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190 DR. WILLIAMS' Case of Vesico - Vaginal Fistula. [March,

cathartic operated, two grains of calomel and two-thirds of a grain of opium were ordered to be given, every hour, unless when the patient was asleep. This treatment was continued until the gums were affected, on the fifth day; the whole time, the pulse never falling below 130, and often was as high as 150 per minute. After the gums were touched, the soreness of the belly subsided, when the calomel was omitted, and opium alone given, in quantities to keep her quiet: on some days she took to the amount of ten grains; when it caused diarrhea, and smaller doses were substituted. It is unnecessary to go more into detail in this connection, any further than to say, it was one of the worst cases of puerperal fever that I have ever seen recover. Now, while recovering from the general symptoms, she had a large discharge of foetid, black matter, mixed with blood; as she supposed, from the bowels, but in fact from the vagina, as, on examination, a large slough had separated, leaving an opening through which two fingers could be passed into the bladder, about an inch behind the pubis. This had been caused by the long-continued pressure of the child's head during labor, and could probably have been prevented by an earlier delivery. The woman convalesced gradually, with a large vesico-vaginal opening, and all its distressing accompaniments.

On the 14th day of October, the woman's general health being well re-established, I performed the operation for her cure, in the presence of my friend, Dr. Valentine Mott, and also assisted by his son, Dr. Alexander B. Mott.

The vagina was healthy; the fistula the largest I ever saw, readily admitting two fingers into the bladder. After the ordinary preparation, I cut away the callous edges of the fistula with a long, narrow bistoury; a much better way, it seems to me, than chisseling it off, little by little, as it gave clean, smooth edges to be approximated by the clamps, which were applied as recommended by Dr. Sims, and the operation completed; which, by the way, is a much more difficult one than would appear from reading about it. There was very little hemorrhage.

The woman was placed in bed, with the syphon catheter in the wrethra, and a dose of laudanum given. The night after the operation, the patient suffered severely from the accumulation of urine within the bladder, to which it had so long been unaccustomed, until it was evacuated, together with the syphon, which was found choked up by coagula, which had infiltrated from the wound into the bladder. This, however, did not occur again. The bowels were kept constipated until the ninth day after the operation, without inconvenience. Things appeared favorable until the fifth day, when urine was found passing again from the vagina, as well as from the syphon; on examination, it was found ulceration bad taken place at one end of the clamps, probably from their having been applied too firmly. It may here be remarked, that the proper application of the clamps is one of the nicest points of the operation. If applied too loosely, urine will escape; if too tight, they will ulcerate. It is difficult to state the degree of pressure necessary ; it is a matter for the exercise of judgment on the part of the operator. It, perhaps, may do to suggest, that if the clean edges of the cut surfaces are brought into exact coaptation it will answer, as the swelling of the parts will then keep them well together. The condition of the clamps was always exactly as stated by Dr. Sims, and need not be here repeated. On the eleventh day they were removed, and the opening, which formerly was so large, now was restricted so as to admit only the point of the finger.

The patient still labored under all the embarrassments of the opening; as soon as her strength was restored, I repeated the operation, with the assistance of Dr. Alexander B. Mott, and Dr. Carroll. The edge of the small fistula was removed with three sweeps of the knife, the sutures inserted, and the clamps applied; the edges of the wound were brought in beautiful contact, and the case conducted, in all respects, as required.

On the tenth day after the operation, the patient complained of some bearing-down pains, which I supposed arose from accumulations in the rectum. An injection was administered, which brought away a quantity of hardened foces, with entire relief. The presence of the clamps in the vagina gave no trouble in either operation. On the fourteenth day after the operation, an examination showed the parts to be healthy, the clamps lying snugly inclosed in a new mucous surface. I cut the shots from the lower clamp, then removed them carefully from their bed, and found the wound closed, and the woman freed from a calamity that none can appreciate but those who experience and have witnessed its bitterness.

The urine would dribble occasionally, for some time, from the urethra, which had partially lost its retentive power; but now, the woman is perfectly well, and happy.

It may be added, that the long needle should be flexible nearly to the point, so that it may be bent to a short curve, as I found it necessary to reduce the temper of mine by the flame of a lamp. The assistant who holds the instrument for dilating the vagina, requires a strong arm and great endurance, for which I found Dr. Carroll fully able; whilst the dexterity and tact of Dr. Alexander B. Mott, in other parts of the operation, were most efficiently afforded.

Case of John W. Francis, Jun. Reported by Richard S. Kissam, M. D.

MESSIEURS EDITORS :

In accordance with your request, I proceed to describe the last and fatal illness of John W. Francis, jun., the eldest son of the distinguished physician whose name he bore. Young Francis possessed an ardent and sanguine temperament, great mental activity, combined with a fine corporeal development. Having received a thorough preliminary education, graduating with honor at Columbia College, he entered upon his professional studies with unusual ardor, and a firm determination to excel.

