brane of the bladder should be drawn with a fine hook into the opening. If at last it unite to the edge, its surface should be touched with lunar caustic, to render it more tough and hard.

There is still to be mentioned VIDAL's proposal of, in complete destruction of the vagina and wall of the bladder, bringing together the labia, having first pared them; after which care must be taken, by frequent introduction of the catheter, and, in menstruation, by injection, for clearing the urine and blood from the vagina. To the same purpose is HORNER's proposal (a) of drawing down the uterus into the vagina, and so to fasten its front that it may supply the loss of the bladder or its neck.

[Among the various plans of treating vesico-vaginal fistula, may be mentioned that of introducing a small Indian rubber bag into the bladder proposed by Dr. KEITH of Aberdeen (b), in consequenceof the following very remarkable case which came under his care.

Case.-J. S., aged thirty years, was admitted into the Aberdeen Infirmary, complaining of constant pain in the region of the bladder, and constant distillation of urine from the vagina. She was delivered in 1831 by the forceps, and fourteen days afterwards the urine came away through an artificial opening in the vagina. This continued for seven or eight years, when she plugged the opening with a pint-bottle cork, and for a time succeeded, and she enjoyed comparative comfort till the cork slipped into the bladder, and was followed by the usual symptoms of stone. For a time the urine flowed again through the fistulous opening, but as the spmptoms of stone became aggravated she regained the power of retaining her water, and this so entirely before the close of the year that she then passed the whole of her urine by the urethra. The irritation of the stone, however, became so intolerable that it was resolved to crush it by the screw lithotrite. The fistulous opening was then large enough to admit a No. 16catheter, having once been large enough to admit a pint-bottle cork. When the stone and cork had been crushed, and the particles evacuated the urine again passed freely through the fistulous opening, which, however, had become sufficiently small to allow a button-headed cautery at a white heat to be applied to it, so as to touch at once the edge all around. This was repeated in six days, again in sixteen days, and lastly in twenty-two days, after which she continued quite cured. "Several points of interest attach to this case," says KEITH; "first, It affords convincing evidence, from the effect produced on the fistula by the presence of her calculus that were a foreign body of a smooth and unirritating character, of sufficient weight, introduced into the bladder in cases of vesico-vaginal fistula, the body would act as a bullet valve, and not only keep the patient dry, but actually favour the contraction of the false opening. After seven years, in the above case, the opening admitted a pint-cork, with so much ease that it slipped through but after a foreign body was lodged in the bladder, nine months sufficed to reduce the opening to less than one-third of its previous size, and it could only have been during the latter six months of that period that the cork could have acquired density and weight enough to operate as a valve-plug. I would suggest a small thin bulb or bag of Indian.rubber filled with mercury. Should incrustation happen in the progress of the cure, a squeeze with a screw-lithotrite, or percussor, or a long esophagusforceps would throw it off, and at last when the opening had contracted to such a size as to admit of its ready cure by the cautery, the thin bag could be easily burst or punctured, and then withdrawn by the urethra. Secondly, If asked why I deprived myself of the bullet-valve, while cauterizing in the above case? I reply, that the constant straining kept up by the rough stone, arising from the inflamed state of the mucous membrane of the bladder, kindled and kept up by its presence, obliged me to remove a source of irritation, sufficient to defeat, in more ways than one, any effort of mature adhesion. Thirdly, It is worthy of remark that the application of the actual cautery inside the vagina occasions nothing deserving the name of pain, and this observation I have had repeatedly corroborated. The heat of the reflected rays may be felt; but I have never found patients say that they really felt pain. Fourthly, It is advised by high authority to allow long intervals between each application of the cautery, that time may be afforded for the consequent contraction of the parts: the advice is judicious; but it applies chiefly to cases where the orifice is large, and where there is much to accomplish in the way of closing in. My bullet-valve will, in future, aid the process much in such cases; but I beg to remark that where we have a fistulous opening of the size of a female catheter, for instance, and where, as in the preceding and succeeding cases, we

(a) American Journal, 1839. No. 7.

