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A TABBY JOKE. The Doctor : You young scoundrel! Don't you darken my door again. (Observer, 09 March 1912). Alexander Turnbull Library, Wellington, New Zealand. /records/27571467

April 1919

In January, 1917, Mrs. F., aged 48, came to me, suffering from an old-standing vesicovaginal fistula. Her history was that ten years previously the present condition had followed a difficult labour. This was partially repaired four months later. Several years afterwards a second operation was performed to fully close the opening and at the same time to repair a weak perinaeum. The fistula recurred and the condition became worse than previously.

On examination the woman showed a very miserable condition. All her urine was voided per vaginam, and she was obliged to change a saturated pad very frequently. There was a very extensive angry, scalded area round the vagina and buttocks. Recently she complained of a bearing-down pain and of a small quantity of blood in the urine, evidently the accompanying cystitis. A moderate-sized crateriform opening was made out a little posterior to the urethral orifice, somewhat craggy in outline. A rectocele was also present.

The preparatory treatment consisted in rest in bed until the irritation of the region was relieved by douches, ointment, etc. During this time urotropine was given in full doses.

Operation.—A collar containing the fistulous tract was isolated; the vaginal mucosa was separated widely from this collar and the bladder. A curved director was then inserted into the anterior urethral orifice, passed along the urethra, and made to appear in the fistulous opening. Then a stout silk thread was carried through the lips of the collar, doublethreaded through the eye of the director, and withdrawn along the urethra. Thus, by exerting tension on the cord projecting from the urethral orifice, the fistulous collar could be invaginated into the bladder to any degree desired. Two purse-strings of fine silk were used to close the rent in the bladder wall, the stitches avoiding the epithelium, and the fistulous tract being buried by tightening these while traction was made on the urethral cord. A third silk stitch was used to strengthen and bury the purse-strings. The vaginal walls were united by a continuous twenty-day chromic stitch (Van-Horn). The silk thread issuing from the urethral orifice was stitched to the skin in the right pubic region, and after the patient came down from the lithotomy position this was tightened moderately. A silver catheter connected to a rubber tube was tied in and the patient put to bed and nursed in the right lateral position. Twice daily the bladder was gently washed out and the vagina douched. The silk cord cut out, as expected, a few days after the operation; it served the purpose of keeping slight tension on the operation area and so preventing a cul-de-sac forming, containing a pocket of urine, which would almost certainly have, caused breaking-down of the sutured wound. The catheter was removed on the eighth day, after which normal urination occurred about every two and a-half hours and gradually less frequently. Urotropine was persisted with until the wound was judged to be healed and a metal catheter occasionally passed. There has been no leakage since the operation, over two years ago. During the first few months there was temporary retention on two occasions, not requiring catheterisation; I dilated the urethra after one of these attacks.

The success of the operation depends, I think, on careful preparatory treatment and on the excellent method described by C. H. Mayo, which, as he says, almost appears as a “trick” operation. An account of his technique may be found in the “Collected Papers of the Mayo Clinic” for 1915.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Acknowledgements

Correspondence

Correspondence Email

Competing Interests

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

c

A TABBY JOKE. The Doctor : You young scoundrel! Don't you darken my door again. (Observer, 09 March 1912). Alexander Turnbull Library, Wellington, New Zealand. /records/27571467

April 1919

In January, 1917, Mrs. F., aged 48, came to me, suffering from an old-standing vesicovaginal fistula. Her history was that ten years previously the present condition had followed a difficult labour. This was partially repaired four months later. Several years afterwards a second operation was performed to fully close the opening and at the same time to repair a weak perinaeum. The fistula recurred and the condition became worse than previously.

On examination the woman showed a very miserable condition. All her urine was voided per vaginam, and she was obliged to change a saturated pad very frequently. There was a very extensive angry, scalded area round the vagina and buttocks. Recently she complained of a bearing-down pain and of a small quantity of blood in the urine, evidently the accompanying cystitis. A moderate-sized crateriform opening was made out a little posterior to the urethral orifice, somewhat craggy in outline. A rectocele was also present.

The preparatory treatment consisted in rest in bed until the irritation of the region was relieved by douches, ointment, etc. During this time urotropine was given in full doses.

