Vesico-vaginal fistula from parturition and other causes; with cases of recto-vaginal fistula

Front matter

ft

CORNELL

UNIVERSITY

Preface

The material presented to the profession in this form was collected with a view of furnishing, through the pages of the American Journal of the Medical Sciences, Philadelphia, a simple record of interesting cases, a portion of which, as an introduction, appeared in the number for October, 1867.

It was soon apparent, however, that this could not be sufficiently condensed, within the allotted space of a journal, to do justice to the subject. Had the change been contemplated in the beginning, a different arrangement might have been adopted, with a review at some length of the literature bearing on the subject.

I am fully satisfied that an analytical digest would have been an addition of great value, in tracing the labors of Jobert (de Lamballe), Follin, Verneuil, Herrgott, Desgranges, Bourguet d'Aix, Duboue, and Courty, of France ; Deroubaix, of Belgium ; Metzler, and G. Simon, of Germany ; Gosset, Simpson, Spencer Wells, Baker Brown, Mathews Duncan, and Lane, of Great Britain ; M. Collis, of Dublin ; Heyward, J. B. S. Jackson, Mettauer, Sims, Bozeman, and Agnew, of the United States ; together with many others.

Yet, with the fullest appreciation of the importance of their contributions to this branch of surgery, I found it impossible, amidst arduous professional duties, to undertake an additional task, without necessitating too great a delay in any attempt to do justice to their work.

I have, therefore, adhered to my original plan of offering simply my own experience as a contribution to the common stock. .

I have endeavered to illustrate, in as concise a manner as possible, the various difficulties which I have met with in operating for these injuries. Having, however, no wish to inflict upon the reader a mere array of cases, I have excluded all but those useful in demonstrating some practical point. To the reader only of the index, it may seem that this rule has not been strictly adhered to, by the introduction of much which may be deemed irrelative ; yet the whole will be found intimately connected with the main ll PREFACE.

subject under consideration. As a sequel to the operation for vesicovaginal fistula, we sometimes have cystitis, with the formation of calculi ; these may cut through and reproduce the fistula ; therefore the operation for removal of stone in the bladder is treated of, as well as for the relief of chronic cystitis, by establishing an artificial opening at a favorable point.

For the closure of a recto-vaginal fistula, situated near the sphincter, it becomes necessary sometimes to divide the perineum and muscle. In this connection, the operation, as practised for closing a lacerated perineum through the sphincter, is described at length.

Fistulae from other causes than parturition are referred to : — the effect of malignant disease ; syphilitic ulcerations ; pelvic abscesses ; the ulceration of the vesico-vaginal septum from calculi, happening after paralysis from injuries, and from the neglect and pressure of pessaries ; with an interesting case of fistula caused by a pistol-shot.

Cases are given of congenital absence of the anus, with the rectum opening into the vagina ; operation for forming an artificial anus ; and the opposite condition, with a deficiency sometimes of the urethral canal, where the vagina and uterus are wanting; the operation for fqrming an artificial vagina before the urethral condition can be relieved ; together with other subjects of minor importance.

It will be found that the needed preparatory treatment, the necessary instruments, the various modes of operation under modified conditions of the vaginal canal, with the after-treament, have been reviewed at full length, with the object of presenting each point in as practical a form as possible.

The classification of cases has been entirely an arbitrary one, the order followed being merely for convenience in clinically illustrating some special subject, by beginning with the simpler examples, and gradually introducing the more complicated ones.

As it is impossible for exactly the same condition to exist ever in any two cases, I have endeavored to present only a sufficient amount of material to be suggestive to any one who will think for himself and study the peculiarities of the special case. With this view, therefore, I have felt that to attempt more would be merely unnecessary on my part.

So far as originality can be claimed, in resorting to various expedients which would be naturally suggested by the peculiarities of any individual case, the chapter on the formation of the urethral canal, with the operations within the bladder, will present many points of interest to the operator, while I hope my experience may encourage others to persevere in their efforts to relieve similar cases, which might be deemed incurable.