(b) Remarks on the Treatment of Vesico-vaginal Journal of Medical Science, vol. iv. p 12; also in Fistula; in London and Edinburgh Monthly BRAITHWAITE's Retrospect, vol. ix. p. 164.

are able at once to make the edges approximate, then I would urgently advise the frequent use of the hot iron, so as to keep up a raw edge, as well as a complete closure, thereby to ensure adhesion and complete obliteration at once." (p. 13.)

[RECTO-VAGINAL FISTULA.

981. Still more serious and distressing to the patient than the vesicovaginal, is the Recto-vaginal Fistula, (Fistula recto-vaginalis,) in which the stools incontinently passing from the rectum, through an unnatural passage in the vagina, convert it into a cloaca, from whence they continually escape by the vulva. When from the discharge of stool by this aperture, it is suspected that a fistula exists between the rectum and vagina, its situation and extent may be ascertained by the introduction of the finger of one hand into the rectum, and a blunt gorget into the ragina; but if the fistula be very high up, a sound must be introduced instead of the finger; in the latter case, however, DUPARCQUE prefers the speculum vagina, as by it, every part, even the most minute fold of the vagina, can be thoroughly examined. He also observes, that "injections are not to be despised, as they point out in the fistula, indications which cannot be so exactly determined by any other means. Thus the injection, which does not return by the vagina in stercoral fistula, otherwise very evident, shows that it is neither with the rectum, nor with the large intestines that there is a communication, but that it belongs to the small intestines. The nature of the matter escaping from the fistula, furnishes also a sign more or less positive of the region of the intestinal canal with which it is connected. Thus the matter is liquid and yellowish from the small intestines; thicker and containing portions of formed motions when the fistula is in the large bowels, and more especially when in the rectum. If the gas formed in the small intestines differ materially from that in the large, it may also afford some guide to the seat of the fistula; the patient should therefore be put in a bath, and the gas collected and analysed." (p. 315.) "The tendency to spontaneous cure which exists in accidental openings, is especially remarkable in tearings of the vagina. As the neighbouring parts converge concentrically towards the solution, so does it diminish, narrow, and at last the opening entirely disappears. The development of the cellular granulations, which is a sort of lengthening of the tissue, contributes to fill up the space, and especially to form the scar. Thus fistulous openings, of which the size is so great as to do away with all hope of occlusion, are notwithstanding, more or less immediately closed, either spontaneously after all treatment has been given up as unavailing, or when it has been perhaps more injurious than beneficial." (p. 327.) A remarkable instance of this kind is mentioned by DUPARCQUE, in which there was one aperture between the vagina and rectum, an inch and a half above the anus, through which the finger readily passed; and a second between the vagina and urethra, about an inch from the orifice of the latter, of an oblong shape, from seven to eight lines long and two wide. In four months from the delivery, the apertures had diminished to half the size they were of, at the preceding month, when first examined; and at the end of eight months, "nothing escaped into the vagina, and there was merely a slight depression indicating the scar of the wounds." (p. 331.) The only treatment in this case was great cleanliness, looseness of the bowels, quiet, and generous living.

DUPARCQUE observes, that "the passage of the fæculent matter over

these accidental fistulas, does not actually prevent their healing, but because the parts on which they are found are not favourably disposed to stretch by their distension, or displacement, to the concentric closing of the opening. Thus the use of sounds, pessaries, and obturators, produce no satisfactory results; but on the contrary, by keeping the walls of the fistulous organs asunder, they prevent the narrowing of the opening. (p. 331.) The passage of the stools over the fistula, is rather advantageous than detrimental to the scarring. In reality, their continual contact with the edges of the opening, excites an inflammation which prevents their scarring simply of themselves; it causes the development of cellular granulations necessary to fill up the space, and produce consecutive union. * But I repeat, the principal and most important indication consists in putting the perforated parts in a condition most suitable for the approximation of the edges of the opening." (p. 132-33.)

