destroyed at the same time as a vesico-vaginal fistula is formed, the opening of the former is found somewhere on the edge of the latter. We have seen above how this condition may be cured, either with or without slitting up the ureters.

Genital Cleisis.-When it is impossible to close a fistula, relief from the troublesome, constant escape of urine may be afforded by closing the genital canal below the seat of the fistula, an operation called cleisis or closure.

We have already alluded to the closure of the uterine os (hysterocleisis), the turning in of the cervix into the bladder (hystero-cystocleisis). The vulva may be made the seat of the closure (episio-cleisis), but this is a very objectionable procedure, since it not only renders impregnation impossible, but prevents coition, and gives rise to the stagnation of urine and the formation of stone in the lower part of the vagina. The most common seat of this closure is the vagina (colpocleisis). In performing this operation the operator should always keep in view the desirability of preserving as much of the depth of the vagina as possible. Closure should therefore not be made at a lower point than necessary, and often much can be gained by giving the line of union a slanting direction.

The patient is placed in Simon's position (p. 359). A narrow strip is cut off from the mucous membrane of the vagina in such a way that the denuded part of the anterior wall fits to the posterior. These are now brought together by sutures according to general rules. During the insertion of sutures on the anterior wall a sound is kept in the bladder, and while working on the posterior wall the operator uses a finger in the rectum as a guide.

Through the development of better methods for the direct closure of urinary fistula, the use of genital cleisis has become more and more rare. Still, the operation is yet occasionally indicated in cases of great loss of substance, when there is much cicatricial tissue around the fistula partly adherent to the bone, when the bladder is inverted and filled with intestines, and especially in certain cases of ureterouterine and vesico-utero-vaginal fistula. (See above.)

When the urethra had been lost or its lower edge was too weak to be pared and stitched, Von Nussbaum combined cleisis with the formation of an artificial supra-pubic urethra. He punctured the bladder above the symphysis, and left the canula in place for two weeks. Then the patients were allowed to get up, and directed to empty the bladder every two or three hours with a female catheter. At the end of a few months the catheter could be dispensed with, the urine being driven out at will, in a jet, by contraction of the abdominal muscles. In the interval the recti and pyramidales muscles kept the little opening closed.

Urinals. If for some reason or other no operation can be per

formed, the patient may derive more or less comfort from the use of a urinal. These may be divided into two classes, the extra- and intra-vaginal. To the first belong rubber bags with a wide opening covering the vulva, and fastened to the pelvis and the thigh. To the second belong the ingenious apparatus of Bozeman and Jay. Bozeman's consists in a flat pear-shaped receiver of silver with a number of holes on the side that comes in contact with the anterior vaginal wall. The urine enters through one or more of these holes, and is led through a tube to a rubber bag attached to the thigh. Jay's consists in a strong soft-rubber ring, to which is attached a bag of the same material, ending in a tube which is compressed by a shut-off. The ring is introduced into the vagina where it stays by its own expansion. The patient takes a daily sitz-bath, and slips the nozzle of a syringe into the exit-tube and fills the urinal repeatedly with warm soap-suds.'

I have, however, found that patients, for different reasons, such as pain, excoriations, lack of coaptation, get tired of wearing urinals and prefer to protect themselves with towels.

Pawlik's Operation for Incontinence.2-It happens sometimes, after a complete closure of a fistula, that the patient continues having a constant dribbling of urine, which now escapes involuntarily through the urethra. This condition may be due to the loss of the sphincter muscles of the urethra, or to traction being exercised on the urethra, by which it is kept open, or simply to the habit of contraction acquired by the bladder while the fistula was open. Sometimes a spontaneous cure takes place by shrinkage of a cicatrix running across the neck of the bladder; but this is at best slow work. Pawlik has devised an operation by which the condition is remedied at once (Fig. 215).

N

FIG. 215.

