Baker Brown-Surg. Diseases of Women, 3d Ed., p. 133; and Lancet, March 1864. Bandl-Wiener Med. Woch., 1875, Nos. 49 to 52; and 1877, Nos. 30 to 32. Bozeman -Remarks on vesico-vaginal fistula, 1856; Americ. Journ. of Med. Science, July 1870; Obst. Journ. of Great Britain, June to Aug. 1878. Byford Medical and Surgical Diseases of Women: Philadelphia 1882. Emmet--On vesico-vaginal fistula: New York 1868. Hegar and Kaltenbach -Op. cit., S. 582. Simpson, Sir J. Y.-Op. cit., p. 30. Sims, Marion-On the treatment of vesico-vaginal fistula : Americ. Jour. of Med. Science, Jan. 1852. Silver Sutures in Surgery: New York 1858. Simon-Ueber die Heilung der Blasenscheidenfisteln; Giessen 1845, and Rostock 1862: Wiener med. Wochenschrift 1876, Nos. 27-32. Winckel-Die Krankheiten der weiblichen Harnröhre u. Blase: Stuttgart 1877, S. 95.

PATHOLOGICAL ANATOMY AND VARIETIES.

THE septum between the urinary and genital tracts may be broken through at various points. According to their situation, we have the following varieties of urinary fistula :

Urethro-vaginal,

Vesico-vaginal,

Vesico-uterine,

Uretero-vaginal,

Uretero-uterine.

The situation of these is sufficiently indicated by their names, and will be easily understood by reference to fig. 357.

A urethro-vaginal fistula rarely occurs alone, but is sometimes present along with a vesico-vaginal one. It lies in the middle line and is, naturally, of small size.

By far the most frequent are the vesico-vaginal fistulæ. They may occur at any point of the vesico-vaginal septum, which measures in height (from the internal orifice of the urethra to the vaginal fornix) about 5 cm. and in breath 4 cm. (Kaltenbach). Their size varies from a pin-point or slit-like hole to a large oval (fig. 362) or four-cornered (fig. 384) aperture. When recent they are of larger size, but after

some months become contracted through the formation of cicatricial tissue. The margins of the fistula are at first irregular, swollen, and

To represent the chief varieties of urinary fistula-urethro-vaginal, vesico-vaginal, and vesico-uterine. Those with the ureters are not seen. The seat of a recto-vaginal fistula is indicated (de Sinéty.) ulcerated; but after a time they become thin and firm, through cicatrisation: these changes have an important bearing on treatment.

Jobert

Fig. 358.

Superficial vesico-vaginal fistula, the cervix is intact (Hegar and Kaltenbach).

Fig. 359.

Deep vesico-vaginal fistula, the anterior lip of the cervix is destroyed (H. and K.).

divided fistula in the anterior fornix into superficial and deep; in the former (fig. 358) the anterior lip of the cervix was not implicated, in

the latter it was more or less destroyed (fig. 359). In cases of fistulæ which allow a free flow of urine, the bladder becomes permanently contracted and its walls thickened; in large fistulæ, the mucous membrane protrudes through the opening and is easily recognised from its deep red colour. The normal relation of the openings of the ureters to that of the urethra and to the cervix uteri (fig. 360) renders them liable to be

-3,CM

4,CM

2.5-3,CM

Fig. 360.

The normal relation of the cervix, the ureters, and the urethra (H. and K.). From cervix to orifice of ureter measures 3 cm., from orifice of ureter to that of urethra measures 4 cm., from orifice of one ureter to that of the other measures 25 to 3 cm. The ureters run through the bladder wall in an oblique direction downwards and inwards, for from 1.5 to 2 cm.

involved in an extensive fistula, or even in a small one lying to one side of the middle line. Sometimes we can recognise their openings on the exposed vesical mucous membrane by means of the urine trickling from the orifices; should the urine be bloodstained, it can be distinguished from blood by its acid reaction to test paper. The urethra, through disuse, becomes contracted; sometimes complete atresia is present and seriously complicates treatment, and a portion of the canal may even be completely destroyed by pressure (v. fig. 389). The vagina is often contracted by cicatricial tissue originating from injuries received during labour. The margins of the fistula are often drawn apart, and sometimes fixed down to the bone, by these cicatrices; this interferes with their closure. Contraction of the vagina below the fistula sometimes makes it impossible to ascertain the condition of the upper part and whether the uterus communicates with the fistulous tract. The relations of the peritoneum to fistula are shown in fig. 361, from which it is evident that only in the repair of very extensive fistula would its relations require to be considered. The difficult labour which leads to the production of the fistula is liable to be followed by puerperal peritonitis or cellulitis; these may disturb the normal relation of the peritoneum.

