rubr. The patient regained her strength quickly, but iu time tnonths tuberculosis developed and she died from this disease. At the autopsy Heine found complete cure of the anus prwternat.
In comparison with this method of Heine's the other procedures are not of special value, as for instance Jobert's plan of separating the upper opening from the vagina and sewing it into an opening made between the rectum and the vagina. Simon's plan is net preferable, and it consists in making a large opening between the rectum and the vagina below the site of the ileo vaginal anus and then in closing the vagina transversely, so that this canal forms part of the intestinal canal. Finally we would mention a still more practical plan, that of Cassamayor, which consists in so connecting the anus vaginalis with a rectal fistula as to leave a broad lateral union between the upper extremity of the small intestine and the rectum. With this end in view Cassamayor inserted one blade of a rectal scissors into the opening of the small intestine, and the other into the rectum, and caused the intervening portion to separate. He was not able to obtain closure of the stercoral fistula, however.
All these procedures, aside from risks and inefficiencies, are open to one aud the same objection, namely, that a considerable part of the intes tinal canal is shut off from the intestinal contents, and that these, hence, are not entirely digested.
From Petit we learn that Roux attempted the following procedure: Laparotomy, resection of the loosened extremity of the injured intestine. and suture of the opening. Owing to the small opening through which he worked, however, he mistook the portion of intestine, and, as the autopsy proved, he sewed the intestine not to the lower but to the upper end of the descending colon.
Weber and Heine's procedure is not always as simple as it seems from the report of their case. Cassamayor, for instance, found only one open ing into the small intestine, and Wilms (Bartel's report) met with such complicAted conditions that Heine's procedure was out of the question. For certain of these cases Cassamayor's method, therefore, must be con sidered relatively the best, and his failure in securing union of the fistula is not to be accounted against it. The cutting off of the part of the in
testine below the opening into the intestine will always result in the patient's nourishment suffering, since the perforated coils uniformly be long to the lower ilium; still the greater part of the small intestine func tionates, and Cassamayoes plan fairly well subserves the desired end. Before, however, in case of one opening, we decide to follow Cassamayoes method, it is advisable to dilate the fistula, and whenever possible to find the opening of the projecting intestinal extremity, and when we can Heine's plan should certainly have the preference. Aside from these methods there remains the possibility of performing laparotomy, loosen ing the adherent intestines, resecting them, and suturing them, even as Roux did in his unfortunate case. Petit remarks with justice that to-day, under antiseptic rules, Bud' a procedure would not be so dangerous as in Roux's time (1828), particularly if we attend to the technique of to-day in regard to the intestinal suture. We cannot, however, grant Petit's statement that the risk from such an operation would be less than in case of removal of an adherent ovarian cyst. Although Weber and Heine's procedure in comparison with laparotomy is less dangerous whenever it is practicable, under other conditions laparotomy should be resorted to since by it alone, after Heine's method, are we able to secure normal re sults. In case of anus prreternat. ileo uterinus laparatomy alone offers the hope of cure. So far, however, instances of the kind, where such an operation was resorted to, have not been recorded.
In case of fistults between the vagina and the small intestine, properly so-called, there exists a single opening into a coil of the adherent ilium lying in Douglas's cul-de-sae; there is present only a partial defect in the wall of the intestine, and through it a portion of the frecal matter is dis charged, the rest following the normal route towards the anus.