Stolz in Strasburg in 1828 first described the vesico-uterine fistula, G. Simon in 1856 first mentions the uretero-vaginal fistula, and A. 11Crard in 1841 first mentions the uretero-uterine fistula,. Finally, among the more recent and larger works upon this subject, are to be especially mentioned those of W. A. Freund (1862) and Ed. F. Bouqu6 (1875). The latter has especially corrected the misapprehension that Marion Sims specially- improved the method for the cure of urinary fistulw since he was the first to use the duckbill speculum to expose and operate on urin ary fistulte. Bouqui. calls attention to the fact that Dr. Schuppert of New Orle'ans has proved that Sims's speculum is'exactly like the speculum de scribed by Metzger in 1346 in the Prager Vierteljahreschrift. For v. Metzger described a speculum as follows: A silver vaginal dilator, consist ing of.a guttered conical blade 5+ inches wide, whose lower + is turned outwards; and an 8. inch long steel staff, fastened at a right angle to the lower third, and provided for 5 inches of its length with a large wooden handle. Probably v. Metzger's invention remained unnoticed so long because be made no drawing of it. At all events, since it has been in troduced there has been an important advance in the treatment of urin ary fistula, since it renders possible complete exposure of the defect, and probably no fistula is operated upon to-day without its help. Thus to a German and not to Americans belongs the credit of this advance.
The Various Kinds of Urinary Fistulte in Women.
Beginning at the ext,ernal urethral orifice, the following abnormal open ings between the urinary passages and neighboring organs may occur: 1. Urethro-vaginal fistula (Fig. 26), always situated at the lower end of the anterior vaginal wall, and opening into the urethral tubercle. Ex amples have been recorded in the literature of the last seven years by Aveling, Engelmann, Frissell, Grune, P6an, Verneuil and Winckel.
2. Vesico-vaginal fistula, which may occur at any point in the posterior vaginal wall from the sphincter vesicte to the fundus (Fig. 26.) If the upper border of such a fistula lies against the cervix, it is called a super ficial vesico-vaginal uterine fistula; if it pass through the anterior lip of the os, it is called a deep vesico-vaginal uterine fistula, both these latter being first named by Jobert.
If the bladder communicates with the vesical neck we have a vesico uterine fistula. Ambrosio, Bozeman, Isenschmid, Lessen, Midler, and Winckel have within recent times published examples of this lesion. If the bladder has an abnormal communication with the rectum, it forms a vesico-rectal fistula (Heath); if there is an opening from the bladder into the small intestine, there is a vesico-intestinal fistula (cases of Srakowi zer, Blanquique, and Valenta. Filially, if the urine exudes from an open
ing in the anterior bladder wall and the abdominal parietes, there is either a fistula of the urachus (page 68), or a cleft bladder (See Chap. I.) or a simple external vesical fistula.
3. The ureters themselves may be perforated, and may empty their secre tions into neighboring organs. These urethral fistula do not indeed be long strictly under diseases of the bladder, but deserve mention among their complications. A ureteral fistula may open either in the vault of the vagina, uretero-vaginal fistula, or it may open into the cervical cavity of the uterus, uretero-uterine fistula (cases of B. Cred6 and Zweifel), or into the intestine, uretero-intestinal fistula, or outwards, external ureteral fistula.' Here we have twelve different urinary fistulre occurring in females; and we may in addition have various combinations of them. Thus we may have urethral with vesico-vaginal fistula (cases d'Ormea, Torreo, Freund, Simon, Engelmann (see Fig. 26), or vesico-vaginal with vesico-uterine fistula; or vesico-vaginal uterine with uretero-vaginal fistula (case of the author). There are also vesical, vaginal, and ureteral &tulle where the vesico-vaginal wall is injured at the spot where the ureter lies between vagina and bladder (case of G. Simon.) Finally, double uretero-vaginal fistula may occur, as W. A. Freund has first proved (1862).
We will now turn to the causes and origin of urinary fistulfe. As a rule their origin is quite clear. By far the great,er part of them are due to malignant new growths of the genitals (see Introduction, page 25), and are not subjects for surgical treatment. Of those which do come under our care most are due to certain puerperal processes. The ori gin, the seat, the whole process in the walls of the affected organs are en tirely different in the other cases. So we may divide urinary fistulte into two great classes, puerperal and non-puerperal fistulte. Puerperal urinary fistul are such as stand in musal relation to pregnancy, childbirth, or the puerperium. In these conditions the walls of vagina and bladder are swollen and vascular, their vessels are much dilated, and the veins are often ectatic; the union of bladder and vagina is more loose, and they are liable to be squeezed between any hard body and the margins of the pelvis. The causes which might work injury are also more active at this period, and affect larger areas of surface. Thus the puerperal fistulte are sometimes enormous in size; and the hypertemic condition together with the irritation caused by the lochial discharge, tend to keep up the ulcerative process. Puerperal urinary fistulte may be urethro-, vesico-, uretero-vaginal and vesieo-uterine fistulte. They may occur spontane ously or in consequence of mechanical violence.