79 Madison Avenue, N. Y.

Contents

PREFACE. - - i

Introduction

Result of the application of the metallic suture, and the introduction of Sims* speculum. Fistula, as a result of parturition, more common among the poorer class. But few cases are incurable. Number of cases operated upon and result. Classification. - - 13

Chapter I

Definition and cause. Delay dangerous after impaction. Extent of injury due to position, and not always in proportion to the length of labor. Treatment after reception of injury. Preparatory operations in freeing soft parts previous to closing a fistula. -----. .-- 10,

Chapter II. Instruments Necessary For The Operation

Sims* speculum. The self-retaining speculum- Tenaculi. Perry's barb-pointed tenaculum. Blunt hooks. Scissors of various curves. Ball and socket-jointed knife. Needle forceps. Feeder. Forceps for bending the silver wire loop. Twisting forceps. Shield. Sponge-probang holders. Silver wire; its quality, and proper size. Self-retaining catheter; importance of a proper curve to suit each case. Relative size of instruments in comparison with the wood-cuts. 24

Chapter III. General Remarks On The Operation

The table, dress of the patient, and position. Mode of denuding the edges. Introduction of the needle, with a silk loop, the silver suture attached afterward. Interrupted suture the best. Great accuracy of introduction not necessary if properly " shouldered," and mode of doing so. Method of twisting and flattening the suture. Introduction of the catheter and washing out the bladder. After-treatment. Removal of the sutures. When the patient should sit up. 33

Chapter IV. Vesico-vaginal Fistula, With Laceration Of The Cer- Vix Uteri

The laceration along the vaginal surface being superficial, or extending entirely through the septum, with but little sloughing or loss of tissue afterward. The formation of calculi after injuries of the cervix, and mode of operating for their removal. Chronic cystitis to be treated by producing a vesico-vaginal fistula; method of doing so, and time of closing the opening afterward.

CASE I. First pregnancy; in labor one hundred and three hours. Antero-posterior laceration of the cervix uteri, with a fistula extending in the median line from the cervix to the neck of the bladder. Cured by one operation. Stone in the bladder removed eighteen months afterward. ------ 30

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CASE II. Second labor of one hour ; natural delivery. Anterior laceration of the cervix uteri, extending in the median line along the base of the bladder. Fissure partially closed by nature, leaving a small fistula in front of the cervix. Cured by one operation. First living child born a year afterward. A suture removed from the cervical canal eighteen months after the operation. 45

CASE III. Fifth labor, of forty-five hours* duration. Instrumental delivery. Laceration of the anterior lip of the cervix, with a fistula in the median line an inch in diameter. Closed by one operation. - 47

CASE IV. First pregnancy; natural delivery after a labor of three days. Laceration in the median line of the anterior lip of the cervix, and along the base of the bladder for an inch. Nature had nearly closed the opening. The original condition was reproduced and closed by one operation. 48

CASE V. Fourth pregnancy j forty-eight hours in labor. Delivery accomplished by hand. Fistula extended an inch and a quarter from the cervix in the median line, with laceration of the anterior lip of the cervix. First operation closed the fistula on the vaginal surface, but a sinus was formed afterward, communicating with the cervical canal. Second operation successful by dividing the cervix through to the sinus, and reproducing the original condition. - 49

CASE VI. Sixth pregnancy. In labor eighteen hours ; delivered by version. Lacerration of the anterior lip of the cervix uteri and base of the bladder in the median line. Partially closed by nature, leaving a sinus communicating with the cervical canal above the vaginal junction. Cured by closing the os uteri. 51

CASE VII. Third pregnancy; natural delivery after a labor of thirty-seven hours. A sinus from the bladder entered the cervical canal above the vaginal junction, and, as in the previous case, from laceration of the anterior lip. - 53

