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A Case of Successful Operation for Vesico - Vaginal Fistula.

To the Editors of the N. York Medical Times :

GENTLEMEN, I beg leave, through the columns of your journal, to make known to the medical profession, a case of vesico-vaginal fistula, successfully treated, according to the method of Dr. J. Marion Sims, of this city. This disease, which reduces the subject of it to a most deplorable condition, has hitherto been to a very great extent, an opprobrium to surgical skill : very few surgeons, even in our large cities, have seen or known of a case of perfect cure.

To Dr. Sims is due the credit of having taken away this opprobrium. By the most patient and persevering experimentation, he has elaborated and perfected a method of suture, highly ingenious, and already sufficiently tested by experience to entitle it to rank among the great improvements of surgical art. It affords me peculiar pleasure to be able to contribute the following case, which may serve to strengthen the confidence of surgeons in the practical value of this operation.

As Dr. Sims has himself presented this subject to the profession within a few months, through other channels, I shall not enter into any detailed description of his peculiar method, farther than may be necessary to elucidate the case to be narrated.

Begging a favorable reception for this communication, I remain, very respectfully,

Your ob't serv't.,

GURDON BUCK, M. D. No. 21 Tenth-st., August 26, 1854. Surgeon to N. York Hospital. VOL. IV.—NO. 1.

1

Case.—Mary Harty, an Irish woman, aged 28 years, married, of good constitution, and enjoying robust health, was admitted into Ward No. 2, in the New-York Hospital, on the 4th July, 1854. About seven weeks previous, she was delivered of her first child after a very severe labor, but without the aid of instruments. It was soon discovered that she had lost all control over her bladder, and that her urine flowed from her constantly and involuntarily. This has continued to be her condition since; and from her own account, the flow of urine is not influenced by position. On examination, a fistula, capable of admitting the end of the little finger, was found in the median line, about one inch and three quarters beyond the meatus. It was situated in a transverse furrow, formed by the folding together of the vaginal walls. The parts in all other respects were healthy. On the 13th July, the operation was performed in the presence of several of the attending physicians and surgeons of the Hospital, and also of the assistants of the several divisions. The mode of procedure was as follows:

The patient's bowels having been previously evacuated with castoroil, an attempt was first made to operate with the patient placed upon her hands and knees, the buttocks being elevated as much as possible. This, however, was soon abandoned, from the impossibility of her maintaining herself in this position a sufficient length of time, and also, from its being inadmissible to employ ether in this position. She was therefore placed upon her back; and after being brought under the influence of ether, her hands and feet were bandaged together, as for lithotomy.

A Jacobson's lithotrite answered a most useful purpose in bringing within reach the fistulous opening, and keeping the surrounding vesicovaginal wall on the stretch, thus very much facilitating the subsequent steps of the operation. This instrument resembles in form an ordinary catheter, with a short curve. The curve, when the instrument is opened, is converted into a jointed loop, or noose. It was introduced closed, per urethram into the bladder, and opened. By elevating the handle of the instrument toward the abdomen, the loop was depressed against the base of the bladder, forcing it downwards into the vagina, and forward towards the vulva. The fistula being thus brought within reach, its edges were pared away so as to render the longest diameter of the opening transverse. Six thread sutures were then introduced from before backwards; and by means of these, as many fine silver wires were drawn through to occupy their places. A narrow, flat strip of lead, called a clamp, perforated with slits at equal distances of a quarter of an inch apart, was threaded upon

the four middle wires on either side of the wound, leaving one wire, at each end of the wound, free. Each of the four wires was then armed at both ends with a perforated shot, and the shot slipped down upon the clamps. A knot was also tied on the distal end of each wire. The proximal ends of the wires were then drawn forward till the distal clamp was brought to its place, in close contact with the posterior edge of the wound. The proximal clamp was next pushed backward to its place, and the shot with it; and so, both edges of the wound were held in close apposition between the two clamps. To secure them permanently in this position, the four shot were successively pinched tight upon the wires against the proximal clamp. The solitary wires at either end of the wound were armed with shot only, and secured in the same way as the wires passing through the clamps.

The adjustment of the sutures being completed, Dr. Sims' catheter was introduced and left in the bladder.

The patient was directed to lie upon her back; her diet was to consist of half a pint of milk and one soda cracker, three times a day. One single-grain pill of opium was to be taken morning and evening, to keep the bowels constipated. The catheter was to be removed and cleansed once in twenty-four hours, and replaced without delay.

The urine flowed in drops from the catheter, from the moment of its first introduction. No suppuration appeared at any time in the vagina, nor did the patient complain of much soreness in the region of the wound.

On the 20th of July, an evacuation of the bowels was procured by castor-oil, followed by an enema of flax-seed tea.