During the last year, he became the subject of severe acute rheumatism, which did not confine itself to the joints, but seriously implicated the heart and pleura. Mr. Francis entirely recovered from his rheumatism. Continuing during the whole of last summer in this city, he unduly exerted himself in severe labors at the New York Hospital, both in the prosecution of pharmaceutical studies, and assiduous attendance on the medical and surgical wards of that Institution.

When the lectures of the University Medical College commenced, he transferred his attendance to those courses, and here again labored with indefatigable zeal, frequently studying until after midnight, in order to achieve excellence. Not unfrequently, he arose at 6, A. M., and faced the cold winds of that early hour, to visit his father's dependent patients, some of whom were subjects of typhus, and other fevers. This course, early in the winter, led to a severe inflammatory fever, though of short duration; it was readily subdued by rest from labor and abstinence from food.

After his recovery, he resumed his usual course, and in ten days suffered a relapse, which his father conquered by antiphlogistic means. From this relapse he apparently entirely recovered ; but again returning to his too laborious course of life, was invaded, on Saturday, the 6th of January, with a severe chill, which proved the commencement of typhus fever, and terminated only with his life. During the ten days preceding this last invasion, young Francis had assiduously attended what he considered to be a case of “Chagres fever.” His determination to acquire knowledge continued even after the severe chill had summoned him to surrender; and on the following day, although suffering from intense headache, continued his anatomical studies.

On Monday, he was obliged to succumb, and did not leave his bed, being alternately shaken with the cold, and heated with the flush of fever.

On Tuesday, the 9th, I first saw him professionally. At that time he had intense headache, and a pulse of 120 in the minute. On the 10th, the fever assumed a remitting form, with most decided evening exacerbations and morning remissions, and so continued until Saturday, the 13th ; when there was no longer any increase and diminution of disease, but fever of a continued type asserted its prerogative.

Sunday morning was ushered in with a pulse of 130, sordes on the teeth and lips, and petechiæ on the surface of the thorax, with partial delirium. Thus situated, I requested a consultation, when Dr. Mott visited him at noon on that day. Up to this time, the treatment had consisted in rest, a gentle purgative, careful sustenance, and ventilation. Soups, jellies, wine whey, and an anodyne at pight, were daily administered. This treatment was followed by quiet nights, and moderately comfortable days.

At the consultation, the patient's condition was alarming, as unequivocal symptoms of typhus were prominently before us. The rapid and feeble pulse was the most disagreeable condition ; and when we considered his former habits, and this his second relapse, we anticipated the most serious issue. Nourishment was now given with greater freedom; wine whey, brandy, beef tea, and chicken jelly were insisted on, and duly administered. The evening anodyne was continued with good effects; and this course was pursued until Wednesday the 17th, when Dr. F. Campbell Stewart was added to the consultation. In accordance with Dr. Stewart's advice, the treatment was continued, with perhaps more energy,-our sole object being to sustain the patient through his sickness, and this without faltering, and with the utmost circumspection.

On Friday, carbonate of ammonia and chloric ether, in addition to the other remedies, were administered with good results.

The coma vigil continued to increase, the strength to fail, the heart to multiply its pulsations, and tympanitis to invade the abdomen ; when, on Saturday, the fourteenth day of his illness, ended the life of a much beloved son, a constant friend, a man of vast industry and acquirements, and of superior mental powers. No postmortem examination was had, owing to peculiar circumstances.

It is well known to all practitioners of medicine, that disease attacking a subject whose brain had been unduly excited by any cause, and more especially by extraordinary mental exertions, is more apt to tend to a fatal result than under any other condition. When we consider the exhausting occupations and inordinate habits of study of our young friend, although directed to a most holy cause, we cannot marvel that a fatal termination should have resulted. The course of treatment was not hastily adopted; every suggestion was carefully weighed ; and all that experience and the most devoted kindness could suggest, was lavished on the case of this gifted and mourned son.

That typhus fever, under peculiar circumstances, is propagated to those in attendance, is no longer a problem. How careful, then, should physicians debilitated from mental or physical causes be, in unnecessarily exposing themselves to this fatal poison. During the last few years, the annals of our profession exhibit a large mortality from typhus fever. The young especially suffer; thus it would appear that greater caution should be exercised by them in encountering this disease.

The mortality in private, it seems to me, does not compare favorably with that of hospital practice. Perhaps it requires a greater amount of poison to produce typhus in well fed subjects than in the starved persons of pauper emigration; and when to this is superadded great mental exhaustion, the case becomes doubly complicated and dangerous.

I join with you in sympathy for our mutual friends, the surviving parents.

Most truly yours,

RICHARD S. KISSAM. NEW YORK, 9 GREAT JONES STREET,

January 22d, 1855.

Observations on Diagnosis by comparison and by exclusion. By NATHAN

P. RICE, M. D.

In order to illustrate what I have chosen as the title for this communication, I will refer to the work of M. Valleix,* a third edition of which has appeared during the past year. The author, and this result of his labors, are great favorites with the juvenile medical world at Paris; and the clear, perspicuous way in which he writes, and the careful nature of

Guide du Medecin Praticien. Paris, 1854.

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