Josephi's patient became pregnant for the second time at the end of February, 1788. She felt no life after the 37th week; from Easter, 1789, she gradually began to menstruate again, and remained fairly well until 1797, save for the occasional pressure upon the bladder of a hard tumor situated in the right lower abdominal region. In 1797 she had chill, colic, pain in the back, and regular bearing-down pains; then an inter mitting fever with 3 exacerbations a day, which lasted for 3 months. From this time dated a dysuria which was excessively painful. She had to pass water every minute, and either urinated upon her knees or with her body well bent forwards. At each attempt she passed but very little, and what she did pass consisted of pus and pieces of a thick jelly-like sub stance. At Easter, 1800, she first noticed a hard body in her urethra, and later in that year she passed her first greyish-white, bean-sized calculus with her urine. Thereupon followed a bone 3.2 inches long, the child's femur; then a calculus; then the petrous bone covered with phosphate of lime; and then 94 millet-seed to bean-sized calculi, one after the other; then some bones of the lower extremities, one of the bones of the ear, six teeth, In 1801 a physician incised the urethra, and successfully re moved the lower jaw. At times there was complete retention of urine; the labia were somewhat swollen, and were red and excoriated from the constant trickling of urine. Through the dilated urethra a catheter could be passed into the neck of the bladder, where it at once encoun tered a large, hard, and immovable body. On account of her sufferings, the patient spent her entire time in a crouching position or upon her knees. The appetite was good, though the bowels were sluggish. When ischuria occurred, as it often did, the urine evacuated with the catheter stunk horribly. Attempts to dilate the urethra with waxen bougies and extract the foreign body failed on account of its size. Therefore Josephi opened the abdominal wall and then the bladder to the extent of 2 in ches, and extracted 112 pieces of bone. Three large calculi lay in the vesical neek which could not possibly have passed per urethram. In the fundus vesicsa, where the head bad been lodged, was an opening. The patient died upon the third day, and J. now found two openings in the bladder wall; one in the fundus and to the left, the size of a cent, with hard e,alloused edges, and one high up on the right side, .8 inch in diame ter, from which he had with difficulty drawn out the child's head during the operation, and which undoubtedly was connected with the extra uterine sac.
In Giessler's case (1856) the woman began to pass pus and the bones of a 7th month fcetus per rectum one year after the beginning of her second gravidi ty.
Urinary difficulties then arose. By means of the catheter bones were deted,ed in the bladder, and were removed per urethram. Defecation was accomplished at times through the bladder, and at times through the rectum. The patient died of exhaustion 3 weeks after the vesical perfo ration. Examination showed fistulous openings from the sac into bladder and rectum.
Thompson had a patient who believed herself pregnant 7 years. By in cising the urethra, he removed from the bladder various fcetal parts. Then from a commttnicating cavity lying to the left of the viscus, he first drew the fcetal extremities, pelvis, and skull into the bladder, and thus removed them. Save for a moderate incontinence of urine, the patient recovered completely.
B. S. Schultze's case was a similar one. Here a tubo-uterine pregnancy had led to perforation of rectum, uterus, bladder, and abdominal wall. A rib and a vertebra passed first per urethram, and then a large number of small bones. The abdominal fistula was dilated, and the bones ex tracted. The fcetal sac was then washed out through the bladder, and
finally the patient was cured, although the abdominal and vesic,a1 open ings were patent. There were repeated urtemic symptoms in this patient, which Schultze explained as due to a catarrhal nephritis, caused by exten sion of inflammation from the mucous membrane of the bladder. In Edgar's case the patient died before the parts of the tubal fcetus could reach the perforated bladder.
Abnormal communications between the bladder and the rectum are ex tremely rare in women. They most often arise in consequence of abscesses in the true pelvis, or in its neighborhood, which may break into the rec tum as they more commonly do into the bladder. Occasionally the posi tion of the fistulous tract is such that while urine may pass into the rec tum, fwces cannot get into the bladder, thus giving us a true vesico-rectal fistula. Thus Eble observed a case in a girl of twenty years, who was suffering from suppurating psoitis. 4 to weeks atter the beginning of the sickness she began to void pus, blood, and urine per rectum. No urine flowed per vias waturales, until the rectal flow stopped. Then it was restored.
If, as in Giessler's case (page 155) the orifice between bladder and rec. tum is large, excrement will of course pass into the former viscus, and may lead to the formation of stone. Similar, though caused in a different way, was the vesico-reetal fistula which George Glen has described. Soon after an arduous labor his patient had symptoms of inflanimatory abdominal processes with marked vesical involvement. She got well for a time; but 14 months later she began to have very painful passages of fteces and intestinal gases per urethram, and died a year later. The walls of the bladder were thin, and at the fundus was an opening which com municated with the bladder. Here an abscess had arisen after the con finement, which had perforated rectum and bladder, and had led to a recto-vesical fistula.
Adhesions between the bladder and the ileum or jejunnm can more readily occur, and from the thin walls of the organ involved, fistula) may he easily pr-oduced. Thus van Geuns has described a fistula colica-vesi ealis; a quill of moderate size could be passed through the funnel-shaped opening, which communicated with the bladder 1 inch above the rectum. The patient had had cholera 5 years before, and had never entirely recov ered. L. Mayer's caae is most instructive.
The patient was 28 years old, and had had 2 normal deliveries. Since her second confinement the year before, she had suffered from profuse diarrheas with meteorism, pains and a tender tumor in the right iliac region. Six mouths later there set in vesical trouble. The patient again became pregnant, and felt one day, almost painlessly, intestinal gases issue from the urethra. Soon she noticed that her urine was at times greenish or gray in color, very thick, and containing flocculi and bodies that looked like undigested aliment, pieces of potato, muscular fibre, chocolate, etc., which were voided 3 to 4 hours after taking them comparatively un changed. Blueberries colored the urine blue. The vesical troubles now remitted; the pregnancy ended normally, though the presentation was transverse, and turning had to be employed. Puerperium natural. But the menses did not return, and the diarrhcea became more troublesome, especially at night, when the abdominal pains and tenesmus would awaken her 6 to 9 times. Stools thin, grayish green in color, and contained un digested aliment; they resembled the evacuations from the bladder, but had a more fwculent odor. The tumor was in the false pelvis, but pro jected into the true one and filled its right anterior upper part.