*

The principle here recommended was, however, carried out much more correctly in an operation for recto-vaginal fistula, first proposed and performed twenty-five years ago by COPELAND, and it is much to be regretted that he has not given to the public any account of it; for though he is well known as having been the original proposer, yet there have been only a few scattered notices of this operation in the works of other writers (a). He has, however, kindly informed me, that his first operation was for a recto-vaginal fistula consequent on delivery, and that it consisted in division of the whole m. sphincter ani, on one side of the anus, so as to produce incontinence of the stools, and quite away from the fistulous opening. The result of this was, that the contraction of the sphincter being destroyed, the parts surrounding the fistula were no longer acted upon by it, and the tendency of the fistulous opening to concentric contraction being not opposed, it gradually drew together till it had completely closed, whilst the divided sphincter uniting more slowly, at last recovered the power of retaining the motions, and thus a perfect cure was effected. He further informs me, that he has operated successfully five or six times, cutting one or other side of the anus, as might be convenient, but never dividing forwards towards the vagina, nor cutting through the fistula and perinæum, as the result would inevitably be permanent incapability of retaining the stools.-J. F. s.]

Besides the writers already mentioned on Vesico-vaginal and Recto-vaginal Fistula, there may be also compared

DIEFFENBACH; in Med. Vereinszeitung für Preussen. 1836, June.

JOBERT ; in Gazette Médicale. 1836, March.

KILIAN, Die rein chirurgischen Operationen des Geburtshelfers. Bonn, 1835. DUPARCQUE, Histoire Complète des Ruptures et Déchirures de l'Uterus, du Vagine et du Périnée. Paris, 1836. 8vo.

BENDZ, H. CH., De Fistulâ Urethræ et Vesico-vaginali. Hafniæ, 1836; with two plates.

ZEIS, Handbuch der plastichen Chirurgie. Berlin, 1818.

JAEGER; in Handwörterbuche der Chirurgie, vol. iii. p. 125.

MICHON, L., Des Opérations que nécessitent les Fistules vaginales. Paris, 1841. LE ROY D'ETIOLLES; in Gazette des Hôpitaux, 1842, September.

(a) MAYO HERBERT, Observations on Injuries and Diseases of the Rectum. London, 1833. p. 23.

8vo.

III.—SOLUTION OF CONTINUITY FROM ALTERED POSITION

OF PARTS.

A.-OF DISLOCATIONS.

FIRST CHAPTER-OF DISLOCATIONS IN GENERAL.

DUVERNEY, G. J., Traité des Maladies des Os. Paris, 1751, vol. ii.

POTT, P., Chirurgical Works, vol. i. p. 373. Edit. 1783.

KIRKLAND, THOS., M.D., Observations on Mr. POTT's general Remarks on Fractures. London, 1770. 8vo. Also an Appendix to the former concerning the cure of Compound Fractures. London, 1771. 8vo.

AITKEN, JOHN, M.D., Essay on Fractures and Luxations. London, 1790. 8vo. BÖTTCHER, J. F., Abhandlung von den Krankheiten der Knochen. Berlin, 1796, vol. ii.

BOYER, Traité des Maladies Chirurgicales, vol. iv.

BERNSTEIN, Ueber Verrenkungen und Beinbrüche. Jena, 1819. 8vo.

Cooper, Astley, Treatise on Dislocations and on Fractures in the Joints. London' 1822. 4to.

CASPARI, K., Anatomisch-chirurgische Darstellung der Verrenkungen, nebst einem Auhange über die complicirten Verrenkungen. Leipzig, 1821. 8vo.

CUNNINGHAM, J. M., Synoptical Chart of the various Dislocations to which the human frame is subjected, comprising their diagnostic symptoms and modes of reduction. London, 1827. fol.

RICHTER, A. L., Theoretisch-praktisches Handbuch der Lehre, von den Bruchen und Verrenkungen der Knocken. Berlin, 1828. 8vo.; with 40 folio plates. HAGER, Die Verrenkungen und die Verkrümmungen. Wien, 1836.

982. A Dislocation (Luxatio, Exarthrema, Lat.; Verrenkung, Germ. ; Luxation, Fr.) is the slipping of a movable bone from its natural articular connexion; and is distinguished from the separation of bones immovably connected with each other (Diastasis.)

