In reference to the first variety, there can be no doubt that persons live for many years and enjoy good health who are liable to the es cape of gas and faeces in this way. I have had the opportunity of ex amining some of those cases which have been described under the term pneumaturia, implying that the urine or other secretion con nected with the urinary apparatus had undergone some form of change by which gas was evolved, and either expelled or temporarily re tained. I have no hesitation in stating that they were all instances of vesico-intestinal fistula. It has been urged that air is met with in the urine in certain cases of glycosuria, and Dr. Guiard proposed the term "diabetic pneumaturia." " I am not aware, however, that this observation has been confirmed. Gas in the urine may some times be caused in this way : An alkaline urine such as that secreted after breakfast is allowed to accumulate for five or six hours; then a discharge from the kidneys of a highly acid urine takes place, the resultant chemical action causing the production of carbonic acid in excess of what can be absorbed. Cases where the communication between the bowels and the bladder is evidently small and is not in creasing, may be kept in good health by careful attention to digestible diet, and by restraining a tendency to diarrhoea, which invariably aggravates any special symptoms they may present.
Passing to the second class of cases, where the communication be comes gradually or suddenly enlarged, or where the urine is rendered so foul as to jeopardize the kidneys as well as other portions of the urinary tract, it is clear that some mechanical expedient in the shape of an operation must be considered. To effect any permanent good under such circumstances, it is obvious that the flow of faeces into the bladder should be prevented by causing them to escape by an artificial opening above the point where they are poured into the bladder, and thus to give the false passage a chance of contracting and closing. This is a proposition which, on paper, is an easy one to make, but in practice may be a difficult one to decide upon. It must not be overlooked that in many cases of vesico-intestinal fistula which appear to have taken their origin in an inflammatory condition, the viscus involved with the bladder was some portion of the small intestine. Taking, however, everything into consideration and the probability of our being able to distinguish when the latter is impli cated, on the necessity arising, it is the safest practice to make the opening as high up in the large bowel as possible, and this will lead to the selection of some portion of the right ascending colon. In the third of the above related cases I was much disposed, considering the condition of the patient, the state of his bladder, and the uncer tainty as to where the false opening was, to give that immediate and safe relief which a supra-pubic opening could have afforded, and be guided as to the future by what this would have enabled the eye as well as the finger to discover.
I assisted Mr. Hakes, in 1869, to operate on a case of vesico-in testinal fistula by colotomy where the patient lived for five years and returned to his employment, subsequently dying of renal disease.
I refer to it particularly, as opportunities of making an examination of the parts at a considerable interval of time after the operation are not very frequent." CASE.—The patient, a man, aged 20, with no history of syphilis, was admitted into the Liverpool Royal Infirmary in 1869 suffering from the passage of fEeces and flatus into his bladder. He was in a very miserable condition. He appears to have had some history of difficulty in passing his motions for three years previously. The rectum was unhealthy from ulceration, and a sound could be passed from the bladder into the bowel. Left lumbar colotomy was per formed, and the patient made a good recovery. He resumed his em ployment as a bus conductor, and for over three years enjoyed perfect health and suffered but little inconvenience from his artificial anus. Then he appears to have fallen ill, and was readmitted into the In firmary in 1874, where he shortly afterward died from renal disease. He never had any return of his vesico-intestinal fistula. The post mortem examination was made by the late Dr. Michael Harris, who attached a drawing of the part to the published records of the case. It is sufficient here to state that the colon from the artificial anus to the bladder was obliterated and converted into a coil of fat: the fis tulous opening from the rectum into the bladder was also soundly closed, nothing but some old cicatricial tissue remaining. The pa tient died from uremia as a result of degeneration of the kidneys. No further light was thrown on the nature of the old ulceration by which the bladder and bowel had been made to communicate other than to demonstrate its non-malignancy. • It should be remembered that when the communication with the bowel is in the small intestine, as is usually the case, neither the air emitted with the urine nor the products of digestion entering the bladder are necessarily either tainted with the odor of faces or have their appearance, as the case may be. With the cystoscope, in a clear medium it is quite possible to see bubbles of air emerging from the orifice of the false route and entering the bladder.
Whenever there are signs of entering the bladder, care should be taken that washing out the viscus is employed, otherwise a concretion may be formed, as in a case recorded by the late Mr. Charles Hawkins." Ulcerations proceeding from the bladder toward the intestines are much less common than the preceding, and are liable to be fol lowed by fatal results before the communication has had time to as sume the characteristics of a chronic sinus. Belonging to this class is the case recorded by the late Mr. T. H. Bartleet, of Birmingham, where a perforating ulcer of the bladder made its way into the ileum and caused death, as it were accidentally, by setting up peritonitis." The ulcer, while confined to the bladder, appears to have gone through all its stages without presenting any symptoms, and while the patient continued to follow his accustomed occupation. A sudden lifting movement, which occasioned acute pain, probably broke down a recent adhesion between the bladder and bowel, and led to extrava sation of urine, which caused death.