We have already mentioned the fact (pages 107, 112) that calculus forma tion is not infrequently seen after transverse obliteration. Tuefferd has recently recorded a very interesting case of this kind. The patient had formerly been delivered by Ciesarian section. Kolpokleisis was done for vesico-vaginal fistula. For a time she menstruated through the lower edge of the sc,ar, thus having a vesico-vaginal and an external vesical fistula. Then she fell sick of cystitis, and several large vesical calculi were detected. Tuefferd opened the vagina and extracted a stone 3 inches in length and weighing 694 grains. The patient died neverthe less.
We are not yet in a position to fully decide upon the merits of the method of transverse obliteration. And although very recently Breisky (1879) and also Schale, have successfully performed it in cases of uretero vaginal fistula not suitable for direct union, its applicability is restricted to extreme cases only.
We may mention here that in the worst cases of vesico-vaginal fistula, when recovery was impossible, it has been proposed to transplant the ureters into the rectum. This has been done, as we have before men tioned, in cases of eversion of the bladder by Jules Simon; but the attempt is fraught with danger, and it is not to be recommended. Much less dangerous is the plan of first making a good sized recto-vaginal fistula surrounded with mucous membrane, and then closing urethra and vagina, or the entire vulva. This has been done successfully by Antal, Bozeman, Brose. Kaltenbach. and v. Pippingskjold. The urine flows into the rectum, and can be voluntarily voided from time to time. For instance Antal's patient passed urine at intervals of to if an hour; the menses passed per rectum; and the organ it,self was in no way injured.
Untoward sequehe of a fistula operation consist mainly of violent vesical spasms, of severe secondary hemorrhage per vaginam or into the bla,dder, of vesical calculus, peritonitis, etc. Spasmodic contractions of the blad der may persist for 3 to 4 days, are sometimes v3ry severe, and can as a rale only be relieved by opium or by morphine injections in the vesical region. I have several times seen profuse secondary vesical hemorrhage, so that the patient became anaemic, and dilatation of the urethra was necessary to empty the bladder of coagula. The hemorrhage stopped on the injection of cold salicylic acid solutions (1:600) into the bladder. An
ice-bag laid upon the abdomen sometimes effects the same end. Hem orrhage into the vagina requires analogous measures, and possibly in the worst case ligature or acupressure applied to the bleeding vessels.
If the urine remains turbid, and pain or hemorrhage persist, in a blad der which has been closed, the urethra must be dilated to ascertain by the touch if there are any solid concretions in the viscus; if there are, they ,must be extracted with the forceps and lavement of the bladder under taken.
Peritonitis may occur from opening the subserous tissue, cutting the peritoneum or including it in the stitches; but the experience of the ovari otomists has shovrn us that there must be other additional moments before peritonitis follows such lesions. If it did occur, opium internally and an ice bag to the abdomen would be proper treatment.
If incontinence, partial or total, still persists after a successful opera tion, Hildebrandt uses cold vaginal douches, and the tampons charged with salicylic acid, or finally applies the pessary recommended by Schatz for this purpose. An instrument of this kind certainly did good to our patient No. 12. In especially bad cases, we can take into consideration the advisability of following Rutenberg's advice (cf. page 207), and, after making a supra-pubic vesical fistula, obliterate the urethra. In one case of this kind I obtained complete continence by narrowing the urethra through the excision of a portion of the urethro.vaginal septum.
C. Pawlik has sought to procure vesical continence by causing lateral stretching and bending of the urethra in the region of the arcus pubis. With a sharp hook he first dragged the urethra to one side, and denuded the space between. This being done on both sides, it was so arranged that the orificium urethrie was dragged up towards the clitoris. Carbolized silk was used; and the operation was done first on one side, and then a week later upon the other.
Patients who will not submit to the operation, or patients upon whom it has either been unsuccessfully done or successfully done without achiev ing perfect continence, may wear a urinal (see case 1), though its use is sometimes very unpleasant and troublesome. Occasionally the fistula, when not too large, may be closed by the insertion of a hard rubber cylinder.