1847.] Pancoast On the Cure of Vesico-Vaginal Fistula. 273

of the fistula should have considerable thickness; and when not found in this state, they are to be thickened by repeated applications of lunar caustic, or, better still, of the actual cautery.

"Having exposed the fistulous orifice as thoroughly as possible with a Charriére's speculum from which the sliding blade has been removed, an assistant at the same time drawing the vestibulum well up towards the front of the pubis, my first object in the operation is to split the most posterior margin of the fistula to the depth of half an inch, with a sharp-pointed sabre-shaped bistoury. I next pare off the edges of the other lip of the fistula, so as to bring it into a wedge-shape; first reverting it as much as possible with a small blunt hook, and trimming off the mucous membrane on the side next the bladder with the curved scissors or scalpel, and then detaching in like manner, the vaginal mucous membrane, to the breadth of threequarters of an inch, along the whole extent of the lip. This is a very difficult but most important part of the process; and great care should be taken to obtain a sufficient extent of raw surface, at the two angles of the fissure, where the lips will rest merely in apposition. Having checked the bleeding by the use of astringent applications, my next object is to insert the raw wedge or tongue into which one of the lips of the fistula has been converted, into the groove which has been cut in the other, and hold them in close connection. This I accomplish, by the means of a peculiar suture that might be called the plastic, and in the same way that I have described its application in reference to some plastic operations, in my Operative Surgery, and in the American Journal of the Medical Sciences, for October, 1842. The suture threads are to be passed with short, sharp, curved needles, held in Physick's artery forceps with the handles made of twice the ordinary length.

"When the sutures are knotted firmly, the tongue or wedge will be found immovably imbedded in the groove. The sutures I leave for two weeks or more, or until they become loose. A gum catheter should be kept in the bladder to prevent the accumulation of urine. To keep the inflamination from running to a destructive height, a bladder of cold water should be applied for thirty-six hours to the vulva.

"On the second day I direct the frequent injection of a solution of Zinci. Sulph. into the vagina, in order to increase the tone of the parts. On the third or fourth day I apply to the line of union a solution of lunar caustic with a camel's hair pencil. This application should be made twice in the twenty-four hours, the solution being gradually increased in its strength. Union by first intention may be expected to take place under this treat

ment to a considerable extent; at such points as it should fail to occur, union by second intention is to be promoted by the use of lunar caustic in substance, so as to raise a bed of granulation on the raw surfaces of the lips, while they are held in contact by the plastic suture. Occasionally, where the fissure is large, it will become necessary to repeat the process after a partial succcess has been obtained by the first operation.

Philadelphia, April 8, 1847.

Case of traumatic Tetanus, successfully treated. By O. H. COSTILL, M. D. of Frankfort, Pennsylvania.

Feb. 18th, 1847. I was called about 10, A. M. to Margaret a coloured woman, said to be in a fit. I found her lying on a settee, her arms, legs, and whole frame perfectly rigid. Her eyelids were drawn down so tightly as scarcely to be lifted, and her jaws were firmly set. Upon inquiry I found that two days. previous she had received a carpet tack in the bottom of her right foot. It was withdrawn, and nothing more was thought of it till the evening previous, when she complained of pain in the foot and stiffness in the leg and back. She had, however, risen in the morning and resumed her usual occupation, until seized as above described. As the surface of her body was cold, I had her placed in bed and her clothes loosened, (though owing to the rigidity of her limbs they could not be removed,) and warm applications to the feet. After some time the spasmi subsided. She opened her eyes, could move her limbs and converse. She complained of extreme tenderness in the anterior part of the sole of the foot; could scarcely bear it touched, though I could find no point where the nail had entered. The pain extended up the leg and back to the neck and jaws, and there was stiffness about the root of the tongue. I directed a lye poultice to the foot and a mixture of castor oil and turpentine to be given every hour and a half, until the bowels should be freely moved, intending after that to commence with opiates should the tetanic symptoms continue.

I saw her again at 12 o'clock. She was much more comfortable but had had one very severe spasm. Medicine had not operated. During the afternoon she became much worse. An urgent mes

sage was sent for me, and as I was absent from home my friend Dr. Taylor, at the request of my family, was on his way to visit her for me when I returned. He was so kind as to accompany me, and at my request attended the case with me subsequently. It was about six in the evening when we saw her. She had had more than a dozen spasms during the afternoon, and one occurred while we were with her. Her breathing was difficult, as

