The urethra was dilated, but the fistulous opening could not be reached with the catheter. Rapid urethral dilatation and palpation of the sur face of the bladder had hardly been done at that time. The patient says that when the intestinal contents enter the bladder, she feels as if a burn ing fluid had been injected, and at once wants to urinate. When she does 80 the vesical pains become spasmodic, extend into the urethra, and are especially bad when pieces of fiecal matter pass. L. Mayer considered that carcinoma of the intestine was the cause of the perforation, and that the lowest portion of the small intestine was involved. The patient rallied under austaining and slightly astringent medication, and the diagnosis WM not confirmed by autopsy. There might just as well have been an opening between the =CUM or the vermiform process and the bladder, caused by a perityphilitis. And vesico-intestinal fistulce, whether caused by tuberculosis or carcinoma, would hardly last 18 months, not to speak of the tumor originating 5 years before.
Very recently Valenta (Laibach) has published a very interesting case of this kind.
Patient was admitted in dying condition, and with the catheter there was removed a small amount of urine distinctly mixed with fzeces. In subsequent attempts the catheter struck against an impassable but soft obstacle. There was constant dribbling of urine. The autopsy showed the bladder to be enormously dilated, its mucous membrane in toto necro tic and covered with urinary sediment. The anterior vesical was so thin and so firmly united to the anterior abdominal wall, that it tore in the attempt at separation. 16 inches of small intestine was adherent to the top of the bladder. There were two openings between the viscera, form ing a perfect anus prieternaturalis. The urethra bad disappeared. Douglas's cul-de-sac was completely filled by the non-adherent uterus, which contained a fcetus of 5 months.
Filially, my former pupil, Dr. Heim-Vogtlin, has had a case of vesico duodanal fistula. 2+ hours after breakfast there appeared in the urine fragments of egg-yolk, 1 an hour later swollen bread crumbs; foul-smell ing gases also passed sometimes. She cured the fistula in short order by means of energetic cauterization with nitrate of silver.
I know of no recorded case of direct union of stomach and bladder in the female. It is possible of course that with an enormously dilated bladder and pericystitis, that union might occur with stomach or gall bladder, and be followed by perforation. Gall-stones have been found in the bladder, as have the contents of the stomach; but it has been brought about by adhesion of the right kidney with the stomach or gall-bladder, and thus forming a bridge down to the bladder. Thus Melion has pub
lished the case of a man fifty-six years old, who suffered from nephritis calculosa, and who evacuated caraway seeds and vermicelli with his water. In the posterior wall of his stomach was an opening communicating with the right kidney, the pelvis of which contained two stones. The right ureter was dilated, and the bladder contained a hard, hen's-egg sized calculus. The like might of course occur in a woman.
The symptoms as well as the etiology of these various forms of vesical calculi, are sufficiently emphasized by the foregoing examples. Diagno sis is not difficult if we carefully examine the urine both chemically and with the microscope in every case of urinary difficulty. Vegetable and animal cells, remnants of food, will be seen. But to ascertain the seat and size of these vesico-intestinal fistulce it is necessary to dilate the ure thra. As a rule, it can then be well exposed by means of the catheter and sharp hooks.
The prognosis of vesico-intestinal fistula is generally unfavorable. As a rule, though they may be relieved, the patients eventually die of their malady. The case of Heim-Vtigtlein (see above) shows, however, that in some cases much may be done by direct therapy. Spontaneous cure also may occur, as in Ed. Martin's case, in which the treatment was dietetic; but this only seems to occur in those cases in which a contracting exudation presses upon the edges of the fistula. In vesico-ovarian and vesico-fmcal fistul, the prospects are upon the whole better; they are more ready to close as soon as all foreign bodies have been removed. In these cases ezerny's operation (see below) may be thought of.
Treatment was formerly helpless. Except when the fistula affected the upper part of the rectum or the sigmoid flexure, when Amussat's colotomy could be done and the fceces diverted from the bladder, we could do hardly anything. Now we are able to reach the vesical end of the channel, and muterize with solid nitrate of silver or chromic acid. Ferrum candens should not be used, on account of the proximity of the peritoneum.
If this does not succeed, Simon and others have recently again recom mended the veaico-vaginal incision (see ante, page 13), so that the bladder can be inverted and the fistula thoroughly caut,erized or even closed by denudation and catgut sutures. The vaginal incision may be opensted upon after the fistula is closed.