218

Peninsular Journal of Medicine.

MORTALITY REPORT OF THE CITY OF DETROIT FOR THE MONTH OF FEBRUARY. Prepared from Statement furnished by C. H. BORGman, Esq., City Clerk.

MORTALITY REPORT OF THE CITY OF LANSING. From Statement by DR.

H. B. BAKER.

THE

PENINSULAR JOURNAL

OF MEDICINE.

APRIL, 1876.

Original Communications.

CASE OF VESICO-VAGINAL FISTULA-OPERATION-CURE. Reported to the Wayne County Medical Society, October 28th, 1875. By THEO. F. KERR, M. D., Detroit, Mich.

MR. PRESIDENT AND GENTLEMEN :-It is not my purpose, neither is it desirable to enter into a detailed history of the operation for the cure of vesico-vaginal fistula. However, a brief allusion to some of the most salient points in Dr. Sims' operation, together with a notice of some important modifications of the operation as now performed by Prof. Simon, of Heidelberg, will help to a better understanding of the case reported to you this evening.

Previous to 1852, for centuries there had been a persistent effort on the part of surgeons to effect a permanent cure of this distressing malady, but without success. In that year Dr. Sims

first reported several successful cases, and minutely detailed the

method by which he had achieved his success. According to Thomas, the three particulars wherein he claimed especial originality were these: 1st. A method by which the vagina could be distended and explored, which is best accomplished by the aid of Sims' speculum. 2d. A suture not liable to excite imflammation or ulceration, that is the silver suture. 3d. A method of keeping the bladder empty during the process of cure, which Sims' self-retaining sigmoid catheter enables us to do.

Gosset, in England, in 1834, had combined exactly these three essentials to success, and twelve years afterwards Metzler, in Germany, used like measures for the cure of these fistulæ, but neither impressed their importance on the minds of the profession at large so as to make them available for the relief of the afflicted.

In performing the operation, Sims advises great care in paring the edges of the fistula and in passing the sutures so as to avoid the mucous membrane of the bladder. In the after treatment, likewise, he insists on the necessity of keeping the bladder empty, and for this purpose retains the sigmoid catheter permanently in that viscus. The patient is almost immoveably confined in bed, and the bowels are constipated with opium until the cure is complete, or failure results.

Prof. Simon on the other hand, has done much to simplify the operation for vesico-vaginal fistula, and has shorn it of many tedious little details which Dr. Sims requires of both operator and nurse. First, in paring the edges of the fistula, and in passing the sutures, he does not avoid the mucous membrane of the bladder, but cuts away all cicatricial tissue even if it considerably enlarges the opening. He claims that the edges thus prepared are more liable to unite than when bevelled as advocated by Sims. Moreover, should a second operation be necessary, it would be more likely to succeed with the thick, square edges than with the thin, bevelled edges which would have to be

pared down still more to afford a raw surface for union. Neither, in his opinion, is catarrh more likely to follow this form of incision than any other.

His after-treatment, likewise, is radically opposed to that pursued by Sims, and is based upon the following deductions. He says: Ist. From a series of observations, I conclude that neither on the wound, nor on the new cicatrix, does the urine have any injurious influence, and neither hinders the union by primary intention nor loosens a once formed cicatrix.

2d. From a second series of observations, I have learned that the healing is not interfered with by a degree of distension which could come in a normal filling of the bladder, provided only that the wound is perfectly freshened and united.

In most cases the permanent retention of the catheter only does harm.

Accordingly, Prof. Simon does not confine his patient in bed in an almost immovable position, but allows her to recline in any posture that she finds most comfortable, and to pass her water as inclination prompts. Sometimes it is drawn every three or four hours. The chief care is to prevent over-distension of the bladder and to keep the evacuations from the bowels in a liquid or semi-liquid condition, to prevent straining at stool.

With this passing notice of the methods of the two men who have done more than any others to make this operation a successful one, we go on to the relation of the following case, giving some details of previous history, that the causes which conspired to bring our patient into her helpless condition may be fully understood :

On the 14th of February, 1875, I attended Mrs. R—, in her fourth confinement. I was sent for in haste, at six o'clock in the morning, and was informed by the messenger that the membranes had broken and that labor was rapidly progressing. However, on reaching the house I found no evidence to show

that the waters had escaped in any considerable quantity, and on making a vaginal examination, the os was found high in the pelvis, beyond the reach of the finger. Labor progressed very slowly, so that it was four P. M. before the head had advanced sufficiently to enable me to make out that it presented in the third position, the forehead lying toward the left ilio-pectinael eminence. The conjugate diaineter of the pelvis was considerably shortened, and the sacral curve was very short. The os was not yet fully dilated, and nothing was done except the giving of an opiate which afforded several hours refreshing repose. Between eight and nine P. M. labor began again and went forward steadily. There was no gush of waters, but they were continually dribbling away. The pains were very regular and tolerably strong, but not too vigorous. Between one and two o'clock on the morning of the 15th, the woman's condition being still, in every respect, excellent, as a scarcely preceptible advance had taken place, the head still lying in the superior strait, I endeavored to hasten delivery by the aid of the forceps, but did not succeed in accomplishing anything. In this extremity I called in Dr. G. A. Foster, who reached the house at about eight o'clock in the morning. He at once proceeded to apply the forceps, which he found a difficult operation, and a half hour was consumed before they were finally adjusted and locked. Powerful traction was necessary to bring the head down on the perinæum, and we took several turns at the handles of the instrument., each one laying out his full strength in assisting the expulsive efforts, before this was accomplished. Final delivery of a dead male child was effected at about nine o'clock.

No untoward symptoms were manifested on the part of the mother during child-bed, and she had been up some when I was informed, on the fifteenth day after delivery, that there had been a constant and involuntary loss of urine during the preceding twenty-four hours. Believing the cause to be paralysis of