If, when the cervix is tightly plugged, the vagina remains quite dry, there can be no uretero-vaginal fistula. Is there a uretero-utero-cervical fistula ? There is, if the fluid issuing from the cervix is distinctly proven to be urine, and if the fluid is not colored by injection as above into the bladder. If, a,s is often the case, the vagina is so stenosed that the fin ger cannot be introduced, the colpeurynter or compressed sponge or inci eion must be employed, to be followed by Simon's urethral specula, and the finger.
Finally, there remains another method of diagnosis, the rapid dilatation of the urethra with specula, and the subsequent palpation of the inner surface of the bladder. Simon ha,s in this way (Publ. No. 10) several times determined the exact size and boundaries of vesical fistuke. But small fistula3 can be felt but with difficulty or not at all, as I saw myself only lately in one which was situated far to the left side.
In the same way we can examine whether any other organ, the ovary, the processus vermiformis, or the small intestine communicates with the bladder, our attention being directed to these points by finding pus, or hair, or remnants of food in the urine; to which points we will return later. It will also enable us to decide whether substances found in the urine come from neighboring organs, or whether they are portions of tumors of the inner surface of the bladder. When we cannot insert the finger into the orifice we feel, we may be able to pass an elastic catheter along side it through the opening. We may thus obtain some of the secretion of the part and 'directly apply treatment to it.
The fistula once found, and its seat exactly determined, the nature of its borders, their fixation, tension, and direction is to be considered, the condition of the uterus looked to, not forgetting to search for more than one fistula. In difficult cases repe,ated examinations will be necessary, and chloroform will have to be used in sensitive patients. We will use, according to circumstances, Simon's dorsal, Bozeman's knee-elbow, or the Sims-Emmett side position, selecting that one which renders the fistula most clearly visible. Only after a most thorough inspection and palpa tion will we be in a position to give a correct prognosis regarding its fis tula, and to take proper means for its cure.
fistula3 are always serious maladies, since they ex ercise a deleterious influence upon the patients' health, and render their condition a most uncomfortable one. It is true that spontaneous cure may occur. Bouque (1. c. p. 86 to 87) has found 60 such cases recorded, including even fistula into whose vaginal opening 1 or 2 to 4 (!) fingeni could be passed.' Some of these cases had existed for months and years.
Thus a case of F. Hildanus had lasted 8 years, one of Duparcque's 4 years, one of Zechmeister's 4 to 5 years, one of Elumann's 14 months, and one of Conradi's 6i years. The author himself records two cases of small fistula in the appendix, which even both healed in 14 days; one spontane ously, and the other after a single cauterization with liquor ferri sesqui chlorati; and he can add two cases of spontaneous cure from the practice of his father. Leishman observed a case of vesico-uterine fistula, in which spontaneous cure occurred in consequence of inflammatory atresia of the cervical canal. But a spontaneous cure is very rare, and therefore every case of this kind is recorded. In c,ases where a calculus caused the fistula, the abnormal opening closed after the cause was removed. In the sixty cases mentioned above, stone was the cause in 6; pessaries in 2; confine ment had preceded the malady in 28, and 17 of these confinements had been completed by artificial means; and once only did the fistula occur in consequence of a fall upon a pointed object. Most favorable of all will the prognosis be in those cases where the bladder has been wounded by a sharp, non-contusing instrument, as in lithotomy. The chalices of spontaneous cure depend on the seat of the fistula, the direction of its long diameter, the tension of its edges, their thickness and vitality, as well as the presence of complications, such as inversion of the vesical mucous membrane.
As regards the prognosis of the different kinds of fistulte, we would ex pect a priori that the lowest, being the most accessible, would be those most easily curable. Such is by no means always the case. Simple urethro-vaginal fistulae have indeed sometimes been cured both quickly and easily. Pecchioli cured one by cauterization with nitrate of silver in 25 days; Da Costa, Duarte and Hobart did the same with cauterization and a single suture; the author cured 12 with stitching simply. But the injuries to the lower portion of the bladder, in which the urethra takes part, are much worse. For not only is the urethro-vagmal septum much thinnes than the vesico-vaginal one, but it is difficult to spare sufficient tissue for the operation, Since the thickness of the muscularis and the whole wall diminishes from above downwards, and the danger of incontinence increases as it gets thinner (Simon). On the other hand those fisbulte which are situated below the vesical mouths of the ureters, and the uretero-vaginal fistulte, were held by many to be of the most unfavorable prognosis. As Simon has shown us, this is not always the case. Those of the first class are all curable, as are also many isolated uretero-vaginal fistulte.