983. The dislocation is either complete (Luxatio completa) when the corresponding joint-surfaces not at all touch, or incomplete, (Luxatio incompleta, Subluxatio,) when they are not entirely separated from each other, with which last must be reckoned Wrenching or Distortion, (Distortio, Lat.; Verstauchung, Verdrehung, Germ.; Entorse, Fr.,) in which the joint-surfaces are partially separated, but their natural condition is again restored by the strength of the muscles and ligaments (1). Dislocations are further divided into simple, (Luxationes simplices,) when unaccompanied by peculiar symptoms, and compound (Luxationes complicate,) which are attended with wounds, bruises, fractured bones, severe inflammation, suppuration and other dangerous symptoms; into recent (Luxationes recentes) and old (Luxationes inveterata); into primary, (Luxationes primitive,) when the displaced head of the bone remains on the spot whereon it had been first thrown, and secondary, (Luxationes consecutiva,) when it is dragged up to some other position by the muscles;

into congenital, (Luxationes congenitæ,) and acquired (Luxationes acquisita.)

(1) Distortion has various degrees, according as the fibrous tissue, the synovial membranes, the vessels and nerves severally, or altogether, are severely stretched or torn through:-1st degree, Slight pain and gradual swelling of the soft parts; 2nd degree, Sudden and severe pain, swelling, and effusion of blood; and therewith, in 3rd degree Unnatural motion of the joint in all directions.

984. The diagnosis of dislocations depends on the disturbed function of the dislocated limb, and on the appearances produced by the bone when removed out of its socket. The most remarkable signs are, entire or partial loss of motion of the limb, with altered form and position; it may be shortened or lengthened according as the head of the bone is displaced in this or that direction, or it may be distorted, which depends on the contraction of the muscles, that, by the dislocation of the head of the bone, are most commonly torn and extended, hence rotation of the limb occurs on the opposite side to that on which the head of the bone is dislocated; the natural form of the joint is changed, the socket is empty, and the dislocated head forms an unnatural projection; the limb is fixed in its position by the stretched muscles, and can only with the greatest pain be moved, and often not at all. To these symptoms are added severe inflammation, pain, swelling, and effusion of blood in the neighbourhood of the joint. The determination of the dislocation is therefore more or less difficult, according to the superficial or deep situation of the joint, according to the nature of the dislocation and the degree of the accompanying swelling. A more remote effect of dislocation is a kind of crackling which depends on the effusion of plastic lymph into the joint and into the mucous bags, and may easily mislead to the presumption of fracture.

[The limb is not always at once immovably fixed after dislocation, even when at the hip-joint. I had a case of dislocation into the ischiatic notch several years since, and when I saw the man six or eight hours after the accident, there was so considerable motion of the thigh, which could be bent quite up to the belly, that I doubted the nature of the accident. On the following morning, however, the limb could not be bent upon the belly, and the other symptoms of dislocation being present, I made use of the necessary means and replaced the bone. I have also seen other examples of the same kind.

Sometimes if a patient be not seen for some hours after a dislocation, it is impossible to ascertain the nature of the accident, on account of the great swelling. The Surgeon should therefore be especially cautious to make further examination on the subsidence of the swelling, so that the patient may not suffer from his negligence.-J. F. S.]

985. The occasional causes of dislocation are external violence or violent contraction of muscles. The former either acts directly on the joint or on the end of the bone opposite, in which case the dislocation is effected more easily; and generally the bone is obliquely situated in reference to its socket, at the moment when the external violence acts. Dislocation specially occurs the more readily, as the parts about the joint and the muscles are lax and the motions of the joint not confined (1). For the latter reason dislocation of the upper arm is more frequent than that of the thigh; and dislocations of the hinge joints and of such as have broad opposing surfaces to their bones, in which the motion is restricted, are mostly incomplete. Old persons are more rarely subject to dislocation, because the heads of the bones are brittle and easily break; young persons also are rarely subject to dislocation, because their epiphyses easily break (2); in persons of middle age dislocation is most common (3).

[(1) Dislocations sometimes happen by mere muscular exertion, some accidental disposition of the bone occurring, by which the ordinary antagonism of the muscles is disturbed, and the efforts of one set become too great for the other. It is in this way