1878 The Lancet  
PESSARY; OPERATION; CURE. (Under the care of Mr. TEEVAN.) ELIZABETH S-, a cook, forty-eight years old, was admitted into the hospital on November 5th, 1877, suffering from a vesico-vaginal fistula. The patient, who was a tall, thin, delicate-looking widow, stated that she had had three children, and that no instruments had ever been used in any of her confinements. About nine years ago a metal pessary was inserted in her vagina by a doctor under whose care she then was. She wore it for four
more » ... s, when she went to a hospital and had it taken out. After its removal her urine dribbled away night and day, and she was always wet. On examination with the duckbill speculum a large fistula could be seen running across the roof of the vagina, obliquely, about one inch in front of the os uteri. A semilunar cherry-coloured piece of mucous membrane hung down from the bladder like a curtain. On November 27th, at 3 P.M., the patient having been put under the influence of ether by Mr. T. G. Alderton, Mr. Teevan pared the edges of the fistula very freely in order to get beyond the dense white cicatricial tissue, and brought them together by seven silver sutures, each of which he secured separately with a coil and shot, as recommended by Dr. Aveling. There was not much bleeding at the operation, which lasted an hour and a half, and had to be performed by the aid of artificial light, as the day was so dark. There was but little to remark in the after-treatment. The patient remained perfectly dry from the day of the operation. On December 6th two stitches were taken out, one on December 14th, another on December 18th, and three on December 22nd. The patient left the hospital on Dec. 29th, quite watertight, and able to hold her water for four hours, which she could pass in a good stream. Mr. Teevan observed that he had in this case employed Dr. Aveling's method of securing the sutures, which he looked upon as a great improvement. It was well known that, in the process of twisting the wires, one would occasionally snap, necessitating the trouble of its removal and replacement by another. Now, by using the coil and shot as recommended by Dr. Av eling, such an annoyance could not occur. Then, again, one of the most troublesome details of the operation was the removal of the sutures, some weeks afterwards perhaps, when they were deeply embedded in the flesh, and were often only extracted with difficulty by the surgeon and pain to the patient. By using the coil and shot all this was obviated. He considered the withdrawal of the urine after the operation, which in this instance had been punctually executed by the house-surgeon, Mr. Lucas, to be of doubtful value. In one case he had allowed the patient to pass her urine naturally from the time of the operation, and had seen no reason to regret having done so. LIVERPOOL NORTHERN HOSPITAL. CASES OF POPLITEAL ANEURISM TREATED BY ESMARCH'S BANDAGE. THE following two cases (for the notes of which we are indebted to Mr. A. Craigmile, senior house-surgeon) are interesting, as they were apparently almost identical in character, and were treated in exactly the same way, but with very different results. The first was readily cured, but the second received no benefit from the elastic bandage, and was cured afterwards by ligature of the femoral artery. CASE 1. Popliteal aneurism successfully treated by Esinarch's bandage. (Under the care of Mr. MANIFOLD.)-Patrick L-, aged thirty-four, dock labourer, was admitted on Aug. 24th, 1877. He had a popliteal aneurism about the size of an orange, to which his attention had been called only sixteen days before by numbness in the leg, cramps, and frequent attacks of pain shooting down to the sole of the foot and up the thigh. His appetite was very poor, and he was in a highly nervous state. The temperature varied from 99° to l0a°; pulse 116. There was slight oedema of the foot. On Aug. 27th Esmarch's bandage was carried rapidly from the foot to the upper part of the thigh, passing quite lightly over the aneurism, which had been covered with wool. The elastic band was put on at the top, and kept on for three-quarters of an hour, during the last thirty minutes of which he had ether. The sac began to get firmer, and continued to do so till the band was taken on, after which a tourniquet was applied for four hours, so as partially to control the circulation. Pulsation returned as soon as the elastic band was removed, but the solid feeling remained. Two days afterwards, as pulsation still continued, though to a less extent, the elastic bandage was reapplied for the same time as before, but pulsation continued when it was removed. The leg was flexed to a moderate extent next day, and the tumour continued to get firmer, and enlarged vessels were felt on the inner and posterior aspects of the joint. By Sept. 8th he was quite cured, but flexion was continued a little longer. The second application of Esmarch's bandage seemed not to affect the result in this case; the flexion was also probably kept up longer than necessary, as it took some time for the patient to regain the use of his leg. CASE 2. Popliteal aneurism treated unsuccessfully by Esnzccrch's bandage, attenwards cured by ligature of the femoral artery antiseptically. (Under the care of Dr. CAMPBELL).—Michael M-, aged thirty-nine, fireman, was admitted on Sept. 19th, 1877, with popliteal aneurism very similar in character to the former. He was a strong, healthy-looking man, but there was well-marked atheroma of the arteries. Esmarch's bandage was applied, as in the former case, on Sept. 25th, and kept on for fifty minutes, but no consolidation took place. A tourniquet was kept on for some time afterwards. Esmarch's bandage was repeated three times, at intervals of some days, and tourniquets were also kept on, but without the slightest effect on the aneurism. On Oct. 15th, Dr. Campbell tied the femoral artery in the lower part of Scarpa's triangle, using carbolic precautions. The wound was kept antiseptic throughout, and the antiseptic dressings were stopped on Nov. 1st, leaving a linear cicatrix. There was never any return of the pulsation after the operation, and he made an uninterrupted recovery, and was able to walk about three weeks after the operation. Remarks.—Probably in the latter case, coagulation might have taken place in the sac if, while the Esmarch bandage was applied, galvano-puncture had been practised, or even the simple introduction of a needle, to furnish the startingpoint for coagulation, as was successfully done in a case of aneurism high up in the common femoral recorded in a recent number of THE LANCET
doi:10.1016/s0140-6736(02)42551-2 fatcat:4uqzfodehvfujjeuqh7d5i2bge