CASE VIII. First pregnancy. Twenty-four hours in labor; delivered by craniotomy. Anterior laceration of the cervix, which, becoming closed above, left a sinus communicating with the uterine canal from a large fistula in front. The original condition was reproduced and operation successful. - 54

CASE IX. First pregnancy. Version, and head delivered by forceps; in labor about thirteen hours. Laceration of the cervix uteri on the right side, with a fistula an inch in length, and cicatricial bands extending from the opening into the cul-de-sac. Closed by one operation. 56

CASE X. Ninth pregnancy ; delivered by forceps, after a labor of forty-two hours. - Lateral laceration of the cervix on the right side. Fistula large, with cicatricial tissue extending into the cul-de-sac. First operation not entirely successful. Cured by the second operation after reproducing the original condition. 57

CASE XI. Fifth pregnancy. Delivered by efforts of nature ; in labor three days. Lateral laceration of the cervix on the left side. Fissure through the cervix closed by nature, as well as part of the anterior edge of the fistula. One operation successful. 58

Chapter V

LACERATION OF THE CERVIX, WITH EXTENSIVE LOSS OF THE SOFT PARTS PROM SLOUGHING.

CASE XII. Second pregnancy. Seventy-one hours in labor; delivered by the efforts of nature. Laceration of the anterior lip in the median line, with sloughing of nearly two inches along the base of the bladder. By contraction of cicatricial tissue, the vagina was drawn into a deep fold on each side of the fistula. Cured by one operation. - - 60

CASE XIII. First labor, lasting fifty hours ; delivered by forceps. Laceration of the anterior lip of the cervix, together with a slough extending nearly to the neck of the bladder. Partially closed by nature from each end, and, by contraction of cicatricial tissue, reduced to a circular opening, situated about the centre of the base of the bladder. Closed by one operation. 61

CASE XIV. Third pregnancy ; delivery by forceps, after a labor of forty-two hours. Laceration of the anterior lip of the cervix, and of the base of the bladder in

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the median line, with sloughing. Fissure in cervix united by granulation. Fistula reduced to a circular one, and vagina shortened by bands extending into the cul-de-sac. Closed by one operation. - - 6a

CASE XV. Third pregnancy; delivered by version, after a labor of twenty-four hours. Laceration of the cervix in its anteroposterior diameter, with loss of about half the base of the bladder in front of the uterus. Fistula was to the right of the median line, in consequence of traction exerted by cicatricial bands extending into the cul-de-sac, which drew the uterus to the left side. Closed by two operations. - - 63

CASE XVI. First pregnancy. In labor about one hundred and four hours ; delivered by the efforts of nature. Loss of two-thirds of the base of the bladder in front of the cervix, the posterior lip of the cervix and cul-de-sac. Laceration of the anterior lip of the cervix, with a false passage existing from the urethra into the vagina. First operation successful, but, by tension, an opening afterward occurred, which was closed by a subsequent operation. - 66

Chapter VI

FISTULA INVOLVING THE UPPER PORTION OF THE VAGINA, WITH SLOUGHING OF THE CERVIX UTERI.

CASE XVII. Sixth pregnancy ; natural delivery, after forty-eight hours in labor. Transverse fistula in front of the cervix, which had sloughed. By cicatricial bands extending into the cul-de-sac, the vaginal tissue in front of the cervix was drawn into a fold so as to hide the opening into the bladder. Closed by one operation. - - - 71

CASE XVIII. Sixth pregnancy ; instrumental delivery, after sixty-seven hours in labor. Uterus retroverted j anterior lip lost, together with a large portion of the base of the bladder. By contraction of cicatricial tissue, the vaginal wall in front was drawn into a fold, so as to hide the fistula from view. Fistula closed by turning the cervix uteri into the bladder. Operation successful; small opening afterward, which was closed by a second operation. - -72

