumbent could retain and pass water naturally. Stools normal.
Vigorous brunette. Uterus movable, not enlarged, anteflected. Por tio split in 4 parts by antero-posterior as well as lateral divisions. Ante rior lip most deeply cleft; in it is a cicatricial furrow .4 inches distant from the lower border of the anterior lip. A lentil-sized depression in this furrow feels like a fistula. By means of milk injections, the real opening of the fistula was found, in front and to the left of the first opening, which turns o'ut to be the os uteri internum. The fistula is left of the internal
and .4 inch from the anterior cervical wail. Pelvis fiat, not rachitic.
Spince 10.6. Cr. 15.2 Conj. ext. 7.2, Conj. diag. 4.4, left oblique 8.8, right 8.8.
Operation October 7. Two strong silk threads introduced into the anterior and posterior lip; the entire portio drawn down, and so spread as to fully expose the fistulous opening. Circumcision of fistula by means of two oval cuts. Breadth .2, length .6 to .8, thickness .4 inch. Bridge of tissue .1 inch left, between interior os and wound. Direction of cut from below inwards to above outwards; 7 Fil de Florence sutures used. Two sutures were used at the angles of the wound to relieve tension, 3 for deep and 2 for superficial union. The two first were at once tied; the others only after all the sutures had been passed. October 8 to 10, thin bloody vaginal discharge. Regular catheterization. October 11, 1st stool, clysma. October 13th removal of sutures. Complete linear union. Complete continence; bladder spontaneously emptied every 3 to 4 hours. October 17th discharged cured.
No. 17. Case 3. Mrs. A. W., 42 years old, received March 5th, 1883.
Menses regular, moderate, no pain, 4 to 5 days, began at 131 years. Last menstruation, end of April 1882. 11 confinements; 1865, 1867, 1868, 1869, 1870, 1872, 1873, 1875, 1877, 1879. Last on February 19th, 1883. First 10 normal; last forceps, dead child, tedious labor, face pres entation, according to physician. Puerperium natural. 1874, abortion at 3rd month. Immediately after last confinement, difficulty and pain in passing water. February 27th or 28th patient suddenly noticed that her urine was passing involuntarily. Costive.
Status.--biedium sized, fairly strong, dark blonde. Chest normal. Coughing forces intestinal coils through the navel ring. Uterus enlarged, 2 to 3 finger breadths above symphysis; anteflexed. Vulva livid. Portio soft, turned backwards, several deep fissures; one on right side of poste rior lip extends to os intemum. In the anterior vaginal wall, just in front of the anterior lip,- is a fistula leading to bladder. Fistula well seen with speculum; urine streams from it freely. Little cicatrization around ori fice; ovaries normal. Pelvis: Sp. 10.8, Cr. 11.6, Conj. ext. 8.2, both Ob lique 9.4, periphery 35.2 inches.