March 20th, narcotized. Fistula brought well into view by loops of thread and hooks; Thorough carbolized injection. Sound passed per urethram into fistula. Above the vaginal opening is found the formerly unseen opening of the cervix. There was thus a vesico-cervico-vaginal fistula. The rupture originally affected the entire anterior lip; but the lateral margin of the cleft had grown together, and there is left a delicate but perfectly palpable cicatrix passing from the fistula over the anterior lip. Thus a bridge was formed which covered the continuation of the fistula into the cervical canal. A broad piece was dissected off all around it, and the margin of the wound united by 11 sutures of finest Listerian silk. Rather more loss of blood than usual. Violent bronchitis soon after operation. Catheterization during first few days; urine ammoniacal. The urethral opening had been drawn in consequence of the operation well into the vagina. March 22d, spontaneous urination; afternoon of same day, involuntary flow again. March 24 to 27, fever; some meteor ism and abdominal tenderness (ether, ice-bag). April 2d, removal of most of the sutures; non-union. Complete incontinence. Eczema of nat,es. April 4th, patient got up; April 19th, last suture removed. Ordered daily introduction of tampons soaked in 2 per cent. ca,rbolic acid.
April 24th. Second operation.—Freshening done through the thick ness of the vesico-vaginal cervical wall. Union in longitudinal direction of vagina by 7 sutures of Fil de Florence. Operation lasted 33 minutes. Catheterized at first; from April 26th, spontaneous evacuation of urine. Since April 30th, partial incontinence again. May 1st, removal of sutures. The upper posterior angle of the fistula is ununited. May 7th and 10th, the small fistula was cauterized with a small iron. May 26th discharged; complet,e continence and cure.
No. 18. Case 4. Cresc. E., 31 years old, servant, Munich; admitted May 19th. 1884. Walked at 2 years, menstruated at 15 years. Menses thin, regular, last 3 to 4 days; considerable abdominal pain. March 16th, 1884, first confinement. Spontaneous vertex; stillborn boy, very large and well developed. Liquor amnii flowed off 5 days ante :partion. Delivery lasted 46/ hours; small loss of blood. Got up on 9th day. Puerperium good. Suddenly noticed on getting up involuntary flow of urine, pre ceded for several days by burning pains. Can retain some urine, and evacuate it spontaneously when recumbent.
Status. —Moderately small blonde; fairly well nourished, but weakly. Vulva not reddened, vagina smooth; bathed with urine. Uterus dis placed somewhat backwards, well involuted, and not enlarged. Os half way between anterior pelvic wall and the spine of the ischium. Anterior lip deeply cleft; the catheter in the bladder can be seen to enter the cer vical canal. Posterior lip smooth, and fissured in its middle. Bladder contains a small quantity of dark muddy urine; sediment contains some blood cells and some epithelium; no albumen. In the posterior vesical wall, towards the middle, is a pea-sized opening communicating with the cervix.
vesico-cervical fistula, with generally con tracted pelvis. May 21st, passed 31 ounces of urine in 4 hours. It is muddy,
dark red, contains some albumen and a few red blood cells. May 23d, in 11 hours obtained 144 5. of urine. May 2fith, in 5 hours obtained . of urine, light gray in color, non-albuminous; contains pus cells, pavement epithelium cells, and crystals of phosphate of ammonia.
Operation. May 27.—Narcosis; lithotomy position; guttered speculum used for posterior vaginal wall; cervix fixed with 2 hooks. Edges fresh ened for .4 inch, then smoothed. 8 sutures of Fil de Florence passed deeply. Insignificant hemorrhage. No ligatures necessary. Fluid in jected into bladder completely retained. From May 28th to June 1st, spontaneous micturition; urine slightly tinged with blood. June 2, first stool; clyster. June 5, menses. June 7th, removal of Fil de Florence sutures. Complete union. June 8, menses still present; constipation; ol. ricin. Urine completely retained and spontaneously evacuated. June 9th, well; 2 stools; arose. June 12th, discharged, well; no urine passes per vaginam; complete ability to retain.
No. 19. Case 5. B. W., 31 years, workingwoman, Munich, 8 confine ments. Married since 1879; admitted November 4, 1884, 2 years ago, after confinement, peritonitis. Menstruated at 16 years, courses regular. last 3 to 4 days, painless. No menses since last confinement, Aug-ust. 1884, 8 deliveries, 6 spontaneous, 2 operative. Last in August, 1884, protracted, forceps. When getting up, 14 days post partum, patient says she noticed for the first time involuntary urination per vaginam. Liquor amnii flowed 3 days before confinement; latter normal.
Status. —Medium sized dark blonde; well developed. Uterus retro verted; anterior lip shortened. Sound can be passed from the urethra through the bladder into the cervical canal, and so out into the vagina.
Diagnosis. —Vesico-cervical fistula in upper third of cervix.
Operation. —November 8, 1884. Narcosis; posterior lip of os dragged down, and fistula thus exposed; it is situated very high up. The fresh ening includes nearly the entire breadth of the anterior lip 9 sutures (Fil de Florence) passed deeply, and the edges of the wound united. November 9th, frequent desire to pass water; moderate pain in the vesical region. No hcematuria. November 10th, mucous vomiting in the morn ing. Vesic,a1 pains cease; less urinary difficulty. November 11, persist ent desire to urinate, with voidance of small quantity every hour. Orange yellow color; no blood. Abdomen slightly sensitive. (Foment. humid. tepid—vesica glacial. ad caput—Pilul. glacial.) November 12th, urinary difficulty continues; patient passes water every hour. No strangury. Clothes quite dry. Urine contains some blood. (Menses?). November 14th, complete euphoria. Menstruating moderately. Novem ber 15th, sat up 2 hours in bed; dribbling of urine all night and in the morning. No incontinence; voluntary emission. November 16th, sutures removed; several small gangrenous spots; through them the urine percolates. November 17th, increased dribbling; spontaneous motion of bowels; at her own urgent request is given leave of absence. Returned in 4 weeks; no trace of fistula; the small openings had closed spontane ously. Complete cure.