Operation.—A collar containing the fistulous tract was isolated; the vaginal mucosa was separated widely from this collar and the bladder. A curved director was then inserted into the anterior urethral orifice, passed along the urethra, and made to appear in the fistulous opening. Then a stout silk thread was carried through the lips of the collar, doublethreaded through the eye of the director, and withdrawn along the urethra. Thus, by exerting tension on the cord projecting from the urethral orifice, the fistulous collar could be invaginated into the bladder to any degree desired. Two purse-strings of fine silk were used to close the rent in the bladder wall, the stitches avoiding the epithelium, and the fistulous tract being buried by tightening these while traction was made on the urethral cord. A third silk stitch was used to strengthen and bury the purse-strings. The vaginal walls were united by a continuous twenty-day chromic stitch (Van-Horn). The silk thread issuing from the urethral orifice was stitched to the skin in the right pubic region, and after the patient came down from the lithotomy position this was tightened moderately. A silver catheter connected to a rubber tube was tied in and the patient put to bed and nursed in the right lateral position. Twice daily the bladder was gently washed out and the vagina douched. The silk cord cut out, as expected, a few days after the operation; it served the purpose of keeping slight tension on the operation area and so preventing a cul-de-sac forming, containing a pocket of urine, which would almost certainly have, caused breaking-down of the sutured wound. The catheter was removed on the eighth day, after which normal urination occurred about every two and a-half hours and gradually less frequently. Urotropine was persisted with until the wound was judged to be healed and a metal catheter occasionally passed. There has been no leakage since the operation, over two years ago. During the first few months there was temporary retention on two occasions, not requiring catheterisation; I dilated the urethra after one of these attacks.

The success of the operation depends, I think, on careful preparatory treatment and on the excellent method described by C. H. Mayo, which, as he says, almost appears as a “trick” operation. An account of his technique may be found in the “Collected Papers of the Mayo Clinic” for 1915.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Acknowledgements

Correspondence

Correspondence Email

Competing Interests

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

c

A TABBY JOKE. The Doctor : You young scoundrel! Don't you darken my door again. (Observer, 09 March 1912). Alexander Turnbull Library, Wellington, New Zealand. /records/27571467

April 1919

In January, 1917, Mrs. F., aged 48, came to me, suffering from an old-standing vesicovaginal fistula. Her history was that ten years previously the present condition had followed a difficult labour. This was partially repaired four months later. Several years afterwards a second operation was performed to fully close the opening and at the same time to repair a weak perinaeum. The fistula recurred and the condition became worse than previously.

On examination the woman showed a very miserable condition. All her urine was voided per vaginam, and she was obliged to change a saturated pad very frequently. There was a very extensive angry, scalded area round the vagina and buttocks. Recently she complained of a bearing-down pain and of a small quantity of blood in the urine, evidently the accompanying cystitis. A moderate-sized crateriform opening was made out a little posterior to the urethral orifice, somewhat craggy in outline. A rectocele was also present.

The preparatory treatment consisted in rest in bed until the irritation of the region was relieved by douches, ointment, etc. During this time urotropine was given in full doses.

Operation.—A collar containing the fistulous tract was isolated; the vaginal mucosa was separated widely from this collar and the bladder. A curved director was then inserted into the anterior urethral orifice, passed along the urethra, and made to appear in the fistulous opening. Then a stout silk thread was carried through the lips of the collar, doublethreaded through the eye of the director, and withdrawn along the urethra. Thus, by exerting tension on the cord projecting from the urethral orifice, the fistulous collar could be invaginated into the bladder to any degree desired. Two purse-strings of fine silk were used to close the rent in the bladder wall, the stitches avoiding the epithelium, and the fistulous tract being buried by tightening these while traction was made on the urethral cord. A third silk stitch was used to strengthen and bury the purse-strings. The vaginal walls were united by a continuous twenty-day chromic stitch (Van-Horn). The silk thread issuing from the urethral orifice was stitched to the skin in the right pubic region, and after the patient came down from the lithotomy position this was tightened moderately. A silver catheter connected to a rubber tube was tied in and the patient put to bed and nursed in the right lateral position. Twice daily the bladder was gently washed out and the vagina douched. The silk cord cut out, as expected, a few days after the operation; it served the purpose of keeping slight tension on the operation area and so preventing a cul-de-sac forming, containing a pocket of urine, which would almost certainly have, caused breaking-down of the sutured wound. The catheter was removed on the eighth day, after which normal urination occurred about every two and a-half hours and gradually less frequently. Urotropine was persisted with until the wound was judged to be healed and a metal catheter occasionally passed. There has been no leakage since the operation, over two years ago. During the first few months there was temporary retention on two occasions, not requiring catheterisation; I dilated the urethra after one of these attacks.

The success of the operation depends, I think, on careful preparatory treatment and on the excellent method described by C. H. Mayo, which, as he says, almost appears as a “trick” operation. An account of his technique may be found in the “Collected Papers of the Mayo Clinic” for 1915.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Acknowledgements

Correspondence

Correspondence Email

Competing Interests

Contact diana@nzma.org.nz
for the PDF of this article

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