H

The patient is placed in knee-elbow position. The urethra is pulled to one side with a tenaculum as far as possible (a). The limits of the fold thus formed are marked on the mucous membrane. From these points two parallel lines are drawn up and made to converge at their upper end near the subpubic ligament. Next the meatus is pulled as far as possible toward the clitoris without using undue force, and that point marked (b). The lines of incision are now continued in a slightly convergent direction to b. The thus circumscribed tissue is cut out in the shape of a wedge, and the 1 John C. Jay, Jr., New York Medical Record, Aug. 28, 1886, vol. xxx. p. 251. The urinal is made by Parker, Stearns & Sutton, 228 South street, New York.

Pawlik's Operation for Incontinence: H, urethra; A, denudation: a, point to which the urethra can be pulled to a side; b, point to which it can be pulled in the direction of the clitoris.

2 Pawlik, Wiener Med. Wochenschrift, 1883, Nos. 25-26, p. 772, and Zeitschrift für Geburtshilfe und Gynäk., 1882, vol. viii. p. 38.

wound united with deep sutures of carbolized silk and covered with iodoform. After seven days the sutures are removed, and, the wound having healed by first intention, the other side is treated in the same

way.

The object of this operation is to stretch the urethra from side to side, and at the same time to bend it in the direction of the clitoris, by which double process its posterior and anterior walls are brought in contact.

The same operation may be performed when the urethra is gaping and the patient suffers from incontinence without having had a fistula. B. Fecal Fistula.-A fecal fistula is one leading from the intestine to the genital canal. They are much less common than urinary fistulæ.

Pathological Anatomy.-There may be one or more openings. The fistulous communication may take place between the rectum and the vulva―recto-vulvar or recto-labial fistula; the rectum and the vagina— recto-vaginal fistula; between the ileum or the sigmoid flexure of the colon and the vagina or uterus-entero-vaginal, ileo-vaginal, and ileouterine fistula.

The size differs from that of an opening so fine that it may be very difficult to discover to that of one easily admitting a finger. Often the aperture is larger on the vaginal side than on the intestinal. The seat varies also very much. A fecal fistula may be situated anywhere between the intestine and the vagina, but it is most commonly found either immediately above the sphincter ani muscles or at the fornix. As a rule, it is found on the posterior wall of the genital canal, but the entero-vaginal variety may exceptionally open in front of the uterus. Sometimes the length is almost nil, the rectal and vaginal walls coming in contact in the thin septum between the two. In other cases, when the fistula is the result of an abscess, the inner opening may be as much as three inches and a half up the rectum, while the outer is found on the inside of the labium majus.

Etiology. The causes of fecal fistulæ are in many respects like those determining urinary fistula. The most common is childbirth, and the fistula may either be due to pressure between the fetal head and some bony prominence in the pelvis or remain as the result of imperfect spontaneous healing of a tear through the perineal body. It may be brought about by rupture of the vagina or uterus, an intestinal knuckle being caught in the rent and becoming necrotic, or by diphtheritic and gangrenous processes due to puerperal infection.

Frequently a fistulous opening remains just above the artificially united perineal body after perineorrhaphy. Rarely hysterectomy has led to the formation of such a fistula at the fornix.

Occasionally the fistula is due to a neglected vaginal pessary, that gnaws a hole into the rectum.

Abscesses, either pelvic, vulvar, or prerectal, end sometimes with the formation of a fecal fistula. At the fornix it is due to a suppurating dermoid cyst or extra-uterine pregnancy; at the vulva the inflammation begins often in Bartholin's glands.

We have mentioned above that direct injury, especially violent coition, may cause a permanent fistula (p. 257) and that the solution of continuity may be due to ulcers-cancerous, tubercular, or syphilitic-perforating the partition between the two canals.

In syphilitic patients the fistula is often found just above a stricture of the rectum.

Symptoms.-The escape of flatus and, when the bowels are loose, thin fecal matter, through the vagina soon attracts the patient's attention. The irritating contact with the excrementitial matter causes catarrhal vulvitis and vaginitis.

