The Symptoms of Urinary Fistula3.—Any opening of the kind under consideration will of course be at once followed by the outflow of urine through the vagina and vulva. This may even occur before delivery, if the slipping forceps incise the bladder. This outflow, however, is often not noticed either by physician or patient; the pain incidental t,o delivery and to the operation, and the flow of liquor amnii and blood, suffice to hide what has occurred. But after several days, when pain and hemorrhage has ceased, it is noticed that there is never much desire to urinate, and that very little is spontaneously voided, and that the lochia have a urin ous odor. In the worst cases the signs of the vesical lesion are at first entirely covered by the general puerperal symptoms; for the patient is feverish, and does not always pay proper attention to the condition of the lochia. The case is different when the fistula is caused by pressure necro sis. There is moderate pain in the vagina, difficulty or inability to pass water, moderate fever and general unrest; a combination of symptoms not at all characteristic. But when a portion of crushed and necrotic tissue suddenly gives way before the urinary pressure, and a large amount of urine is voided through the vagina, the vesical distress suddenly ceas ing, then the characteristic picture of urinary fistula is developed. But the symptoms depend largely upou the size and seat of the fistula, the length of time it has existed, the amount of reaction shown by neighbor ing tissues, the complications, and the patient's constitution. Even the first and most important symptom, involuntary discharge of urine, is ex tremely variable; for in urethro-vaginal fistuhe it is not involuntary in regard to time, but in regard to direction, the stream being directed back wards and downwards, and into the vagina. In vesico-vaginal fistulae it may flow by drops, or in a stream, continuously, or with longer and shorter interruptions. The flow is permanent if the orifice is large, unless there be stenosis of the vagina with calculus formation. When the orifice is in the vaginal vault the flow is often voluntary and involuntary; voluntary when the patient is in the erect position, the lower portion of the bladder being filled with urine, and the patient micturating at will; involuntary when she is recumbent, the water flowing out directly through the fistula. In utero-vesical fistuhe the same is the case; and since the orifice of com munication is usually small, the amount of urine voluntarily emitted is considerable. I operated upon one case with a large vesico-vaginal fistula (case 11), only a lentil-sized fistula being left at the orifice of the urethral; in twenty-four hours she spontaneously evacuated 41 ounces of urine, losing a small quantity at night drop by drop.
If the uterus is moderately movable, the edges of a fistula in the vaginal vault may be dragged into approximation when the patient stands up, and the involuntary flow of urine greatly diminished. In the isolated uretero-vaginal fistulaa but little urine escapes per vaginam, and that only occasionally; besides this, the patient can regularly evacuate what urine accumulates in the bladder.
If the amount of the involuntary flow is considerable, the above-men tioned changes in the neighborhood of the fistula occur, though in cleanly persons they may be warded off for a considerable time. The more marked they are, the greater the disturbance of the functions of the genital ap paratus do they occasion. Menstruation may be absent, irregular, or
painful; but it may also lie quite normal. It is natural that there should be a certain distaste for cohabitation on the part of both husband and wife; the woman dreads the pain, and fears another conception. C. v. Braun claimed that a fistula caused sterility; but Simon, Schmidt, Freund, and others have disproved this. But Simon believes that when it does occur under these circumstances, an abortion or a premature delivery is the re sult. A case of Schmidt, and one of the author's, show that this is not always so. In fact, my father had a case in which pressure at the same spot of a child at term at the next confinement caused the fistula, due to the previous one, to heal. We must admit that conception is rarer among these patients than in healthy persons, for few patients with fistula be come pregnant; but some do. I mention a patient in my Berichten und Studien, (Vol. II. p. 129,) who had a very considerable vesi3o-vaginal fis tula, and in whom after an unsuccessful attempt to secure direct union transverse obliteration bad been done. This was not entirely accom plished; a small opening was left, and through this coitus was accom plished during a short visit which she made to her home. She aborted at the 5th month. In the same volume on page 79 is recorded the confine ment of patient No. 931 (1874) with an unviable and macerated girl; a ceph alotripsy done 4 years ago had occasioned 4 fistulte, and there were a large number of cicatricial bands in the vaginal vault. Nevertheless she con ceived again. Naturally, succeeding pregnancies may enlarge the fis tulze, or delivery may be hindered by the cicatricial bands, etc. In the last mentioned case air entered the gaping cervical vessels, and the patient died four hours after delivery. The puerperal period may be greatly in fluenced by the recrudescence of subacute inflammatory processes in the neighborhood of the uterus. As a rule a new pregnancy meaias increased trouble and greater danger for the patient.
On the other hand K. Schriider maintains that the power of conception is not much altered in women with urinary fistulw, and the ensuing preg nancies and deliveries are normal. Kroner's thorough investigation of sixty cases of fistula in the Breslau Klinik do not confirm Schroder's state ments. He found that menstrual disturbances frequently accompanied the affection. The periods often ceased entirely, or only began some time after delivery, or they were irregular and painful. In only 23 per cent. were they normal. 6 cases only conceived; and. in all the literature of the subject he only found 37 cases of fistula that did so, including these 6. This small number alone, among the hundreds of cases of fistula which have been reported. (BouquC. alone cites 639 operated upon by su ture) proves the rarity of conception in these cases. Among Kroner's 37 cases 21 were pregnant once, 12 twice, 3 three times, and one had a series of children. 36 of them bore 54 children; 9 only went to full term, and 23 suffered from abortion or premature labor. There was much varia tion in the exact mode of birth; but the number of cases was too small to draw any definite conclusions about. Out of 9 cases in which the fistula was subsequently examined, 8 were unchanged, and one considerably enlarged. Finally, in 37 confinements, many of which were premature, there were 2 deaths, a high percentage.