On the 27th of July, the parts were examined for the first time, and union was found to have taken place throughout the entire wound. The anterior clamp had worn for itself a superficial furrow in the mucous membrane. The clamps and suture were removed, and no suppuration found.

The catheter was now left out for two hours, during which she remained dry. On being again introduced, the urine flowed in a jet.

The catheter was now left in the bladder only during the night, and resorted to at intervals of two hours, during the day.

On the 29th, the catheter was only introduced every three hours, and on the 31st, every four hours ; the patient still keeping perfectly dry.

On the 1st of August, a careful examination was made, and every thing found in good condition. The abraded furrow made by the lower clamp had healed. Nearly five hours having elapsed since the catheter had been used, she was allowed for the first time to void her urine unassisted, which she did with a smart jet, and, as might be supposed, with the greatest delight. She now left her bed, and kept about. Up to the time of her discharge, on the 3d of August, the bladder performed its functions in a perfectly healthy manner, and the patient passed the night without rising.

On the 18th of August, the patient reported herself at the Hospital, still doing very well.

Case of Congenital Obstruction and Imperfect Closure of the Mitral

Valve. By John A. Swert, M. D., Physician to the New York
Hospital, &c.*

I was called on the 22nd of September, 1851, to visit a young gentleman, 23 years of age, in whom I found the physical sign of regurgitation through the mitral orifice of the heart, viz., a bellows murmur with the first sound of the heart, heard over the apex of the organ. The heart did not appear to be much enlarged; the apex seemed to strike in the natural position, and the percussion over the precordial region was quite as clear as is natural. The action of the heart was moderate in degree, but its rhythm was irregular. There was some complaint of palpitation, but much more of dyspnea. The pulse was very feeble and irregular, and there was slight ædema of the feet, with signs of effusion into the cavity of the pleura.

The patient was, as I have stated, 23 years of age, and a book-keeper. From early childhood, his breathing had been short; but for eight or nine years past this symptom had been more prominent. For the last year it had been still more distressing, and was attended by palpitation. Still, he had been able to follow his occupation until a comparatively recent period. A few days ago, the ædema in his feet commenced. His countenance was pale, but he was not much emaciated : his urine was high-colored and scanty.

Remedies, chiefly of a diuretic character, were administered by the attending physician, Dr. Hobart, but without material benefit. The dropsical tendency increased. IIemoptysis, of a severe form, ensued during the last week of his life, and was frequently repeated. A pulsation was noticed in the epigastrum, as if the right side of the heart was enlarged Slight jaundice ensued, and delirium followed by coma closed the scene, without a struggle, on the 11th of October.

* This case was given to the Editor of the Medical Times for publication two or three years ago, but was accidentally mislaid, and has just been found. Its value is enhanced by the fact, that its lamented author has now passed from among us, and been removed from the practice of the profession, to the ad vancement of which his talents and labors contributed so much.

On postmortem examination, 24 hours after death, the right cavities of the heart, and the left auricle, were much distended with recent clots of blood; while the left ventricle appeared empty and small, like an appendage to the rest of the organ. The right side was generally enlarged by hypertrophy and dilatation, and the pulmonary artery was larger than the aorta, and nearly as thick. The left auricle was also much enlarged by hypertrophy and dilatation; and besides the soft and recent clots found in it, abundant and old fibrinous clots, partially decomposed, like those we notice in old aneurisms, existed, united to the lining membrane of the auricle by a thin, smooth, and transparent layer of lymph. The same kind of thin layer of lymph adhered to the inner membrane of the pulmonary artery. All the valves and orifices were healthy, except the mitral orifice, which was so contracted as only to admit the end of the forefinger. The structure of the valve was somewhat thickened, but smooth, without ossification, vegetations, or other evidences of inflammation. At each extremity of the valve, there was a seam, or slight depression, each half an inch in length, shewing where the opening of the valve should have been continued. The left ventricle was quite natural, except that its walls were rather thinner than usual: some fluid existed in the pericardium.

About two pints of reddish, turbid serum, existed in each pleural sac, with a slight effusion of lymph. The lower lobes of both lungs were not much compressed, but were solidified and of a very dark red color, and giving out on pressure an abundance of dark, viscid blood. No distinct matter of pulmonary apoplexy existed; but both the lower lobes were, I think, passing into this condition.

There was slight cirrhosis of the liver. The other abdominal organs presented nothing abnormal : there was but little venous congestion.

Biographical Sketch of the Life and Character of Samuel W. Moore,

M. D., By C. R. Gilman, M. D.

The life of a practicing physician is very rarely one of startling adventures or striking events. His duties, though important as the value of life itself, are chiefly performed in the privacy of the sick-room; and of consequence the manner in which he performs them is known only to

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