When the fistula is small, high up, and there is but little loss of urine, the general health may be entirely unimpaired. I have seen patients who not only did not suffer in their nutrition from pretty large fistulie, but who could not make up their minds to undergo the operation necessary for their cure. But these are exceptions. The constant wetting, the urin• ous odor, the excoriation and pain around the genitals, the loss of appe tite, the disturbed sleep, the frequent colds, eventually cause loss of strength, a gray amemic appearance, and melancholia; the patients become a, nuisance to themselves and their friends, and readily submit to repeated operations in the hope of cure.
One symptom remains to be mentioned of which different explanations have been given; that is constipation. Jobert believes it to be due to a tonic contraction of the rectal muscular fibres from the irritation caused by the flow of urine. Freund believes that increased urinary secretion is caused by the ready outflow (as occurs in other secreting organs under like conditions), and hence the sluggishness of the bowels. Although Schafer (Giessen) has proved that there ia such an increase, it is so small (2 to 5 per cent.) that it can hardly be the cause. It is probably due to want of exercise, depressed spirits, the puerperal state, and the amemia resulting from these various causes.
Death rarely ensues in consequence of urinary fistula. These women live on miserably year after year until they' are either cured by operative procedure or they die from some intercurrent disease. In one of my cases a pleuro-pneumonia with subsequent phthisis followed within three months of her confinement, and carried off the patient before any opera tion was done (see Kohler's case, 7).
Diaynosis of Urinary Fist soon as a women who has had a severe confinement, or has cancer, or has had some operation like removal of the portio vaginalis with ecraseur or galvano cautery, begins to complain of trouble in making water, a thorough examination of the entire genital system should at once be made. It might of course be possible to detect by touch a necrosed spot in the vesico-vaginal septum from the pain occa sioned by pressure there, and thus the existence of a fistula be suspected; but as a rule the task of determining the exact seat, size and complications of the fistula is not an easy one. If it is half an inch or more in size, and if it is situated iu the anterior vaginal wall, digital examination, and the passage of a catheter into the bladder and through the fistula into the vagina wt11 suffice. But if the fistula is situated to one side, and is small,
or perhaps is placed in the depths of a forceps-cut, the task is much more difficult. The finger does not recognize it, nor can the catheter be passed through it. The bladder must be emptied by the catheter, to find out if there is any urine in the organ, and if there is whether it is bloody or not. If none is found, the patient is to be forbidden to urinate voluntarily for one or two hours, and dry napkins. laid under her. At the end of that time the catheter is again passed, and any urine obtained is to be quan titatively and qualitatively examined. If there is still doubt, Simon's speculum and the duck-billed instrument for the posterior vaginal wall is to be employed, the mouth of the womb accurately and firmly closed with a plug of white cotton, and 8 to 12 ounces of some dark-colored fluid poured gradually into the bladder with a Hegar's funnel through a clean catheter. Close observation of the anterior vaginal wall will inform us whether any fluid passes or not. If such an exuding spot is found, it is to be immediately fixed with small hooks, and an attempt should be male with the sound to penetrate through the fistula into the bladder. Milk, or a solution of permanganate of potash are the best fluids to use for this purpose, and of course the anterior vaginal wall should be well dried beforehand, so that the smallest quantity of fluid raay be recognized.
If not a drop flows into the vagina, there cannot be a vesico-vaginal fistula; but there may be a vesico-uterine fistula. The plug is now taken out of the cervix, and, if there is such a fistula, the white cotton will be found to be colored, and the dark fluid will exude from the os uteri. The cervical canal can then be rapidly dilated with metallic dilators or an ap propriate speculum, ctr the commissure may be incised, so as to expose its inner surface to view.
If the fluid pass through neither of these channels, and if it is certain that there is an involuntary loss of urine, a fluid containing urea flowing into a clean porcelain vessel when the urethra is closed by a solid bougie, there can only be a uretero-vaginal or a uretero-uterine fistula. In the first case there will be near or behind the vaginal portion a little orifice, or a button-shaped prominence with a hole in it; into this the sound can easily be passed for a certain distance upwards and backwards; and care ful examination will reveal the fact that a clear fluid flows in varying quantity from the orifice.