Of entero-vaginal fistula there are two varieties with very different symptoms. If the opening is small (ileo-vaginal fistula), they do not differ materially from any other fecal fistula, but if the whole circumference of the intestine has been destroyed and the edges have coalesced with the rent in the vagina (preternatural anus), all the feces find their exit through the vagina. "If the affected part, as usual, is the ileum, undigested food mixed with bile will make its appearance at the fistula about two hours after meals, and the patient will loose flesh and finally die from starvation. Her weakness may also cause amenorrhea.

Large fecal fistulæ can be felt, small ones may be seen, but are often hard to find on account of their diminutive size. Probing and injection with colored fluid may help to find the inner opening.

In an entero-vaginal fistula, a whole intestinal knukle having been destroyed, there may be two openings with a so-called spur between them.

Prognosis.-Fecal fistula have in so far a better prognosis than urinary as a larger number of them heal spontaneously, but, on the other hand, those which have no such tendency, are harder to heal. by operation, the reason of which is doubtless that while urine is harmless or can easily be given an exit, the intestine is always full of pathogenic microbes, which it is difficult or impossible to keep away from the wound. Mechanical difficulties are likewise of much importance in jeopardizing closure by first intention. If we induce constipation large fecal masses will accumulate, and their final expulsion may tear open the already healed fistula. If, on the other hand, we keep the bowels loose, the contraction of the perineal muscles during the act of defecation is liable to cause a fistulous tract to remain just above the sphincter ani muscles.

We have already intimated that in certain forms of fecal fistulæ nutrition becomes insufficient.

Treatment.-Preventive Treatment.-Much can be done to prevent the formation of fecal fistula by having their etiology in mind. Thus an enema of soap-suds should invariably be given in every labor case before the head enters the pelvic cavity.

The pelvis should be carefully examined before labor in regard to narrowness or projecting points, and according to circumstances recourse should be had early to the high-forceps operation, version, craniotomy, or even Cesarian section.

Pessaries should always be kept clean with daily vaginal injections, and removed at least once every two months. If there is any gnawing, the pessary should be left out for a week and carbolized injections used until all abrasions or ulcers are healed.

It goes without saying that most strenuous efforts should be made to prevent syphilitic ulcers from forming fistula. Perhaps we will soon have in one of the many remedies now being experimented with a means of checking tuberculous ulcers in their destructive progress.

Even at the height of sexual passion men should exercise a reasonable control over themselves, especially if nature has endowed them with an unusual development of the part concerned. Pus in the pelvis or near the lower end of the rectum should be given an exit by timely operative interference.

Curative Treatment.-A cure may be obtained by cleanliness, the elastic ligature, or cutting operations.

A. Since many small fecal fistulæ have a decided tendency to close of themselves, this happy result should be facilitated by scrupulous cleanliness, especially sitz-baths, rectal and vaginal injections, and prevention of constipation, combined with cauterization (p. 356).

B. Ligature. In recto-labial fistula, which we have seen often extends far up the gut, a cutting operation would be liable to cause great hemorrhage, and by forming a cloaca leave the patient in a worse condition than she was before. This affection is treated successfully by changing it into a common fistula in ano, and treating that with the elastic ligature.1 The usual surgical silver probe, armed with an elastic ligature, is introduced into the labial orifice, pressed down to the perineum just outside of the sphincter ani, where the end is liberated by an incision and the probe withdrawn. A more ductile one is substituted, and passed through the sinus from the labial opening to the rectal opening, having the eye threaded with the other end of the ligature. The finger introduced into the rectum recognizes the probe, which is then curved and gently drawn through the rectum and anus. The two ends of the ligature are tied, shotted, and clamped (Fig. 216). The labial orifice is left to itself and closes in a few days,

This method originated with Rhea Barton of Philadelphia, and was improved by I. E. Taylor of this city, who, on November 18, 1885, read a paper on Recto-labial and Vulvar Fistula before the New York State Medical Association.