The most recent collection of statistics as to curability are those of Bouqu6. They are as follows: 60 fistulae of various kinds healed sponta neously; 109 ditto healed by e,auterization; 25 out of 34 by immediate secondary union = 71.4%; and 463 out of 639 fistulae by suturing = 72.0%.
Thus -1-16 of all cases are incurable in the hands of the most skillful prac titioner. Besides this, a large proportion of the patients cured had to undergo several operations. Many operations done by most skillful sur geons fail; as has happened to Jobert, Bozeman, Simon, B. S. Schultz, Baker Brown, Schuppert, Courty, Spiegelberg, de Roubaix, Follin, An drade, etc. Many fistulw are at once declared incurable, either on ac count of the great loss of substance, or because of the destruction of the urethra. Even when the operation has been successful, complete con tinence has not always been obtained, some patients being unable to retain their water when standing or walking. In addition to this the operation itself may be dangerous, especially when working in the neighborhood of the peritoneum; so that death has occurred in the most skillful hands.' So that we must be cautious in giving a favorable prognosis for certain fistulte; nor must we forget that whether we use cauterization, or the knife, whether we are tyros or practised operators, we may possibly mako the patient's condition much worse by increasing the size of the fistula. Thus Bozeman's case No. 2 was one previously operated upon by G. Simon (No. 10); and the lentil-sized fistula. which Simon had left was large enough to accommodate a finger easily after Bozeman's operation.
Finally, many fistulfe can only be closed by operations which render the patient sterile for the future, either by using the posterior lip of the cer vix to the defect caused by the loss of tissue, or by obliterating the vagina transversely. Occasionally after this latter operation, as after marked stenoaes of the vagina, a satisfactory cohabitation is no longer possible.
Even after the operation is done the sufferings of the patient are by no means necessarily ended. Calculus formation, cystitis, and pyelitis (case 2 of Simon) may still cause a fatal termination.
The causes of death in non-operative cases are either of a locaL or of a general nature. Local inflammatory processes; peritonitis, ulceration, general exhaustion, or even tuberculosis, may occur. The cases that died after operation were either cases in which peritonitis followed injury to the peritoneum (Spiegelberg, Simon, Bozeman), or where death was caused by pyelitis or septictemia following suppurative inflamnaation of the connective tissue befween bladder, uterus, and rectum.
On the other hand weak and emaciated patients sometimes recover so quickly after a successful operation as to be hardly recognizable. The ex
tensibility of the bladder, even when large defects have been present. increases continually. If conception now ensues, pregnancy, delivery and childbed may run a perfectly normal course, if there are no extensive stenoses. This wa,s the case in Simon's eases 6, 23, and 30. I have already mentioned my father's case, in which a new contusion at the same spot in the next delivery cured the fistula. In recent times the success ful operations of the German surgeons have risen to 85 to 90 per cent.; ' the mortality hardly reaching 2 to 3 per cent. It is true that Verneuil lost 5 of the 80 patients he operated upon = 6.2 per cent; but they were done at a time at which antiseptic precautions were hardly used in France.
Treatment of Urinary rbpeated examination of the fistula will soon show us whether there is any hope of cure by operative proced ure, or whether it is incurable, and the symptoms only can be treated. In all recent cases, before thinking of operation, we would endeavor to obtain spontaneous cure by removing all hindrances and obstacles to the process.
Various are the ways that have been proposed to obtain this end. Fabricius Hildanus used frictions of the edges, injections, balsams, and internal remedies. Desault placed a cylindrical pessary in the vagina; Monteggia, Barnes, Marjolin, Ilerrgott, Habit, Maton, Danyau, Follin, Conradi, Gaitskel employed the permanent catheter, either with or without vaginal injections; others tamponed the vagina in addition, so as to prevent the outflow of urine through it, as Cumming, Freund. Burkner, Aubinais, Danyau. Others again introduced a sponge. Elsasser had one patient lie upon her abdomen for nine weeks, without using the catheter, and giving only low diet; he cured her in twelve weeks. Bur chard (Breslau) cured four cases of vesico-vaginal fistula by the vaginal tampon alone. Some, like Duparcque and Dupuytren, used mild aperi ents, secured extreme cleanliness, and saw the fistula heal without further local treatment. In this category belong the cases of spontaneous cure after the extraction of perforating calculi or incrusted pessaries. Reid cured a fistula by plugging it, so that no urine could pass, by means of a bottle-shaped bag of inflateable rubber. Raffaele (Florence) recommended the use in the vagina of an inflated bladder to cause pressure. Tomes de la Villanueva improved his patient, and secured continence of urine for several hours, by making his patient lie continuously on one side; she finally got entirely well. A like case of vesico-uterine fistula is related by Habit. Zechmeister had a patient who could only endure the catheter for forty-eight hours; so he had it used every half hour while walking and standing, and every 2 to 3 hours while lying down.