44 THE TONER LECTURES. 



to close them was hopeless, I proceeded to close the vagina. 

 At fir«t 1 attempted to preserve and utilize the remnant of tlie 

 urethra, which gave me great trouble and necessitated several 

 operations ; but at the last operation, Dec. 28, 1875, I gave up 

 the attempt, excised the useless urethra, and closed the entire 

 vulval aperture by ten wire sutures. The operation has been 

 a complete success. At present, after nearly seven weeks, she 

 defecates, menstruates, and micturates entirely by the rectum, 

 and without the slightest trouble. She rises usually once, 

 sometimes twice, in the night, and micturates only five or six 

 times during the day. My greatest fear has been that the 

 softened feces would pass into the vagina or bladder and give 

 trouble, but thus far at least, none has arisen, and she is 

 happily rid of the annoyance of four years.^ In the last four 

 operations, instead of the usual sigmoid female catheter to 

 empty the bladder, I inserted the curved branch of a pocket 

 case male catheter into the vagina and bladder, by the recto- 

 vaginal fistula, thus draining these cavities, while I drained 

 the rectum below the eye of the catheter, by an ordinary drain- 

 age tube inserted into the rectum, lest the feces should be 

 softened and then pass into the vagina. They answered admi- 

 rably. The difficulty in obtaining a cure, I believe lay 

 partly in the inherent difficulty of the case, and partly in her 

 deteriorated health ever since the fever. 



The perineum suffers mostly in males as 8 to 3, while in 2 

 cases the sex is not stated. Typhoid was the cause in 11, 

 typhus in 2. Although not all cases of gangrene, they may 

 be surgically grouped together, since all but one produced 

 perineal fistulse. The exception^ was a case fatal from a large 



' Soon after this was written, a small fistulous opening appeared in 

 the cicatrix, caused probably by the feces. This healed after a thir- 

 teenth operation, and now (May, 1877} she has remained entirely well 

 for over fifteen months. The rectum has answered perfectly both for 

 the urine and the menstrual discharire, as stated above. 



2 De Change, Arch. Belg. de M6d. Mil., 1861, xxviii., 126. 