CASE XIX. Fifth pregnancy ; instrumental delivery, after forty-eight hours in labor. The posterior lip of the cervix was lacerated during labor backward into the cul-de-sac, with subsequent pelvic cellulitis. Sloughing of the anterior lip, and a portion of the base of the bladder, just in front of the cervix, took place. The uterus became gradually retroverted, and the base of the bladder doubled on itself from contraction of cicatricial tissue, so as finally to hide the fistula from view. Closed by one operation. - 74

CASE XX. First pregnancy ; instrumental delivery, after seventy-two hours in labor. A large portion of the base of the bladder lost, together with the cervix and cul-de-sac. By contraction of cicatricial bands, the vaginal tissue became drawn backward over the fistula. Closed by one operation. - 76

CASE XXI. First pregnancy; natural delivery, after thirty-six hours in labor. Transverse fistula in front of the uterus, with loss of anterior lip. A fold existed in front of the opening, from cicatricial tissue extending forward toward the neck of the bladder. The cervix uteri was turned into the bladder, and the opening closed by one operation. «• - 77

CASE XXII. Second pregnancy; instrumental delivery, after seventy hours in labor. Loss of the anterior lip of the cervix, with a large portion of the base of the bladder. By contraction of cicatricial tissue, the anterior wall of the vagina was drawn backward, and nature had nearly closed the fistula by uniting a portion of its edge with the posterior lip of the uterus, thus shutting up the uterine canal within the bladder. Two openings remained, which were closed by one operation. ■ - - - 80

CASE XXIII. Third pregnancy ; natural delivery, after a labor of twenty-six hours. Loss of the cervix uteri, with the whole base of the bladder. By bands in the cul-de-sac, the fistula, which was three inches in length, was drawn into a crescentic form, with its cornua posterior to the cervix uteri. Closed by one operation. - - - - - 82 vi CONTENTS.

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CASE XXIV. Fifth pregnancy ; natural delivery, after a labor of fifty-six hours. Loss of the anterior lip of the cervix and upper third of the base of the bladder. The vaginal tissue was drawn backward as a hood so as to hide the fistula. The fistula was brought into view and closed, but no union took place, as its edges were cicatricial. Second operation successful, by cutting out the fistula with the surrounding tissue, and bringing together healthy surfaces. - 83

CASE XXV. Third pregnancy; instrumental delivery, after a labor of some forty-six hours. Loss of the anterior lip of the cervix and upper portion of the base of the bladder. By contraction, the vaginal tissue was drawn laterally into two folds over the cervix and fistula, and these extended in the long axis of the canal, from the cul-de-sac nearly to the neck of the bladder. Closed by one operation. 85

Chapter VII. Fistula Confined To The Upper Portion Of The Base Of

THE BLADDER.

CASE XXVI. Second pregnancy j instrumental delivery, after a labor of forty-nine hours. A slough had extended in the median line, from the cervix uteri nearly to the neck of the bladder j but, by contraction of cicatricial bands, the opening became a transverse one in front of the cervix. Cured by one operation. 87

CASE XXVII. Seventh pregnancy j natural delivery, after sixty-seven hours in labor. Loss of the whole base of the bladder. Fistula was crescentic in shape, with its cornua drawn toward the cul-de-sac. The anterior lip of the cervix formed the posterior boundary of the fistula. Closed by one operation. 88

CASE XXVIII. First pregnancy ; natural delivery, after a labor of one hundred and one hours. Loss of one-third of the base of the bladder in front of the cervix. By cicatricial bands extending into the cul-de-sac, the fistula was lessened in size, the vagina shortened, and a fold drawn backward over the opening, so as to hide it from view. Closed by one operation. 90

CASE XXIX. Third pregnancy $ instrumental delivery, after thirty hours in labor. Loss of the upper half of the base of the bladder, with lateral laceration of the cervix uteri by a previous labor. The fistula was crescentic in shape, with its cornua extending into the cul-de-sac, and the anterior lip of the uterus formed its posterior boundary. Closed by one operation. 91

