traction of teeth, examination of injured limbs, acute asthma, etc., not pertinent to this journal; and further details would add numerical rather than practical data. The general effects have been: Obtusion of the deeper sensibility, confusion of intellect, control of motility, diminution of cutaneous sensibility, acceleration of pulse and respiration, suspension of intellectual functions, abasement of temperature,-all gradual, temporary, and apparently without danger.

The physiological micro-chemistry of chloral offers interest.

If chloral in the test-tube devolves chloroform, does it also when subjected to the laws of vital chemistry?

VESICO-VAGINAL FISTULE, WITH LACERATION OF URETHRA.

BY NATHAN BOZEMAN, M.D., New York.

(Seventh Series commencing Oct. 1867.) Case XII. Mrs. M., of Jordan, New York.

THE lesion in question is referred to her first labor of 42 hours, terminated with forceps, in April, 1852. Four or five days afterwards, the urine began to dribble through the vagina.

The September following, a surgeon of Syracuse opened, by incisions, the vagina, which had closed almost completely, and afterwards attempted unsuccessfully to close the fistule.

Jan. 19th, 1867 she came under care of Dr. Emmet, as chief surgeon of the N. Y. Woman's Hospital. He has published the surgical history as Case L. in his

treatise on V. V. F., 1868. After dividing the bands of contracture, and dilating the vagina, Dr. Emmet proceeded to close the large opening, by soldering the anterior lip of the cervix uteri to the root of the urethra with fifteen interrupted silver sutures. The dribbling recommenced a few days after their removal, and a second operation was made, with five sutures, about seven weeks after the first. This patient is further reported to have "returned home cured the last of May," but we find her readmitted the next March, and complaining that she had been dribbling urine ever since she left the hospital last year. Dr. Emmet examined her and found the fistule "not larger than a good-sized bristle." Its edges were pared and closed a third time by the interrupted silver suture, but the result was no better than in the preceding operation. Her health being impaired, she was again advised to return home, but assured of cure, as a very simple matter, by a fourth operation.

This woman placed herself under our care on the 29th of April, 1869. The mouth of the vagina was somewhat contracted, and a small vesico-vaginal fistule appeared about half an inch to the right of the upper end of the urethra, with cicatricial borders of extreme thinness, and there was a rent half an inch long in the outer extremity of the urethra. The relation of the cervix uteri to the remains of the urethra showed that the case must have been originally one of urethro-vesicoutero-vaginal fistule.

The cervical canal, so patulous that the index finger entered with ease into the womb, was on a lower plane than the urethra; thus, while lying down she could re

tain a little urine, but none in walking about. Menstruation had become habitually scant, irregular, and painful, and nervous irritation had reached a state bordering on insanity. She complained more especially of a pain about the neck of the bladder "that would drive her crazy." This had commenced after her second operation, as an uneasy feeling under the pubic arch, that broke her rest at night.

Could the rent in the urethra from the meatus backwards have escaped Dr. Emmet, or had this occurred since the patient's second discharge? No mention is made of it by him, yet it had certainly exerted a most pernicious influence, and its management constituted a most important part of our subsequent treatment.

The first point made was to widen the mouth of the vagina by incisions and dilating tents (bags of oil-silk stuffed with sponge) during several weeks, which prepared for our operation on the 6th of July.

In presence of Drs. Finnell, Moses, Hunter, and others, the patient was secured upon our operating chair in the right-angle position on the knees and chest, and ether administered. Our speculum was then introduced, and the operation commenced without any assistance. The thinned borders of the fistule were removed without hemorrhage and the fistule enlarged thereby to the size of two fingers. Before, it had only admitted a probe. Four interrupted sutures were introduced, and adjusted with a button 14 inches long, the shape of which is shown in the annexed drawing (Fig. 1), with its curves as secured in position. An elastic catheter was next introduced and the patient put to

bed. The whole after-treatment consisted in keeping the catheter open, and giving a little morphine now and

then, to control the bowels and to keep the patient in a state of dreamy quiet.

On the eighth day, the suture apparatus removed, left closure of the fistule complete. So long as the catheter remained in the bladder the patient kept perfectly dry, but a few days afterwards, and on assuming the erect position, the urine escaped, which we ascribed to the shortening of the urethra. In the dorsal position the bladder held a certain quantity of urine, but any excess ran off through the urethra, without apparent control over it. The course of the urine was back into the vagina and cavity of the womb, this being favored by the position of the cervix and great dilatation of the os tinca, which was depressed, while the body of the womb was retroflexed. Thus the urine had a gradual fall from the urethra, on the anterior vaginal face, into the cervical canal, and thence into the fundus uteri. After plugging the urethra, the cavity of the womb could be wiped dry. When this was not done, and when the patient was turned upon the knees and elbows,

we saw the urine run from the more elevated fundus of the womb into the vagina. The linen test, infallible in such circumstances, when applied to the cervical canal, completed the proof against a vesicouterine fistule, and showed the direct escape of urine from the urethra alone. We now determined to attempt closing the rent in the urethra, and thus to double its length.

Operation: August 6th. Present, Dr. Pelechin, of St. Petersburg, Russia, and Drs. Moses, Chauveau, and Davega, of this city. The patient was secured, as before, in the knee and chest position, our self-retaining speculum introduced into the vagina, and a No. 4 elastic catheter into the bladder. We trimmed off with scissors the edges of the lacerated urethra, from the meatus back to the commissure, and drew the parts together over the catheter with three interrupted sutures. These sutures were secured with our button, so as to relieve the approximated edges of the urethra of the weight of the catheter, and secure union to the very extremity of the canal, a point essential to the complete restoration of function.

FIG. 2.

Fig. 2, a three-quarter front view, shows the adjustment of the suture apparatus, with fixed elevation and