Then the opening between the intestine and the vagina was denuded and sutured even as in case of a simple recto-vaginal fistula. This case is the only one in which this method was followed by success, and it is of such interest that I will record it.
It concerns a slightly-built woman of twenty-three, of tubercular paren tage, who at her first delivery suffered a large rupture in the vagina fol lowing on artificial removal of the after-birth. The unfortunate " ac coucheur " inserted his hand through the laceration into the abdominal cavity, and thinking that he had grasped the placenta, pulled down a coil of intestine, removed it, and did not recognize his error; sixteen hours thereafter the placenta mils spontaneously expelled. Dr. Winterwe ber saw the patient one hour afterwards, and found the abdomen swollen and tender, the temperature elevated and a pulse of 144. Between the thighs lay a long piece of the small intestine, about two and a half feet and reaching to the knees. The intestine was separated from the mesen tery, dark-red in color, in places black, and filled with gas and fluid. In the rosterior cul-de-sac he found a transverse laceration. Rest in bed, ice, morphine, and antiseptic cloths over the intestine, kept the patieut in good general condition, and on the fifth day the intestine separated. At the end of four weeks the patient left her bed, but she did not im prove in health, and she complained of constant hunger. The constant passage of grumous brown intestinal contents from the opening in the vagina, which caused severe excoriation of the skin and the external geni tals, impelled Winterweber to send the patient to the surgical clinic at Heidelberg, which was then in charge of O. Weber. He found extreme emaciation, no fever, constant appetite, and all the functions, except the rectal, in order. The fteces were passed from time to time from the red dened and sensitive vagina. None were passed by the anus, and the patient never had the desire to go to stool. Only the excoriated skin and mucous membrane were painful. The patient disseminated a fEeculent odor. In the posterior vaginal cul-de-sac, to the right of the os, ttere were two separate intestinal openings, the one a trifle above the other.
The anterior median one alone gave exit to the intestinal contents. The sound entered it to the left and upwards, and into the other to the right and upwards. The intestinal mucous membrane was prolapsed through both openings.
Weber endeavored to convert the anus prEeternat. into a fistula ster coral., and after thorough cleansing of the parts, he passed the blades of a modified Dupuytren's scissors into both openings to the extent of about one and a half inches, and clamped the spur between them. On the third day the first natural passage since the delivery occurred. At the end of six days the instrument was removed, and there remained but one opening of the intestine into the vagina. Over this the opposed rectal wall still fell, and caused partial closUre of the lumen. The attempt was then made to prevent this pi olapse by a sponge on a holder, and this kept the intestinal canal patent, but caused intense inflammation of the vagina and the vulva. After further treatment, the hot iron was applied. to cause shrinkage and closure of the fistula, but this only partially suc ceeded. The patient then returned home for awhile, where she remained in bed for six and a half months, when she was again brought to the clinic. Weber had in the meantime died, and Heine undertook the treat ment. Since the spur still projected considerably, he again applied the clamp. After awhile, since the fistula had contracted down to the size of the top of a finger, IIeine denuded the edges of the fistula and converted it into a transverse slit which he united by suture. Union resulted ex cept at a point to the left covered by the anterior lip of the cervix, anti at a small opening in the right angle of the wound, which shortly closed spontaneously. .Since slight cauterization was negative in its results, Heine denuded again with implication of the remnant of the posterior lip. In a few days a small amount of fcal matter was passed from an opening at the inner angle, the size of a large pin's head. This healed eventually under repeated applications of tr. cantharid. and ung.