ILEO-VAGINAL FISTUL2E, AND ANUS PILETERNATURALIS VAGINALIS.
When coils of intestine are in fistulons communication with the vagina., then either the continuity of the intestine is entirely broken by the fistula and the upper end of the intestine discharges its contents into the vagina, anus prEeternaturalis vaginalis, or else the continuity is not broken and the fistula is purely a partial defect in the intestinal wall communicating with the vagina, fistula ileo-vaginalis. Such is SimOn's definition, and he was the first as far as I know to sharply differentiate the conditions.
The anus prxternat. vaginalis is termed as the result of traumatic rup ture, generally intra-partum, of Douglas's pouch, prolapse of the intesti nal coils into the vagina, the formation of adhesions, and gangrenous separation of the intestine, associated generally with symptoms of incar ceration. Since such instances are usually followed by death, the number on record is small. Generally but one part of the intestine is affected, although a number of coils may be implicated, as happened in the case reported by Bartels.
L. H. Petit has with great care collected all the instances of fistulous communication between the small intestine and the vagina, as also those between the intestine and the uterus, and given the histories in extenso. Of forty-two instances in twenty-one the communication was between the small intestine and the vagina, Smellie's and Penell's cases not being in cluded, sinc,e they appeared doubtful. Of these twenty-one cases only eight can be classed as anus prFeternat. vag. Here belong the cases of Birkett, McKeever, Favera, Jones, Cassamayor, Heine, Bartels. The cases of Roux, Verneuil, Kiwisch, Gussenbauer, certainly dated from difficult labor, and without prolapse of intestine having been noted the contents of the intestine were passed per vaginam on the sixth to the tenth day after delivery. With the exception of Favera's case, where the cause was brutal rape of a ten ye,ar old child, in all the instances there was trauma tism during labor as the cause. In a number there is no statement in regard to a mechanical obstacle to labor. Jones witnessed prolapse of the
intestinal coils in a healthy woman of twenty-four, in the third month of her second pregnancy, as the result of rough examination on the part of the " physician " whom she had consulted on account of pain in the abdomen which had set in aft,er lifting a heavy weight. Cassamayor's often-quoted case concerns a VII-para after miscarriage at the fifth month. In Heine's c,ase the vaginal fornix was torn during the removal of the after-birth. Generally, where long coils are prolapsed they are taken for the umbilical cord or the membranes twisted into a cord. In Jones's cases nineteen and a half feet of intestine were separated from the mesen tery, one end of which was completely torn, and the other only connected to the intestine by a band. Jones was led astray in his diagnosis and amputated the intestine, the patient urviving for seventeen days. McKeever'a patient, a II-para of twenty-six with narrow pelvis, was de livered by perforation after a, long labor, and without doubt the cervico vaginal vault was torn. On the following morning a " substance " six, inches long was found in the vulva and taken for membranes. Since after two days interval they had not been expelled, one of her attendants pulled on them strongly until the patient's screams made her desist. McKeever found about 41- feet of gangrenous intestine prolapsed with substance defects here and there. He. also detected a vesico-vaginal fistula. Cassamayor's patient, where the intestines had prolapsed to the thigh, necrosed and perforated, while waiting for her medical attendant had tied them as high as possible. In Heine's case two and a half feet of intestine, reaching about to the knee, had been drawn down by an at tendant who thought the placenta was thus being detached.
In all these cases prolapse of the intestines have caused more or less marked symptoms of incarceration, with consecutive necrosis and perito nitis. As the result of the injury, only one of the patients died (Jones's), and she at the end of seventeen clays.