many fatal cases the edges of this wound have been found flaccid and gaping. But in the majority of, if not in all, these cases the operation had been performed on women exhausted by protracted labour; and, on the other hand, in women operated upon at a selected time, when the powers are unimpaired, the uterus commonly contracts well. Winckel says he has never lost a case from hemorrhage, and has not stitched the uterine wound. Mr. Spencer Wells has had a successful case in which he used a long piece of silk as an uninterrupted suture, leaving one end hanging out through the cervix and vagina. By pulling on this end the suture was removed after several days.

Another mode of suture would be to carry the same suture though the uterine and abdominal walls, so as to secure adhesion between the two parts. A serious source of danger is from vomiting the straining and relaxation attending this accident tend to promote the opening of both wounds, and to force the discharges through them. This risk would be lessened by uterine sutures. Upon the whole the case may be stated thus: -If the patient is operated upon at a selected time, if the danger of vomiting is lessened by not taking chloroform, and if the uterus contracts well during the operation, the sutures may be dispensed with; but under the opposite circumstances, it would be better to stitch the uterus as was done in Mr. Spencer Wells's case.

Closure of the Abdominal Wound.-The methods adopted in ovariotomy may be followed. I am inclined to prefer the uninterrupted silk suture. Winckel's cases were closed by the more common method of interrupted sutures, with intermediate skin sutures. The important point is to close the wound completely.

After-treatment.-A full dose of opium should be given immediately either in form of pill or suppository. Light nourishment and perfect repose are the things to be observed. The dressings should not be removed for five or six days. To obviate foulness, sprinkling with Condy's fluid or weak carbolic acid may be resorted to. The sutures may be removed on the seventh or eighth day. The bowels may be relieved by enema on the fourth or fifth day.

What is the risk to life attending the Cæsarian section, numerically expressed? I have already made some remarks upon this, the statistical aspect of the question. I doubt if any satisfactory answer can be given. Can any quasi-analogical deduction be drawn from the mortality attending ovariotomy? Take this to be one death to two or three recoveries; may we expect a similar result from the Caesarian section--I mean, of course, when performed at a selected time? It would be rash to expect an equal success; and there is a consideration which, I think,

VOL. LIX.

is generally neglected by obstetricians. It is this: we are not justified in treating the particular patient whose case is before us as an abstract entity, a mere arithmetical unit. Her fate is not to be decided by what are called statistical laws, but which are in reality too often nothing better than the accidental issues of blind gropings. We must study case by case; compare them; analyse clinically. "Non numerandæ, sed perpendendæ sunt observationes."

The Dangers of the Operation and Prognosis.-The principal risks run are as follows:

1. If the operation is performed as the last resource after protracted attempts to deliver by other means, the woman is liable to sink from shock and exhaustion within a few hours; or if she survive beyond a few hours, there is the risk of hemorrhage, of peritonitis, and of puerperal fever. It may be said that the prospect of recovery, when the operation is performed under these circumstances, is very small.

2. If the operation is performed at a selected time, the woman escapes the shock attendant upon the protracted labour, and encounters the shock of the operation with unimpaired strength. Still, the shock is very great, and is not seldom fatal per se. This is the first and most pressing danger. Could it be in any way modified or controlled, the Cæsarian section might be undertaken with more confidence. But shock necessarily attends all severe abdominal injury. It affects different persons in different degrees. Nor can we readily predicate of any given person that she will bear shock well or badly. It is an uncertain element, and must probably ever perplex all calculation as to the result of the Cæsarian section in any particular case. I do not think that chloroform materially lessens the shock; and it adds the danger of vomiting.

3. The next danger is hemorrhage, and as hemorrhage is often associated with prostration as cause and as effect, the danger is serious. This may come on within a few hours. It might be expected that hemorrhage would be liable to come from the inner uterine surface, as after ordinary labour, but the more common source is probably from the sinuses divided in the uterine wound. The quantity lost may be enough to cause a fatal anæmia. But the more common evil is from the irritation caused by the blood collecting in the abdominal cavity giving rise to

4 Secondary shock and peritonitis.-That secondary shock precedes peritonitis I have no doubt. Intense pain, even tenderness on pressure, rapid small pulse, accelerated and impeded breathing, suggest the diagnosis of peritonitis; but if at this stage the patient die and is examined, probably no trace of peritonitis, as revealed by redness or effusion, is discovered.