CASE XXX. First pregnancy ; instrumental delivery, after a labor of some ninety-six hours. Loss of the upper third of the base of the bladder. The opening was contracted and surrounded by cicatricial tissue. The fistula and neighboring tissue shut in at the bottom of a deep pouch extending across the vagina. Operation successful. - - "93

CASE XXXI. Fifth pregnancy ; delivered by version, after a labor of eight hours and a half. A vesico-vaginal fistula, where nineteen attempts had been made to close it previous to admission. Found no cervix uteri, but two openings in the median line, high up in the vagina, leading into the bladder, with a septum between the two, about half an inch in width. This septum was divided, when it was ascertained that the fistula was situated immediately in front of the remains of the cervix. Its edges were cicatricial, and the loss of tissue had been extensive. Healthy tissue was brought together from beyond over the opening, and closed by one operation in the axis of the vagina. 94

CASE XXXII. First pregnancy ; instrumental delivery, after a labor of about ninety hours. Fistula in front of the cervix. Partially closed by an operation previous to admission, but, by the use of the cautery afterward, the surrounding tissue had become cicatricial. No union after the first operation. The second operation successful, by removing the unhealthy tissue. 96

Chapter VIII. Fistula Involving The Base Of The Bladder

CASE XXXIII. Fourth pregnancy ; instrumental delivery, after a labor of twenty-one hours. Child weighing sixteen pounds. Loss of the whole base of the bladder. The fistula was more than three inches in length and extended ob-

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liquely to the right, across the axis of the vagina, from contraction of bands in the cul-de-sac. Closed by one operation. A small opening subsequently occurred from getting up too soon. Second operation successful. By traction, a portion of the line separated which had been closed by the first operation. By the third operation, but partial union was obtained. Discharged for disorderly conduct, readmitted afterward, and discharged, cured by the next operation. 98

CASE XXXIV. Second pregnancy ; instrumental delivery, after a labor of ten hours. The fistula extended obliquely across the axis of the vagina, from the right of the cervix uteri to the left of the neck of the bladder. Operation successful, and at the third month of pregnancy. - 104

CASE XXXV. Fourth pregnancy ; delivered by forceps, after a labor of fifty-one hours. Loss of the entire base, with the neck, of the bladder. The fistula was closed by bridging over the opening with vaginal tissue turned into the bladder. 106

CASE XXXVI. First pregnancy; m labor forty-five hours, and delivered by forceps. Loss of the whole base of the bladder. The fistula was closed, after dividing the bands in the cul-de-sac, by drawing down the cervix uteri, and uniting it to the neck of the bladder. . 109

CASE XXXVII. Fourth pregnancy; one hundred and five hours in labor; delivery by forceps. The whole base of the bladder lost by sloughing, with the inner face of the left ramus denuded. The fistula was closed by three progressive operations. - no

CASE XXXVIII. First pregnancy ; in labor about fifty-eight hours, and delivered by forceps. A fistula existed, involving a loss of the whole base of the bladder, with the face of each ramus nearly denuded ; the inverted bladder, with a portion of intestine, frequently became strangulated by protruding through the fistula. Closed by one operation. - - 113

CASE XXXIX. First pregnancy; in labor two hundred and twenty-four hours; delivered by forceps. Loss of the whole base of the bladder, the cervix uteri, and cul-de-sac, with the inverted bladder protruding through the fistula in the midst of cicatricial tissue. By four operations the opening was nearly closed ; she was discharged to recruit. Readmitted, and cured by the fifth operation. 114

CASE XL. First pregnancy; natural delivery, after a labor of twenty-four hours. Loss of nearly the whole base of the bladder, a portion of the neck of the uterus, and the cul-de-sac. The fistula crescentic in shape, and the vagina shortened, by contraction of cicatricial tissue, to an inch and a half in depth. After a preparatory operation, for enlarging the vagina and dividing the bands, the fistula was closed by two operations. - 117