if choking, the jaws were set, foam proceeded from the mouth. The body was bent in a bow-shape resting upon the occiput and heels (opisthotonos.) Upon examining the foot after the spasm subsided, we could find no point where the nail had entered, but excessive tenderness on the anterior part of the sole within a space of the size of a dollar. Within this space I made two incisions crossing each other at right angles, into which lint saturated with spirits of turpentine was inserted, and the lye poultice re-applied. We directed her to take a pill containing two grains of opium and two of calomel every hour. We saw her again at half past 9 o'clock. She had taken two pills; had had no spasms-ordered one pill every two hours through the night, unless asleep. 19th, 9 A. M. Had taken four pills; had no spasms until six A. M., then had two, but not so severe; we applied at this time a solution of caustic potash along the spine. She was sick at the stomach this morning, and vomited light green fluid. To continue the pills, and as the bowels had not been moved since the attack, we directed a laxative enema. Evening. No spasms through the day; still sick, and vomiting occasionally; some pain in the limb extending up the back; neck and jaws better. The bowels have been freely moved three times. Mouth sore from the calomel. To discontinue the pills, and take two grains of opium at 10 o'clock, with nourishment through the night. 20th, 9 A. M. Slept some during the night, but was much distressed by sickness--vomiting the same light green fluid. Much more prostrate. The pulse, which had been nearly natural, till this morning, was frequent and feeble. To take a mixture containing 5 grains carb. ammonia and twenty drops tinct. opii every two hours; blister to the epigastrium. Evening. Much better; pulse full and soft. Sickness nearly gone. The blister had drawn but slightly. 21st, 9 A. M. Has slept well. No sickness-says she feels very well. To take the ammonia, &c., occasionally-from this time she continued to recover, and is now at service. The wound from the incision made in the foot continued sore for several days; but we could not say it suppurated.

I offer this case for publication, not because there was anything new in the means used for its cure; there certainly was not, but rather as additional evidence that this dreadful malady, so often fatal, will sometimes yield to the ordinary method of treatment. A case occurred to me many years since, in which the tetanic symptoms were very decided, though not so strong as in the case just related, which recovered by the liberal use of opium and stimuli and the dilatation of the wound.

March 24th, 1847.

Congenital obstruction of the Colon in an infant. By JAMES BRYAN, M. D.

April 2d, 1847.-On the 31st ult., I was requested by my friend Dr. L. P. Gebhard to make a post obit examination of J. B., a male infant three days old, who had died without having had any discharge from its bowels after birth. The child had been cheerful and took the breast at first, but gradually became languid, and sunk without evident cause, except the want of a discharge per anum.

On inspection of the body, the abdomen was found very much. enlarged and of a greenish colour. The capillaries of the skin were injected, and the cuticle of a purple colour, as low as half way down the thighs, involving the genital organs, groins, &c.; the abdomen was tympanitic; the os frontis was freely separated down to the root of the nose; the general appearance of the infant in other respects was that of health.

On making an incision through the integuments in the direction of the linea alba, a large quantity of fœtid gas escaped from the abdominal cavity. The bladder appeared healthy and contained a little urine; the uracus was attached to the umbilicus and bladder; the peritoneum in every direction was engorged with dark coloured blood, and the circulatory arcades of the mesocolon with the small vessels of the colon were filled with blood, and easily seen when the intestine was held between the eye and the light. The greater part of the hypogastric region was filled by a tumour about four inches in diameter. On opening the colon above this tumour (which proved to be situated in the sigmoid flexure of the colon,) large quantities of meconium and fecal matter were discharged. The peritoneum when divided was found to cover a smooth surface of the tumour; this surface proved to be the outer coat of the intestine, which was very much distended and contained the tumour in the form of coagulated blood, as black as pitch. The descending colon was distinctly traced into the covering of the tumour, and was found to adhere to the margin of the pelvis, and to be entirely imperforale in the direction of the rectum.

The anus was in a natural condition; a probe would pass without difficulty, and had been passed during life up the rectum to the tumour or obstruction. A few drops of blood had followed the introduction of the probe. The genital organs were well developed; so also the liver, stomach, and small intestines. The tissue of the intestines around the tumour was found apoplexied.

The explanation of this case would appear to be, that a rupture of some of the vessels of the sigmoid flexure of the colon

took place during uterine life. A gradual discharge of blood into the intestine and between its coats took place, producing pressure on the surrounding parts, and in this way, inducing adhesions to an extent to close the passage of the blood towards the rectum, and causing the general adhesions which were found outside of the intestine.

The treatment of this case, provided the diagnosis had been made out, would be, to make an opening into the tumour through the rectum; this failing on account of the adhesions, we might perhaps resort to the production of an artificial anus in one of the situations usually recommended; in this case the latter operation would probably have relieved the patient, at least temporarily.

To the Editor of the Medical Examiner.

Sir,-Permit ine, through the pages of your journal, to direct the attention of the younger members of the profession to a practice, which prevails more or less with many of them, of asking for farther advice in difficult cases of their seniors, by letter, and thus subjecting them to manifest inconvenience and responsibility, without accompanying their request with the wonted, or any, honorarium. Where special relations exist, or have existed, as between preceptor and pupil, there may be apparent, if not real, propriety in the latter seeking occasionally for farther enlightenment; but wherever the patient can afford to remunerate the consulting physician, it ought most assuredly to be the pleasure-if not the duty of the attending physician to suggest the appropriate accompaniment. The undersigned has been subjected to repeated inconvenience on this head, and he knows that others have been equally annoyed. Philadelphia, April 17, 1847.

IATROS.

[We publish the foregoing communication with pleasure, in the hope that it may be useful in correcting an evil of which we hear many and just complaints. We often receive communications complaining, indeed, of eminent physicians for not having answered letters asking counsel, and invariably we have found that the letters sent contained no fee, and sometimes were not even postage paid.-EDITOR.]