Vesico-uterine fistulæ are rare.

From their position they can be re

cognised only after dilatation of the cervical canal (v. fig. 388), and it is evident that they must be very small.

Fig. 361.

Relations of peritoneum, indicated by dotted line, to a fistula which has destroyed the whole of the anterior wall of the cervix and the infra-vaginal part of the posterior wall (H. and K.).

Uretero-vaginal fistulæ are situated in the fornix vaginæ. They are of small size, admitting only the point of the sound, and have either sharp edges or open at the point of a small papilla.

Of uretero-uterine fistula, only 9 cases are on record (Kaltenbach).

ETIOLOGY.

Malignant disease is the most common cause of fistula (v. p. 429); but we place this form aside, as it is beyond treatment and merely indicates a stage in the progress of the malignant growth.

The most important cases of fistula which we have to consider here, arise through injury received during labour. This injury may act directly, producing laceration of the septum; more frequently it acts indirectly, producing necrosis secondary to pressure or inflammation. The causes which predispose to fistula are a narrow pelvis and pendulous abdomen, a firm or large head (hydrocephalus) and face presentations (Winckel). The immediate cause is the compression of the soft parts between the child's head and the bony wall of the pelvis; if this pressure continues for a long enough time, it destroys the vitality of the soft parts which afterwards separate as a slough.

Fistula produced by instruments are situated in the lower part of the vagina, and are accompanied with extensive cicatrices and adhesions ; those due to pressure of the foetal head are placed in the upper part (Winckel). In craniotomy, the soft parts have been sometimes lacerated by the instruments, or by splinters of foetal bone. Forceps are often cited as a cause of the injury. It is not however the use of the forceps

after a prolonged labour which is to blame, but the not using of them at an early period before the parts have been destroyed by pressure.

Fistulæ have followed diphtheritic inflammation in the puerperium, but this is rare. Inflammation and ulceration round badly fitting pessaries have also produced them.

SYMPTOMS.

The leading symptom is the involuntary flow of urine from the vaginal orifice. This will not appear until the slough separates, that is till about the third or fourth day; its separation may be delayed for three or four weeks, when the necrosis is secondary to puerperal vaginitis (Byford). When a direct laceration has been produced, the urine will flow at once per vaginam; but even here it may escape notice till the second or third day, as it is masked by the lochial discharge.

The power of retaining varies, in certain cases, with the position of the patient; with a fistula situated high up, the erect posture allows the lower portion of the bladder to be used though the flow is continuous in the recumbent posture. With a urethro-vaginal fistula, there may be perfect continence from a sphincter-like action of the muscular fibre in the wall of the urethra; the patient observes, however, that the urine does not pass by the urethral orifice.

Secondary symptoms are due to a constant wetting of all the surrounding parts with the urine. The urinous odour is quite characteristic in urinary fistula; there is excoriation round the vulva, the inside of the thigh is red and irritated. Menstruation is generally in abeyance, returning after the fistula has been cured. There is usually sterility; although cases of conception, often followed by abortion or premature labour, have been recorded. The disagreeable surroundings interfere with the appetite and digestion; there is constipation, which Freund has ascribed to increased secretion by the kidneys but which is more probably due to reflex contraction of the muscular fibre of the rectum (Winckel). The general health thus becomes seriously impaired so that the patient is willing to submit to any operation which promises relief.

DIAGNOSIS.

The irritated appearance of the external genitals with the characteristic odour at once indicates that there is fistula, but the diagnosis of its position is often very difficult.

Urethro-vaginal and vesico-vaginal. When large, these may be felt by the examining finger; on our passing the sound into the bladder the