CHAPTER L.

VESICAL AND URETHRAL FISTULÆ.

Classification and Pathology. -The classification of fistulæ which I shall adopt is as follows:

I. VESICO-VAGINAL.-This is subdivided into (a) those occurring in the trigone, the opening being situated at the neck of the bladder; (b) those occurring at the bas fond, the opening involving the inferior portion of the bladder.

II. URETHRO-VAGINAL.-The opening being between the urethra and vagina...

III. UTERO-VAGINAL.-The opening communicating with the bladder, vagina, and cervix, or with the body of the uterus.

IV. In this variety the entire vesico-vaginal wall is destroyed, and sometimes the urethro-vaginal wall also. This variety is fortunately quite rare.

The relative frequency of these varieties is about in the order in which they are given in the classification. The last and rarest one is attended with extensive destruction of tissue, and includes the first three classes. In fact, it covers the ground occupied by all the other varieties.

The direction of these fistulæ may be transverse, oblique, or longitudinal, and their form may be oval, round, linear, angular, or irregular. The dimensions of the opening also vary from one so small as barely to admit an ordinary probe to one measuring two inches in diameter. The direction of the fistula may possibly be determined by the cause of the primary injury.

The form of the opening depends upon the arrangement of the muscular fibers of the vagina. This influences the line of laceration, and also the healing process, which latter modifies the final shape of the opening.

The condition of the borders of the fistulæ and their form differ much at first; sometimes they are thin, inverted, quite pale, and

smooth; this is especially the case with the upper border. In other instances they are thick, soft, and muscular, or, again, they may be hard, inelastic, and anæmic. The mucous membrane of the bladder often projects through the opening if it is large, forming a red erectile tumor.

Symptomatology.-The chief symptom is incontinence of urine. This is always the same, no matter how small or how large the opening may be. In some cases, indeed, this is the only symptom. In others there is much pain in the pelvic region, and irritation from the constant flow of urine, the pelvic pain being most marked at first, and in those cases in which there is much scar tissue.

Sometimes there is inflammation of the bladder and urethra, which causes pain.

If the fistula is due to parturition, the state of the bladder immediately succeeding the labor is such that for two or three days there is an inability to evacuate its contents without some pain or uneasiness, requiring perhaps the use of the catheter. After this the urine may escape through the urethra, or it may do so from the very beginning.

In from five to ten days after confinement the urine begins to escape entirely from the vagina. A sense of something giving way is sometimes felt at that time.

The labia, the inner surface of the thighs, and the perinæum, being constantly bathed in the urine, become red, inflamed, and covered with pustules, which sometimes form ulcers of considerable depth. The external genitalia and the surface of the vagina frequently become incrusted with a saline deposit consisting of urates, and there is also a strong urinous odor about the person and the clothing of the patient.

These symptoms and physical signs, while they are strong evidences of fistula, are not sufficient to base a diagnosis upon. A physical exploration of the parts must be made to ascertain with certainty the presence or absence of a fistula.

Physical Signs.--The patient should be placed upon a table in Sims's position in a good light, Sims's speculum should be used to open the vagina, and the perinæum should be drawn well back toward the sacrum until the entrance of the air distends the vaginal cavity.

The fistula, if one exists, will most likely be at once detected, unless it is very small. If it is not found in this way, a probe should be used to explore any pockets or depressions that may exist in the vaginal wall. Should this fail, milk may be injected through the

urethra into the bladder to distend its walls, and special attention given to see if any of it passes into the vagina.

Incontinence from some muscular lesion of the neck of the bladder, which allows the urine to find its way back into the vagina after escaping passively from the urethra, is the only affection which simulates fistula, but a careful examination made in the manner just described will determine the diagnosis.

Complications.-These are stricture of the vagina, recto-vaginal fistula, obliteration of the urethra, and cicatrices of the vagina and cervix uteri. Inflammation of the edges of the fistula and deposits of urinary salts in the vagina may be present; cystitis, vaginitis, and urethritis may also be found accompanying the fistulæ.

Prognosis. If the fistula is of such a nature that it can be closed by an operation with any reasonable hope of success, and in the great majority of cases this is possible, the chances of a perfect recovery are excellent.

Good operating will generally insure success, except in extraordinary cases, and these are very rare.

Causation.-Pressure of the foetal head is the most common cause of vesico-vaginal fistula. Almost all authors agree in attributing about ninety per cent to this cause.

