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 finger touches it through the fistula. The speculum shows their position and extent, and reveals smaller ones which escape detection with the finger; by stretching the folds of the mucous membrane with tenacula, we may detect a fistula concealed by them.

To recognise small vesico-vaginal fistula and to differentiate them. from the vesico-uterine and ureteric, proceed as follows: pass Sims' speculum, carefully wipe away all mucus from the anterior vaginal wall, clear out the cervical canal with a dressed sound and plug it with a pledget of dry cotton wadding; now pass a catheter, and through it distend the bladder slowly with a coloured fluid, such as milk or permanganate of potash; as the bladder distends, watch carefully the anterior vaginal wall for any oozing of the fluid (Winckel). If there is no oozing, the fistula is not vesico-vaginal. If on withdrawing the plug from the cervix it be found stained with fluid, the fistula is vesico-uterine. If neither of these forms be present, the urine must come from a ureteric fistula; the rarity of this form should lead us to suppose that the fluid may have been temporarily kept from escaping from the bladder by a valvular action of mucous membrane, and the examination should be repeated after a time. In a case of uretero-uterine fistula, Bérard collected the urine which escaped per vaginam in one vessel and that in the bladder was drawn off per urethram by a catheter into another; the quantities in a given time were found to be equal. His conclusion was that he had obtained the secretions from each kidney separately, so that the fistula was ureteric.

PROGNOSIS.

A natural cure will depend on the recentness of the fistula and its size. Small fistulæ, if kept clean, heal of themselves during the puerperium. Large ones require operative treatment; cure by this means depends partly on the size of the fistula, but more on the condition of its margins -whether they contain much cicatricial tissue, and whether they are bound down.

TREATMENT.

There are two essentials for successful operative treatment: (1) complete exposure of the fistula, so that (2) the edges may be thoroughly pared and carefully adapted with sutures. The great difficulty lies in the inaccessibility of the field of operation, to which the failure of the older operative measures is chiefly to be attributed.

Marion Sims (1849) first rendered successful treatment really possible by the complete exposure of the fistula with his speculum, and by the careful adaptation of its margins with silver-wire sutures. To Simon of Heidelberg is due the credit of having elaborated the operation, and of having extended its sphere so that almost no form of fistula has in his

hands proved incapable of treatment. We may shortly contrast the methods of these two leading operators as follows: Sims pares the edges

of the fistula in a sloping manner (Fig. 364), carefully avoiding the mucous membrane of the bladder, then adapts the margins of the fistula with

Fig. 364.

Sims' is shown on the

The American and German methods of paring the edges of fistula contrasted. right margin of the fistula, Simon's on the left. The mucous membrane of the bladder is above, that of the vagina is below. The edges may be pared first according to Sims' method, and if a raw surface is not thus obtained the tissue can be removed up to the fine line (Kaltenbach).

silver wire, and drains the urine continuously per urethram through a catheter; Simon pares away the edges vertically, not specially avoiding the

mucous membrane of the bladder, unites the edges with silk sutures, and encourages the patient to pass water unaided from the first-drawing it off with the catheter only when necessary. Bozeman, a pupil of Sims, has drawn attention to the advantages of the genu-pectoral posture in operating and to the importance of preparatory treatment by dividing and stretching cicatricial contractions; he fixes the sutures with lateral plates and buttons.

When a fistula has been discovered during the puerperium our first aim is to aid the natural effort at cure. A catheter (Fig. 390) is placed in the urethra to carry off the urine by the natural passage; the vagina is syringed out occasionally with warm water; the edges of the fistula may be kept together, in some cases, by tampons suitably placed in the vagina.

If the fistula does not close by the natural process, we have recourse to operation.

Operation for Vesico-vaginal Fistula.

There is difference of opinion as to the time for operating. According to Hegar and Kaltenbach, the best time is 6 to 8 weeks after the confinement; "the lochial discharge has ceased, the necrosis of the tissues is defined, the margins of the fistula are vascular and juicy and are at the same time of sufficient firmness to hold the sutures;" the cicatricial tissue which forms round the margins makes the operation more difficult afterwards. Marion Sims delays the operation for a few months.

Under the operation, we shall describe—

1. Preparatory treatment;

2. The operation, which consists of (a) the paring of the edges of the fistula and (b) their adaptation with sutures;

3. After-treatment.

1. Preparatory treatment is only necessary when there are cicatricial bands drawing the margins of the fistula apart or contracting the field of operation. These must be divided and made to heal over a glass plug, or the vagina must be kept distended with air-bags. Frequent vaginal injections are necessary in all cases, to bring the edges into as good condition as is possible.

2. For the operation itself the following instruments are required : Sims' speculum,

Spatulæ,

Three or four tenacula,

Blunt-hook,

Vaginal douche for permanent irrigation,

Hot water to check hemorrhage,

Dissecting and artery forceps,

Small bistouries straight or set at an angle-on long handles,

Bozeman's scissors,

Several small sponges and sponge-holders,

Short curved needles and needle-holder,

Curved needles on fixed handles,

Silver wire (cat-gut in reserve),

Wire twister.

Good light is essential and as complete exposure of the field of operation as is possible; this last will determine the position of the patient,

Fig. 365.

Fig. 366.

Fig. 367.

Knives for paring a fistula. Fig. 365, straight knife; Fig. 366. bent knife, which is shown laterally at Fig. 367 (Sir J. Y. Simpson).

according as Sims' or the lithotomy posture allows us to get more readily at the fistula. The drawing down of the cervix with volsella or sutures (Fig. 362), or the protrusion of the edges of the fistula by a catheter in the bladder, is of use in some cases; where the mucous membrane of the bladder (by prolapsing through the fistula) comes in the way, it can be kept back by the sound in the bladder or a sponge probang pushed through the fistula (Sir J. Y. Simpson).

Fig. 368.
Sponge-holder.

Chloroform is always an advantage, as it gives the operator more freedom in exposing the parts and prevents the patient from moving; the actual pain of the operation does not demand it.