The formation of such a fistula necessitates the adhesion of a portion of the ilium to the peritoneum covering in the vaginal vault. As the re stilt of ulceration, a communication is formed between the vaginal and in testinal walls. The ulceration depends occasionally on laceration of the vagina, more frequently on puerperal inflammatory proe,esses; it may, how ever, be dependent on other causes, such as cauterization (Simon). It may also follow on the rupture of an extra-uterine gestation cyst, and on degeneration of malignant growths of the vaginal and neighboring intes tinal wall.
Kiwisch saw an ileo-intestinal fistula after rupture of the cervix, of the bladder and of the vaginal fornix, the cause of which he believed to be partial pressure. The result, no prolapse of intestine, spontaneous cure in fourteen days, spe,ak for an ulceration into a small portion of the in testine, in consequence of pressure. In Dahl mann's case, where a vesico vaginal and an ileo-vaginal fistula formed after difficult version, a likely cause was primary rupture. In the remainder of the cases occurring during the puerperium there is no reference to laceration as a cause, al though considerable trauma resulted during labor, as, for instance, in Veit's, Breitzmann's, Thurmann's, Roux's, Demarquay and Verneuil's, and Gussenbauer's cases.
Colman and Muller have recorded instances of ulcerous communica tions between the ileum and the vagina from extra-uterine gestation cysts.
In Simon's case the use of caustic potass for the cure of a small vesico vaginal fistula lying in the midst of dense adhesions, resulted in perfora tion of a portion of the small intestine.
Hufeland has recorded an instance of fistula between the vagina and small intestine due to carcinoma of the uterus and the vagina.
The usual seat of the vaginal opening of these fistulEe is the posterior since it is altve this that the intestines ordinarily lie. Breitz mann and Dahlmann have, however, seen fistulEe anteriorly in the vesico uterine pouch.
Owing to the small size of these fistuhe and the practical continuity of the fEecal current, their course is more favorable than that of anus prEe ternat. ileo-vaginalis, and there are four recorded instances of spontaneous cure (Breitzmann, Kiwisch, V.eit, and Dahlmann) [in the latter the result of cauterization by nitrate of silver].
In general, spontaneous cure will depend on the size of the fistula and the complications; the larger the fistula, the more copious the escape of fces, the more the conditions approximate those of anus prEeternat. The most frequent complication is pelvic abscess, which ordinarily leads to depreciation of the patient's strength. So far the results from opera
tion have not been favorable, but it does not follow that such will be the case in the future with the better means at our disposal.
The diagnostic points are: 1. The seat in the posterior at the upper part, which is covered by peritoneum, (exceptionally in the an terior fornix). 2. The thin grumous chyme which flows through the fis tulous opening. 3. The singLe opening through which the sound may be passed both upwards and downwards. 4. The intact condition of the portion of the recta an near the fistula. 5. The cause being ulceration with or without the coLcurrence of inflammatory puerperal conditions, gener ally without symptoms of 'ncarceration, in no instance association with prolapse and expulsion of 'ntestine. 6. Passages by the rectum regularly occurring. The charactEristics noted under 3, 5, and 6 differentiate at once anus prteternaturalit.
The trEatment of fistulte between the vagina and small intestine is similar to that of recto-, aginal fistulte, cauterization, or denudation and suture. Where the fistula is small, the reported cases of cure from sim ple cleanliness, injectioas, frequently changed tampons, speak possibly in favor of the slower bu less radical method by cauterization. Where the fistula i t larger, however, as in Heine's case, where it was formed artifi cially f- Jna an anus ,meternat., then the above measures are not likely to be followed by good result, and the denudation method is requisite. Iu these instances the operation is only possible per vaginatn. They are less readily accessib'e owing to their elevated seat and the complicating cicatricial tissue. It may be necessary as in Heine's case to denude at the same time the of the cervix. The technique is similar to that in caseE of other fistt A. Bidder, in remarkable case (also seen at an earlier stage by Roseler) of inus prEeternt t. colo-utero-vaginalis, which had changed into a utero vaginal fistula, /as able to cause closure by dissecting off the intestinal mucous membrane from the uterus and vagina, and thus obtaining broad. surfaces for union of the vaginal flaps. The dissected intestinal mucous membrane projected into the intestinal lumen, and, like a valve protected the walls from the intestinal contents. Bidder recommended this method, which has latterly been followed by KrOnlein, and which is termed by French surgeons '` dedoublement " of the fistula-edges, in the treatment of fistulaii implicating the small intestine and the vagina.