Compression of the soft parts in tedious labor causes death and sloughing of these tissues, and the edges of the opening thus made failing to unite, the fistulous opening results. If the vitality of the parts is not completely destroyed, but is greatly diminished, inflammation and ulceration may occur, and lead to the same result as in the case of sloughing. The best evidence that pressure of the fœtal head in delayed labor is the chief cause of fistula is obtained from the fact that since the progress and improvement in the obstetric art, by which difficult labors are more promptly terminated, fistula is far less frequent than formerly.

Wounds of the vesico-vaginal wall may occur during the use of instruments or long-continued efforts in manual delivery. The slipping of a perforator in cases of craniotomy may be especially mentioned as likely to open the vesico-vaginal septum.

The forceps have come in for a large share of blame in times past, but they have little agency in producing such an accident; the earlier and the more frequent that they are employed by educated hands, the fewer fistula will occur. This is a fact obtained from the records of obstetrics and gynecology.

Foreign substances in the bladder-vesical calculi, for example -may cause fistula by perforating the vesico-vaginal septum. Many

years ago I saw a case, with Dr. J. H. Hobart Burge, of Brooklyn, in which this happened. The first calculus formed in the bladder was discharged through the vesico-vaginal septum, and several more were discharged through the fistula. Badly fitting pessaries, worn for too great a length of time, may also be mentioned among the causes inducing this lesion. Then there are a number of cases recorded in which a pessary has destroyed the vesico-vaginal septum. The process by which the opening is made is no doubt ulceration from pressure and irritation. The process of ulceration is probably favored by the deposit on the instrument of the salts of the urine, and the irregularities of this deposit produce destruction of tissue. There is no doubt that this accident happened more frequently in past times when the material used for pessaries was unsuitable, and the methods of adapting them were not so well understood as they

are now.

The vesico-vaginal septum is often destroyed by malignant disease in the advanced stages, but this does not belong to the subject on hand, and will not be discussed here.

Treatment. The treatment of fistula is either palliative or curative by surgical means.

Palliative treatment is little more than an attempt to make the patient comfortable by protecting her from irritation and filth consequent upon the constant flow of urine.

The curative treatment includes the preparation of the patient, the operation, and the subsequent management.

Preparatory Treatment.-The operation for the cure of fistula should not be done until after the lapse of at least three months from the date of its occurrence. Some have operated earlier with success, but these early operations can not be expected to result successfully. It requires at least three months before the system has completely recovered from the influence of gestation and parturition, and complete involution of the sexual organs is secured.

In case of fistula the process of involution is apt to be delayed from the local irritation and general depression which usually attend such injuries. If the patient is feeble, with loss of appetite, and is nervous, months of preparatory treatment may be necessary, consisting of good diet, fresh air, attention to the intestinal and other secretions, with the use of tonics.

It is certain that no one familiar with the treatment of this form of fistula will be rash enough to subject his patient to the inconvenience of such an operation before attending to these preliminary measures. There is no operation in surgery which depends more

for its success on good general health than this one. As regards the local treatment, all inflammation must have subsided, and good general nutrition of the tissues about the fistula should be secured in order to give a fair chance to obtain union after the operation. To secure all this, due attention to cleanliness should be given and the vaginal douche of hot water frequently employed. The excoriation due to the urine flowing over the parts can be relieved by Lister's ointment of boracic acid. The saline incrustations which form on the edges of the fistula and other parts can be removed with the forceps, and their reformation can be checked by tonics, the mineral acids being specially indicated.

About one week after menstruation has ceased is the best period to operate. If it is delayed until near a menstrual period the anæs thetic which must be given and the irritation produced by the operation itself are liable to induce premature menstruation. Besides, the tissues are in the best condition to undergo the healing process at that time.

The complication most commonly met with is stricture of the vagina and scar tissue at the edges of the fistula. No operation should be undertaken until these are disposed of as far as possible. The methods of relieving stricture of the vagina, and also of treating scar tissue, are by dividing the cicatricial bands and dilating.

For a fuller discussion of this subject the reader is referred to the section of this work on cicatrices of the cervix uteri and vagina. It may be remarked that in cases where the scar tissue can not be removed entirely, the best results are obtained by dilatation with the tampon.

OPERATION FOR THE CURE OF FISTULA.

An exceedingly interesting chapter might be written on the many methods suggested and practiced to close vesico-vaginal fistula but, while interesting, it would not be sufficiently profitable to oecupy time in this connection. It may be briefly, yet comprehensively, stated that all operations and all methods of treatment tried were failures until Dr. J. Marion Sims by his genius solved the problem. Furthermore, it may be stated that all modifications of Sims's method suggested and practiced by others have not been improvements worthy of notice. A very few changes of a trivial character have been made which simplify some of the details of the operation, but beyond this the operation in principle and practice remains the same as when given to the profession by Dr. Sims, to