Peritonitis may come on the day following the operation. It may be met by fomentations to the abdomen, by opiate suppositories; and the prostration soon ensuing must be combated with wine, brandy, beef-tea, chicken-broth. Salines are often useful, especially at first.

5. If the patient escapes the preceding dangers, there is still the risk of septic infection, of septicaemic puerperal fever. The source of this is the absorption of septic matter from the cavity of the womb or from the edges of the wound; or it may arise from general blood-dyscrasia resulting from the accumulation in the circulation of effete matters which the excreting organs are unable to dispose of.

6. In addition to the dangers incident to the operation and to the puerperal state, there is the danger inherent to the disease which rendered the operation necessary, liable in some cases, as in cancer, to be aggravated by the operation, which may accelerate the fatal issue.-Med. Times and Gazette, Dec. 26, 1868, p. 717.

97.-ON VESICO-VAGINAL FISTULA.

By Dr. MAURICE H. COLLIS, Surgeon to the Meath Hospital
and County Dublin Infirmary; Examiner in Surgery to the
Royal College of Surgeons in Ireland; Chairman
Irish Medical Association.

The first branch of plastic surgery to which I wish to draw attention, is that which deals with fistula connected with the vagina and the bladder or rectum. These have been treated by cautery, by suture, and by transplantation of flaps. To the various methods I have contributed one, which has proved not unsuccessful in my hands, and in those of others who have taken pains to master its details. I got the idea from Pancoast, an American surgeon, and author of a work on Operative Surgery. He describes a plan by which he treated a vesico-vaginal fistula successfully. It is briefly as follows. He pares one side of the fistula so as to make it wedge-shaped, stripping it of its mucous membrane, both on vesical and vaginal surfaces. The

Fig. 1.

opposite side or margin of the fistula is split so as to form two flaps, one vesical and the other vaginal; the raw surfaces, when undisturbed, lying in contact. Between these two flaps, the

FIG. 2.-Inner dark line shows margin of fistula.

Dotted line shows extent of dissection.

raw wedge-shaped margin on the opposite side of the fistula is pushed and held by sutures. This sort of dovetailing of the flaps seemed to me an ingenious and happy method of increasing the amount of raw surface, and so, of increasing the chances of union.

I had not been long acquainted with this method, when I chanced to meet a case of vesico-vaginal fistula which seemed to me capable of cure. It was the first I had seen; for at this date (1856) they were looked upon in Dublin as incurable. At least, the success was so slight, that men had given up trying any plastic operation for their cure. If a touch of the cautery would close them, well and good; but if the size were too great for that, they were dismissed as incurable.

I

The method I adopted in my first case has since become known in foreign parts as Collis's method. It is, however, simply a modification and improvement on Pancoast's. split the margins of the tistula all round to an extent of at least half an inch. This incision of the margins must always pass well through any tough cicatricial tissue, and reach sound areolar tissue. If this point be

D

not attended to with great care, the operation will fail. Having split the margins, I now insert a sufficient number of quilled sutures (Fig. 2), and, on tying the loose ends with a moderate degree of tightness, the flaps open up, and a very large amount of raw surface is made available for union.

Fig. 3 shows the position of the quills and margin on the stitched or vaginal aspect.

Fig. 4 is a sectional view, showing not only the position of the parts depicted in the previous figure (3), but also the mode in which the vesical flaps adapt themselves to one another; also, the position of the quills and sutures.

This mode of treatment has succeeded well in my hands, and in those of Dr. Kidd and other friends. The result in my own practice is thirteen cases and nine cures.

Even

The advantages of this method are-1. There is no loss of tissue, as in paring operations. 2. There is a very large amount of raw surface compared to any paring operation. 3. The flaps towards the bladder will often unite, while the vaginal flaps may fail to unite, either from suppuration or ulceration. when the vaginal flaps have been allowed to slough off from undue tightening of the sutures, union of the vesical portion has taken place. 4. These flaps act also as valves to prevent the access of urine in the wound.

I would only add, that the length of time I leave the sutures uncut depends on the extent and the toughness of the flap. It will vary from the third to the sixth day. I keep the bowels quiet with moderate doses of opium. I keep a catheter in the bladder for forty-eight hours; and I generally place a piece of soft sponge in the vagina to support the sutures, just enough to assist in making a moderate pressure on the bladder, and keep