THE COLLEGE AND CLINICAL RECORD. 
89 
she was attended in her confinement by a mid- 
wife who, mistaking an over-distended bladder 
for the head of the child, seized hold of it and 
attempted, by the employment of much force, 
to deliver it. The result of the application of 
this force upon the vaginal and vesical walls, 
which had been subjected to prolonged pres- 
sure, and with the bladder distended by urine, 
was, then and there, a rupture, just behind the 
neck of the organ ; so much for the cause. 
The second point to which I desire to call your 
attention is with reference to the number of 
operations which have been performed for the 
purpose of securing closure of the rent. She 
states that during a period of eight months she 
submitted to five operations, all unsuccess- 
ful, except the 'last, and after the lapse of a 
year she piesents herself for the relief of a 
dribbling of urine through the cicatrix, show- 
ing that, for some reason, there is a recurrence 
of the fistula. On examination, I find that 
the reopening of the fistula has been due 
probably to the formation and accumulation of 
small phosphatic calculi, which, lodging about 
the site of the cicatrix, have produced ulcera- 
tion at this point. She has passed several of 
these calculi, and still suffers from their accu- 
mulation. An interesting condition is ob- 
served on examination of the vagina, showing 
that the method taken to close the fistula con- 
sisted in drawing down the cervix-uteri and 
uniting it to the neck of the bladder. This 
method can be employed successfully in cases 
where the opening involves the neck of the 
bladder, the anterior lip forming a part of the 
vesical wall, and in this way closing the open- 
ing- 
Before making an attempt to close the very 
small opening which now exists, we must give 
remedies which will change the character of 
the urine, and for this purpose we will place 
the patient upon the acid treatment, ordering 
ten to fifteen drops of the dilute nitro-muriatic 
acid to be taken three times daily, in a sherry- 
wineglassful of water. You can readily under- 
stand that it would be useless to attempt to 
close the fistulous opening while the condition 
of the urine remains as at present. The im- 
portant lesson to be learned in the study of 
this case is with reference to the obligation 
which rests upon the physician, of knowing 
personally that the bladder has been evacuated 
before labor progresses to any extent; in all 
cases where the forceps are used the catheter 
should be introduced and the bladder entirely 
emptied. The mistake made by the ignorant 
midwife I mention only to add that if com- 
mitted by a graduate in medicine it would 
justly subject him to prosecution for malprac- 
tice, and, on conviction, the penalty should be 
[Reported for the College and Clinical Record.] 
Clinical ^rturc. 
JEFFERSON MEDICAL COLLEGE 
HOSPITAL. 
GYNECOLOGICAL CLINIC, HELD MARCH sist, 1883, 
BY J. EWING MEARS, M. D., 
Clinical Lecturer on Gynaecology and Gynaecologist to the Hospital. 
Case I.-Vesico-vaginal Fistula of Unusual Origin. 
Gentlemen :-At the last clinic I brought be- 
fore you a woman suffering from vesico-vaginal 
fistula, and made some remarks upon the causes 
and other features of this condition. I present 
to you to-day another patient, who has a fistu- 
lous opening between the bladder and vagina, 
the history of whose case verifies, in marked 
manner, the statements made on the previous 
occasion. With regard to the cause of her 
condition, this patient makes an interesting 
statement, one which I am sure will carry 
weight with you, and teach all an important 
lesson. She says that some eight years ago 90 
THE COLLEGE AND CLINICAL RECORD. 
so heavy as to make it impossible for him to 
continue in the practice of medicine. 
2. HAIR-PIN INCARCERATED IN THE CANAL OF 
THE UTERUS REMOVAL. 
This patient is thirty years of age. married, 
but living apart from her husband. She has 
been brought to the Hospital by her medical 
attendant, Dr. Bunn, who states that five 
weeks since she introduced into the uterus a 
hair-pin, for the purpose of producing abor- 
tion. She has suffered much pain, especially 
when in the sitting posture, and is quite 
alarmed with regard to the results which may 
follow the long-continued lodgment of the 
foreign body in the womb. She states that 
she intrpduced the hair-pin bent end tip, and 
that it slipped from her fingers and got so far 
in that she could not grasp the points. Since 
its introduction she has had her menses, and 
she is satisfied with the results of her efforts in 
that direction. She condemns the instrument, 
however, on account of the manner in which 
it disappeared into the recesses of the womb. 
She refuses to take ether, and we will therefore 
be compelled to subject her to some pain, in 
effecting the removal of the foreign body. On 
the introduction of the sound, the pin can be 
felt occupying the canal, extending from a 
point just below the internal os to the fundus. 
One point is imbedded in the post* rior wall; 
the other is free. I will draw down the uterus 
to the mouth of the vagina and hold it with 
the volsella, and will then grasp the free arm 
and endeavor to push it up, so as to dislodge 
the imbedded point. This I find it impossible 
to accomplish. I will now seize it with these 
narrow-pointed, strong forceps, and make an 
effort to turn it. This, you observe, is accom- 
plished, although the posterior lip is perforated 
by the imbedded point. No hemorrhage fol- 
lows the effort at extraction. The patient will 
be kept in bed for a few days, opium supposi- 
tories used, and the hot-water douche em- 
ployed. By these means we will e ideavor to 
prevent the occurrence of inflammation. 
The literature relating to the introduction of 
instruments of various kinds into the uterus 
for the production of abortion, is very interest- 
ing and well worth your study. An extraordi- 
nary instance was recorded a few years since, 
by Prof. T. Gaillard Thomas, of New York, in 
which the woman used a metallic umbrella rod, 
and forced it through the walls of the uterus ; it 
then traversed the abdominal cavity, perfor- 
ated the diaphragm, and finally entered the 
lung; death followed, as a matter of course. 
My colleague, Dr. Longstreth, has related 
to me a case in which he made a post-mortem 
examination, and found malignant disease of 
the uterus. The patient had produced abor- 
tion a number of times, using for that purpose 
the "family whalebone," a piece of whale- 
bone which had been fashioned so as to serve 
the purpose of a sourrd, and had done service 
in the family for a long time. Knitting needles 
and crochet needles have also been used. 
It would seem somewhat difficult to intro- 
duce an instrument of the length of a hair-pin, 
unless the uterus was much prolapsed. In the 
case before you, the pin introduced measured 
two inches and three-quarters. The patient 
states that her womb "comes down a good 
deal." 
[Note.-The patient left the Hospital at the 
expiration of a week, no condition requiring 
special treatment having occurred during that 
period.]