The chief accompaniment of a recto-vaginal fistula, spontaneous pas sage of fwces and of flatus by the vagina, makes the complaint most un bearable and is the cause of great depression, owing to the loathsome nature of the affection, and the resulting irritation of the neighboring CI ale parts. This symptom is not, however, always of the same intensity, but it depends on the size and the direction of the fistulous tract, as well ai on the consistency of tbe fmces. Nevertheless, even under most favorable conditions, there is always likelihood of occasional uncontrollable passage of gases or of fluid fEeces. The remaining symptoms from these abnor mal communications, such as inflammation and erosion of the borders of the fistula, the foul vaginal discharge caused by mixture of fEecal matter with the vaginal secretions, the vaginitis, depend essentially on the atten tion which is paid to strict cleanliness. As long as there is no ulceration, these further symptoms, under favorable conditions, are scarcely noticea ble, and exert scarcely any effect on the patient's general state.
The ultimate result depends on the cause, size, and complications of the fistula. Fistulm, the result of carcinoma, simply increase in size; traumatic and ulcerous fistuhe shrink considerably in the process of cies, trization, and this is the mei,hod of cure, frequently, in case of small fis tuke. Occasionally spontaneous healing results in recent large communi cations between the rectum and the vagina, those following on delivery for instance, which, owing to the traction at the time of occurrence, appear still larger. Winckel records an interesting instance of spontane ous cure within two weeks after delivery. During the exit of the head the perinea! division of the septum was torn so that the hair on the fcetal head could be seen in the rectum. Large fistuke, with cicatricial edges remain stationary, and cause greater symptoms than the smaller. Very small fistulae may be enlarged at the next delivery, and again diminish in size, even disappear entirely, as I noticed myself in a case where a small fistula remained after a perineorrhaphy. At the next delivery it was en larged so that it was patent for the finger, and yet three months post partum, it could not be detected.
The etiological connection between difficult labors and puerperal ulcer ations makes clear the frequent association 'of recto-vaginal and vesico -vaginal fistulEe with cicatricial contraction of the vagina. The complica tion with chronic ulcers and with tumors, leads to permanency of the fistula. We would make special mention here of the rare cases where, in the presence of deep-seated recto-vaginal fistuke, tumors had prolapsed through Douglas's pouch into the vagina. Winckel saw an instance where the tumor was composed of intestinal coils as far as the sigmoid flexure. The patient had been delivered by forceps, and entered the Dresden lying-in hospital later for the relief of escape of fzeces by the vagina. In the upper portion of the posterior vaginal wall, there existed a tumor the size of an apple, and in its centre was an opening which led into the sigmoid flexure. By the side of this irreducible tumor, to the
right and to the left, was a large opening into the rectum. Winekel made the diagnosis of recto-vaginal fistula through which the upper por tion of the sigmoid flexure had inverted and had u-nited to the vaginal borders of the fistula. He endeavored to re-invert the gut by the col peurynter, and by loosening the portion of the intestine which was adher ent, and when he had accomplished reposition he sewed the edges together, inserting fifteen sutures. The patient was entirely relieved.
I have seen a very rare instance of prolapse of a dermoid cyst through a deep-seated recto-vaginal fistula. A woman of thirty-nine, who had borne nine children and miscarried one,e of twins, was delivered for the eleventh time on the 25th of April, 1875. The breech presented and the after-coining head was only extracted manually after great effort. The placenta was artificially removed on account of profuse hemorrhage. On the ninth day of the puerperium, the patient had an attack of pelvic peritonitis accompanied by high fever and great pain. At the same time a profuse diarrhcea set in and a purulent vaginal discharge. In four months particles of hair began to be passed in the vaginal discharge, and a large mass from the rectum. A few days afterwards the vaginal discharge became fetid and contained fa?ces. These symptoms lasted intermittently for a number of months. In nine months after delivery the menses recurred at normal intervals. With the disappearance of the inflammatory symptoms the discharge, and the passage of hair and fmcal matter, ceased. I saw the patient first in June, 1876. She was thin and anemic, but able to attend to her household duties. The vagina *as distended by a tumor the size of a fist, and pear-shaped, and resembling a polyp. The surface of the tumor was covered in places with hair which could readily be removed by the finger. The pedicle was as thick as the finger and proceeded from an opening in the left lateral fornix, through which the finger could be passed into a cavity resembling that of Douglas. There was a second opening at the lower border of the pedicle, which ex tended into the rectum. The uterus was elevated and anteposed, not specially movable, and a trifle enlarged. There was no palpable exudation in the pelvis, and the ovaries and the tubes could not be felt. I reached the diagnosis of inverted dermoid cyst prolapsed into the vagina; my explana tion of the occurrence was tlutt a dermoid cyst (of the left ovary ?) adher ent in Douglas's pouch, had proved the obstacle to delivery, at which time the fornix vagime was torn transversely, and through this tear a portion of the cyst prolapsed and this was the beginning of the inversion. The communication with the rectum did not form till later, since fTces did not pass per vaginam till the fourth month after delivery. I re moved the cyst (vide Fig. 34), and the patient recovered well, but as yet she has refused operation on the fistula.