In the non-puerpeml fistulm, the condition of the edges is of much lees importance, and indeed depends mostly upon the nature of the can cer, perforating calculus or foreign body which cause them.
After a urinary fistula has existed some time, there occur certain changes in neighboring organs, in the urinary organs, in the genitals, and even in more distant portions of the pelvis. The most important change in the urinary organs is the change in the urethra; the urine no longer passing through it, it becomes smaller and smaller, is gradually obliterated, and is said in some cases to have been difficult to find at all. (?) As examples of this we may cite the cases of W. A. Freund, Hoffmann, Lancerotte, and G. Simon (5 cases, 29, 30, 31, 32, 33=12 per cent. of all cases.) The bladder also diminishes in size, the walls come in contact with each other; as a rule the anterior wall covers the fistula, and may even prolapse through it to the extent of becoming visible in the external genitals. It is usually in a hypertemic and catarrhal condition, and some times (as in W. A. Freund's case) has polypoid growths upon its surface. It may become adherent to the posterior vaginal wall (case 39, Simon). The vesical muscularis is generally hypertrophied, and the serosa is some times injected; and pericystitis with perimetritis may cause varying ad hesions between the two organs.
The ureter is often involved in the changes of shape, position, and tension of the fistulfe. If it is torn across, the lower end will atrophy like the urethra; cicatrization will approximate it to the ureter of the other side. Its wall will usually be thickened on account of the inflam mation of the subserous tissue; and the canal will be dilated above the thickened part. The kidneys are also very liable to suffer, especially in uretero-vaginal fistula3, since injurious matter can most easily reach the pelvis of the kidney from the vagina. The case of B. Cred6 is noteworthy in this respect, he finding the extirpated kidney belonging to the injured ureter in a high state of interstitial nephritis. Verneuil has very recently paid particular attention to this subject.
The external genitals are continually moist, pale bluish red in color, eroded in places, and sometimes secreting pus. After the fistula has ex isted for some time, we often find small flat tumors, hypertrophies of the papillary bodies, pointed condylomata and excrescences. (Cases of Hoffmann and G. Simon.) In recent cases the vagina is hypertemic, swollen, and dilated; when much scar tissue is formed it is often stenosed, and at times the seat of complete atresia (Fig. 27). Thus in one of
Freund's cases the lower part of the vagina was much narrowed by cica tricial tissue; then came a wider portion, containing the vesico-vaginal fistula, and then above this was another stenosed portion, from which urine also flowed. The vaginal contracture and irregularity may be so great as to render it difficult or even impossible to find the cervix and fix the position of the uterus. Erosions of the vaginal wall also occur. In old large fistulte we not infrequently find the vagina relaxed and dilated, pale in color, and with its epithelium very like that of the epidermis. If the fistula is near the uterus, or involves that organ itself, the lips of the uterus are swollen, eroded, and covered with weak granulations. The lower part of the organ is chronically inflamed, partly from constant con tact with urine, partly from the same influences that caused the fistula, and partly from the resulting cicatrization, which dislocates the cervix and causes disturbances of circulation and position. The subserous con nective tissue and the serosa of the uterus often participate in these chronic or subacute inflammations, and abscesses around the cervix and perimetritis with fixation of the uterus are apt to occur. The anterior layer of the omentum may fall down into the neighborhood of the fistula and adhere, as G. Simon has first shown us.' He lost such a case (No. 4) 14 days after the operation from peritonitis, the fold of omentum being included in the sutures.
It remains to not,e that with urinary fistuhe stony concretions and even full-sized calculi may form in the bladder, in the vaginal pockets, in the uterus, and in the external genitals. (Petit, Wendt, Saxtorph, Bock.) Thus the ligatures of a partly healed operative case may become covered in a few days, and in rare cases the salts form a crust over the surface of the vaginal canal. Simon's experience is that e,alculi occur oftenest in fistula3 when there is at the same time vaginal stenosis below its orifice; he never found one with a simple fistula, save when a foreign body wa,s present. The urine stagnates in the diverticulum, and causes deposit of the lime ealts, especially around their orifices; and from here it spreads over the interior of the vagina and bladder. Among 42 patients Simon could find only 1, number 38, where there was a large vesical calculus several years after the delivery which caused the fistula.