CASE XLI. Tenth pregnancy; ninety-five hours in labor; delivered by hand. Loss of right half of the base of the bladder, with shortening of the vagina, and the fistula hidden by folds. Closed by one operation. 120

CASE XLII. First pregnancy ; in labor one hundred and five hours; delivered by forceps. Urine not voided during the time in labor. Loss of the left half of the base of the bladder. Closed by one operation. 122

CASE XLIII. Second pregnancy; in labor ninety hours ; delivery accomplished by the efforts of nature. The left half of the base was lost by sloughing, with the neck of the uterus and cul-de-sac. The vagina was shortened and narrowed, with occlusion of the uterine canal. By two operations the fistula was closed. A small opening subsequently formed, which closed by contraction, 123

CASE XLIV. Fourth pregnancy; seven hours in labor; natural delivery. Loss of the entire base of the bladder, with bands extending from each side of the cervix uteri to the pubes, which, by contraction, shortened trie vagina and drew down the cervix uteri nearly to the neck of the bladder. The first and second operations were but partially successful; the third one entirely so. 126

CASE XLV. First pregnancy; eleven hours in labor; delivered by forceps. Nearly the whole base was lost and the uterus left immovable. The fistula was closed by splitting its posterior edge and drawing forward the bladder or under portion, which was united to the anterior edge of the opening. - - 128

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CASE XLVI. In labor eighty-one hours ; first pregnancy ; natural delivery. Two fistula;, one near the neck of the bladder, to the right, and the other near the cervix, on the same side. Vagina shortened by a cicatricial band extending from the lower fistula across the vagina to the left, around in the cul-de-sac, to the upper opening. Each closed by a single operation. - 1 30

Chapter IX

FISTULA, WITH OCCLUSION OF THE VAGINA, PARTIAL OR COM- PLETE, POSTERIOR TO THE OPENING INTO THE BLADDER.

CASE XL VII. First pregnancy ; in labor one hundred and two hours ; delivered with forceps. A transverse fistula extended across the vagina, about two inches from the mouth of the urethra, and, from its posterior lip, the vagina was entirely occluded beyond. The uterus could be felt from the rectum, embedded in a mass of tissue resulting from pelvic cellulitis. The fistula was closed by uniting its anterior lip to the posterior wall of the vagina. - 1 34

CASE XLVIII. First labor, lasting five days ; delivery with forceps. A transverse fistula at the neck of the bladder, with occlusion of the vagina beyond. The fistula closed by one operation. The vagina was opened five times by the knife, each operation unsuccessful, with subsequent retention of the menstrual Bow. Finally, a satisfactory result was obtained by laceration. - 136

CASE XLIX. First pregnancy ; no labor pains ; delivery by forceps, six days after rupture of the membranes. The vagina was narrowed at the depth of an inch and a half, a transverse fistula beyond, with perfect occlusion of the canal from the posterior edge of the opening. The vagina was opened to over three inches in depth, without detecting the position of the uterus. The fistula into the bladder was closed after two operations, by bringing together the tissue along the axis of the vagina in two folds, and shutting up the fistula at the bottom of a pouch. - - 143

Chapter X

FISTULA, WITH PARTIAL OCCLUSION OF THE VAGINA ANTE- RIOR TO THE OPENING INTO THE BLADDER.

