On the other hand it is not infrequently observed that large and sharp edged pessaries, or those left too long in situ, have caused perforation of the vesico-vaginal septum. The cases of Fabricius Hildanus, Breschet, B6rard, Dupuytren, Dieffenbach, Lisfranc, Busch, and others prove this. Erosions occur in the most tensely stretched portion of the vaginal wall, then ulcerations, and finally the pessary breaks through into the bladder, and occasionally into the rectum at the same time. Zwanck's pessaries are especially dangerous in this respect; I have seen one and Pagenstecher has seen two cases of vesico- and recto-vaginal fistula caused by them.
Ulcerative malignant processes may cause fistula in carcinomatous dis ease of the uterus and the vagina. Statistics show (see page 25) that half of these patients eventually suffer from perforation of the bladder; and. most frequently the vesico-vaginal wall suffers. In hardly 20 per cent. of the cases does the new growth destroy the utero-vesical junction.
It is doubted by many whether tubercular or syphilitic ulceration can cause urinary fistula. The pulmonary and intestinal complications pro gress more rapidly than do those of the urinary organs, and we sometimes seem them causing hypertrophy of the vesical wall. A case of W. A. Freund teaches us that specific vaginal ulcerations may cause urethro vaginal fistula, and one of Beckwith's shows us that they may cause vesico vaginal fistula.
Among the diseases of the bladder, which may cause spontaneous vesico vaginal fistula, the most important is stone in the bladder. (See Chap. VI.) Others are: chronic ulcerative vesical catarrh with diverticulum formation; and carcinomatous degeneration beginning in the vesical mucous membrane.
Finally we must remember that disease in the neighborhood of the walls of the bladder occasionally causes fistula; pelvic abscesses may perforate both bladder and vagina; luematocele may do the same, and so also may ovarian abscesses, and those due to an extra-uterine pregnancy (see cases of Simpson and others).
The Anatomical Relat tons of Urinary Fistula3 in the Female.
We must now more minutely specify the exact seat, size, form, and edges, etc., of the abnormal openings which we have been considering. We will begin with the seat, upon which often depends the shape. The urethro-vaginal fistulte are usually placed in the middle of the lower wall, are round, from a hair to a bean in size, and are rather orifices than c,anals. Only very exceptionally are they cross rents, as in a case of Freund's, and in mine, No. 12. Freund has also given us an example of a perforation caused by syphilitic ulceration of the introitus vaginm. The vesico-vaginal fistulm are situated as a rule at one side of the lower third of the vagina when caused by operative procedures, and nearer the laqua3 vagina3 when occurring spontaneously with contracted pelvis. It is not certain that
they occur more often upon the left than upon the right side, though this is claimed by Simon, Neugebauer, Jarnatowski and Spiegelberg (Archiv. VII., 346). As in so many other cases, this assertion has been based upon the analysis of only a small number of cases. G. Simon found it so 10 times in 17 cases, but adds " or at least they extended more to the left than to the right side." Their shape is variable. The smaller are circular or oval; and oval especially when they are fixed to one or other rami of the pubis by cica tricial bands. Busch found those situated near the sphincter vesicte, to be half-moon shaped, with the concavity directed forwards, on account of the action of the transverse muscular fibres. Others again are mere fis sures; and these fissures may vary in size from a slit so small, or so im bedded in a carcinomatous or other growth, as to be invisible, to openings large enough to pass several fingers through. But both size and shape vary with the time that has elapsed since they first appeared. As a rule, they are the larger the more recent they are; in the older ones cicatricial contraction of the fistula itself, together with vaginal stenosis, which may go on to the extent of complete atresia, (comp. Fig. 28) tend to diminish their calibre.
Uretero-vaginal fistulte are situated at one side in the vaginal vault, or at its posterior portion; or they may be in front and above the left half of the posterior lip, the anterior having been destroyed, and the ureter being drawn to the right by cicatricial contraction. The size of the ureteral opening is of course small, though a sound can easily be introduced into it; its shape is round. In my case the mouth of the ureter formed a button-like prominence, from which the urine flowed in a thin stream as the speculum was moved about. Busch, 1. c. p. 77, mentions a case from B. S. Schultze's clinic, in which two small fistula3 of the right ureter were attached to the right pelvic wall. W. A. Freund has observed a case in which both ureters were involved in the destructive process. The fistula was seated in the median line, was elliptical, being lig inches long, inch wide, and distant from the uterus 1th inch, and from the external meatus 1th of an inch. The terminal portions of both ureters had been de stroyed for 1 of an inch; they projected as round prominent openings into the lumen of the fistula, and. were visible in the vagina. (1. c. p. 61).