FISTULCE FOLLOWING PUNCTURES AND WOUNDS. Fistulce following Punctures and Wounds.—Cock's operation of puncturing the bladder above the prostate, and proceedings of a like nature through this part, have been followed by fistulous communica tions. In these cases it must, however, be remembered there is usually the complication of a urethral stricture. The first indication in treatment is to remove, where practicable, the obstruction. In stances, however, will be found where these fistulae have proved per manent by reason of the nature of the obstruction, the rectum being used as a common receptacle for urine and forces, and it is remarkable how little inconvenience is suffered by some of these persons. As a rule, when the fistulae occupy this position, and are small, the pas sage of fecal matter into the bladder is seldom complained of; but should the opening be of such a size as to allow the contents of the rectum to pass into the bladder and distress the patient, then the pro priety of colotomy would have to be considered. Some years ago I met with a patient who had been operated upon in this way. He told me that he passed all his feces quite comfortably through a, col otomy, and reserved his rectum for his urine, as his urethra was en tirely obliterated by an old stricture. I only saw him on one occasion, and had no opportunity of further verifying his statement, but he ap peared to be in excellent health.
Fistulous communications of this kind are sometimes the result of injuries accidentally received. The following instance illustrated a remarkable form of injury, and a result which was certainly better than could have been anticipated: CASE.—In 1871, I saw a boy, aged 14, who, in endeavoring to pass between a railway wagon and locomotive, became empaled on the coupling, and was squeezed with much force. When I examined him there was a lacerated wound of the rectum, caused by the entrance of the hook, almost encircling the bowel. The membranous urethra and back of the bladder were bared, but not torn across. Ten days after
wards it was found that urine and feces flowed from the bowel, which was in a sloughing condition. Eventually he recovered, but the whole of his urine was passed by the rectum.
I saw this patient about fifteen years afterward, and was surprised to find, considering the extent of his injuries, how comparatively com fortable he remained. The rectum answered fairly well the double function of bladder and bowel. The membranous urethra, prostate, and a portion of the posterior wall of the bladder were involved in scar tissue. The case was quite beyond the reach of any plastic oper ation.
In one instance of vesico-rectal fistula I had to abandon an attempt to close the false route by a plastic operation conducted through a supra-pubic opening, by reason of the vesical aperture not correspond ing directly with the intestinal. Had I closed the bladder opening by sutures, as I think I could have done, there still would have remained a considerable pouch connected with the intestines, in which fecal matter would have lodged. The patient was a young man who liad suffered from this fistula for some years. The attempt thus made to close the sinus was followed by acute cystitis, in the course of which the entire mucous membrane was exfoliated and removed like a bag with a, hole in it through the supra-pubic opening, somewhat resembling a case previously described. The wound healed, but the connection between the bladder and bowel still exists, though it has since contracted considerably. As a recurrence of calculus may take place, there appears to be no alternative but that of establishing an artificial anus by opening the bowel at a point above where it com municates with the bladder. Atrophy of the gut below the line where the artificial anus was made would be likely to lead to a closure of the false route, as happened in an instance already referred to.