CASE L. First pregnancy ; in labor forty-eight hours, and delivery by forceps. Entrance to the vagina nearly closed, from contraction of a circular slough. Outlet opened, the whole base of the bladder was found to have been lost, with the cul-de-sac destroyed, and the vagina shortened to an inch and a half in depth. The vaginal canal was opened to the depth of three inches, and the fistula closed. Shortly after the sutures had been removed, the angle behind the right ramus separated ; this was closed by a subsequent operation. 149

CASE LL First pregnancy; five days in labor; artificial delivery. The vagina was nearly closed at the depth of an inch. After this contraction had been divided, it was found that nearly the whole base of the bladder had been lost beyond, together with the cul-de-sac, the os uteri occluded and the vagina shortened, with evidence of previous pelvic cellulitis. Several operations were performed for opening the vagina, and the last was followed by an attack of pelvic cellulitis. The fistula was closed, but the sutures were removed soon afterward, in consequence of hemorrhage. A second operation was abandoned from excessive hemorrhage, but a third one was successful. 151

Second pregnancy, twins ; partial occlusion of the vagina, with the antero-posterior diameter found contracted to 2-f inches, Twenty-eight hours in labor; delivered by perforation, the first child presenting by the breech y the second by the head. Recurrence of the fistula in the old line, and subsequent contraction of the vagina. The fistula again closed, and the vagina allowed to contract after the operation, to guard against the recurrence of pregnancy. - - - 153

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CASE LII. First pregnancy; about fifty-one hours in labor; delivery by forceps. Vagina shortened and partially occluded by bands crossing the vagina. After division of the bands, the fistula was exposed, and found situated in front of the cervix. The edges of the fistula, with the surrounding cicatricial tissue, were removed, and the opening closed by one operation. - 155

CASE LIII. Sixth pregnancy ; one hundred and fifteen hours in labor, and delivery by forceps. Vagina almost closed at the depth of an inch and a half, with destruction of the cul-de-sac. The vagina was fully opened after two operations, and the fistula in front of the cervix closed by one operation. - - 156

CHAPTER XL

FISTULA, SITUATED IMMEDIATELY BEHIND THE RAMI.

CASE LIV. First pregnancy; fifteen hours in labor; delivery by forceps. The vagina was almost closed throughout its length, with loss of the cul-de-sac. Vagina opened by the scissors, laceration, and the knife. The fistula was found situated immediately behind the left ramus. Several days after removing the sutures used for the first operation, a small opening occurred from traction, in consequence of the surrounding cicatricial tissue. This opening remained closed after a second operation. - ■ 158

CASE LV. Fourth pregnancy ; seventy-four hours in labor, and delivery by forceps. A triangular-shaped fistula situated immediately behind the left ramus. Before the opening could be brought fully into view or closed, it was necessary to dissect its base free from the bone. Closed by one operation. 161

CASE LVI. Fourth pregnancy ; in labor forty-four hours ; natural delivery. The fistula was similarly situated behind the left ramus, as in Case LV, but with less sloughing ; while the soft parts being more yielding, it was closed by one operation, without being freed from the bone. 1 6a

CASE LVII. Sixth pregnancy ; about twelve hours in labor ; delivery by traction. The fistula was situated behind the right ramus, lessened in size by the contraction of cicatricial tissue, and the vagina shortened by a cystocele. The fistula was closed by an operation for the relief of the cystocele. - 163

Chapter XII. Fistula At The Neck Of The Bladder

CASE LVIII. First pregnancy; natural delivery; forty-eight hours in labor. A transverse fistula was found at the neck of the bladder, with loss of the cervix uteri and cul-de-sac. By contraction of cicatricial bands extending along the lateral walls, from the cul-de-sac to the outlet of the vagina, the canal was shortened, with a resulting cystocele. The fistula was closed by the first operation, with the exception of a small opening. At the second operation the small opening was closed by the one instituted for the relief of the cystocele. ... - 166

CASE LIX. Fourth pregnancy; in labor one hundred and two hours; delivery by forceps. After great loss of tissue and narrowing of the vagina, a small opening was left at the neck of the bladder, which was brought into view on separating two deep folds ; these were formed by contraction of cicatricial tissue, and extended under the arch of the pubes, downward and backward on to the recto-vaginal septum. Fistula closed without dividing the bands, for had they been incised, incontinence of urine would have resulted, as the neck of the bladder had been lost. - - - 1 68