Urinary fistulEe due to violence may occur inter partum from instru mental or manual interference. In Bouque's 65 confinements before mentioned, 37 were delivered with forceps, 7 with the lever, 12 by cephal otripsy, craniotomy or embryotomy, and 3 by the blunt hook; turning was employed 5 times. The forceps may cause a fistula directly or in directly; directly, by cutting the vesico-vaginal wall with its sharp edges as it is drawn out, by their use before the os is sufficiently dilated, by too rapid change from one position to another, or by rotating them upon their longitudinal axis to alter the position of the head. If the instru ment lie in the oblique diameter of the pelvis, the anterior blade may cut the vesico-vaginal septum; if it lies transversely, it may cut the sides of the vagina. Cuts in the vaginal walla made by the forceps are often found, even after easy operations. They appear as cleanly marked cuts 1 to 2 inches in length, and mostly in the posterior wall, being caused by the hinder surface of the blades as the handles are being elevated. Less often we find them at the sides, just behind a point opposite the place of union of pubes and ischium. In these latter cases, as once happened to me in spite of the greatest care, and an easy and strictly lege artis extraction, the vesical wall is often injured. The case of childbirth recited in the appendix was in my presence ended with the forceps by my assistant, on account of danger to the child; yet a cut was made upon the right side. A single application of liquor ferri sesquichlorati to the small fistula sufficed to cure it. The fistuhe caused by the forceps are, as we have said, usu ally in the lower third of the vagina, and are often greatly complicated, since they are mostly due to pressure-necrosis. But direct cuts and tears are not of rare occurrence. Thus I operated upon two patients in both of whom one and the same surgeon had torn the vesico-vaginal septum upon the left side from the vault of the vagina to within half an inch or so of the orifice of the urethra.
It has occasionally occurred that one blade of a forceps has pierced the vaginal vault; the same thing has also happened with the scissors-shaped perforator. The parturient parts have often been torn with the sharp hook, as also by the use of the cranioclast (see Saxtorph's case). Turning may cause injury to the bladder by the hand being forcibly passed through the cervix before it is sufficiently dilated; as also when, as Spiegelberg, horribile dietu proved in one case, the hand of the accoticheur is intro duced into the urethra instead of into the vagina; and finally, when ver sion is difficult, though the foot has been seized, the attempt to drag it down causes too great friction and pressure upon the anterior pelvic wall. After version is completed, extraction may cause vesico-vaginal fistula, either by tearing or by gangrenous destruction from pressure. The uretero-vaginal fistuhe occurred in all cases so far known (Simon 2, Panas, Landau, and my own) after deliveries ended by operation; and Landau is certainly right when he ascribes them to the interference. I also observed a fistula of this kind, which had been caused by a pessary.
An injury to the ureter near the fundus vaginfe, appears to be only possi ble when it has been fixed by precedent parametric inflammation, and suffers a direct injury from some instrument.
A well-known German gynecologist lately told me that once, while operating upon a ruptured cervix with Greenhalgh's instrument, and without the blade being set very far out, he caused a uretero-uterine fis tula, which, however, happily soon healed under tamponade of the cer vical canal. According to Bandl, Bozeman wounded a ureter in two vesico-vaginal fistula operations by enclosing them in a suture, and thus causing fistula of the ureter.
Forced catheterization during labor may perforate the bladder from within outwards, as occurred in Dieffenbach's case. The bladder has been repeatedly incised in the operation of .syncliondrotomy during labor.
The only remaining causes of fistulte are the ulcerative or so-called diphtheritic processes which occur in the vagina of puerperal women, and perforating ulcers of the bladder. Carcinoma, pant- and perimetric processes, and ovarian abscesses not infrequently break through the vesi cal wall. Fistula may occur, though rarely from these e,auses; thus in the case of IIamonic already cited, an ulcerative inflammation of the ure thra caused a urethro-vaginal fistula.
In my 14 cases the fistula occurred: without use of instruments, once (No. 10); without instrumental violence twice (Nos. 4 and 13); probably through the use of instruments 3 times (Nos. 1, 2, 14), and almost posi tively through their employment 8 times (Nos. 3, 5, 6, 7, 8, 9, 11, 12.) The non-puerperal urinary fistuhe may also be either due to violence, or they may occur spontaneously, from certain morbid processes. The first class may be caused by perforation with the sound, with the litho triptor, or by other foreig-,n bodies, especially hair-pins. A fall upon a sharp body, as upon the 'pointed stake of a fence, etc., may cause fistula; or puncture of the bladder in retention of urine, due, for instance, to retroflexio uteri gravidi, or an accidental wound in vaginal puncture of the ovary may cause it. It may follow lithotomv. Further. the bladder may be injured in amputatio calli uteri, in prolapsus uteri; also in ovari otomy, and, as the cases of Dieffenbach and W. A. Freund teach U8, in the attempt to open with the knife an imperforate vagina.
Mittelhauser claims that the forcible passage of a finger into the urethra has caused incontinence. It is well known that fissures may be caused in this way; but that by the passage of one finger the entire urethra may be torn through to the bladder, and the bladder wall then also perforated in the same manner, seems almost impossible. For I have often made digital exploration of the inner surface of the bladder, when the urethra in spite of specular dilatation still offered great resistance, and have caused no tear. Still less likely is the occurrence of a fistula by concubitus vio lentus, as Munnik has claimed. A blunt body like the male penis can hardly tear the walls of so dilatable a cavity as the bladder, either per vaginam or per urethram, even in the case of a rape committed upon a girl six years old, as in Pollak's case.