a fibroid in the recto-vaginal partition is in reality a uterine fibroid that has developed downward, just as, on the other hand, a true vaginal fibroid may extend into the vulva.

According to the predominance of the connective or muscular element, these tumors are harder or softer. Like similar tumors of the uterus, they may undergo a softening by accumulation of serous fluid in the meshwork of their interior.

Originally they are globular sessile tumors imbedded in the wall of the vagina, but when their weight increases they have a tendency to become pedunculated, and may then even protrude through the vulva. Such pedunculated tumors are called fibroid vaginal polypi. Exposed to the air and friction of the clothes, they may begin to ulcerate on the exposed surface. In the lower part of the vagina they often become intimately adherent to the urethra.

As a rule, they are single.

Etiology. They may be small as a pea, but they may also become quite large and weigh up to ten pounds. one, and may extend over many years. in adults, but may occur in children. is unknown.

Their growth is a very slow They are commonly found The cause that produces them

Symptoms. When small they give rise to no symptoms, and are found accidentally. When they increase in size they cause leucorrhea. When they become still larger and heavier, they cause a dragging sensation, dyspareunia, dysuria, dyschezia, and may oppose a very serious obstacle to childbirth. Sometimes they are accompanied by severe hemorrhage.

Diagnosis. When small or middle-sized, they are easy to diagnosticate by their elastic hardness. It is true, a thick-walled cyst gives a somewhat similar sensation, but all doubt may be dispelled by means of an aspirator. When they are large enough to fill the vagina, it may be difficult to differentiate them from uterine fibroid polypi. If it is possible to reach the os, this will be found undilated, and no pedicle passes out through it. From sarcoma a fibroid is distinguished by its slow growth; it does not undermine the constitution; and the microscopical structure is entirely different.

Prognosis. The prognosis is favorable. Small fibroids give no trouble. They grow slowly, and if necessary they can be removed by operation. When they suppurate, there is, however, danger of septicemia.

Treatment.-A pedunculated fibroid may be removed by tying an elastic ligature around the pedicle, which will be severed in a few days. Or it may be cut at once with an écraseur or a galvano-caustic snare, or transfixed with a needle armed with a strong double silk ligature, which is cut in the middle, and the two halves crossed and tied on either side, when they are interlocked like the links of a chain.

Finally the tumor is cut off. Any of these methods prevents hemorrhage.

A sessile fibroid is removed by making an incision over its longest diameter and enucleating it. In order to avoid hemorrhage, fingers and blunt instruments should be used as much as possible. The galvano-caustic knife or the thermo-cautery may occasionally be used to advantage when there is much hemorrhage. If the tumor is large, a part of the mucous membrane covering it is included between two curved incisions blending at their ends, and the circumscribed piece is left on the tumor. After plain enucleation the edges of the wound are brought together with deep sutures. Otherwise the wound must

be packed with iodoform gauze.

3. Mucous Polypi.-Rarer than the hard fibroid polypi are soft growths of similar shape, in structure like the mucous, or glandular, polypi so common in the cervical canal. They give rise to the same symptoms as fibroid polypi. They are very vascular, and the safest way to remove them is, therefore, by means of the elastic ligature or by transfixion of the pedicle, as just described.

4. Sarcoma.-This is a rare disease. It appears in two formsone circumscribed, forming interstitial globular tumors like fibroids; the other diffuse, extending along the surface like carcinoma.

It has been noticed that of the small number of cases recorded comparatively many have occurred in early childhood.

In the circumscribed form the development is slower, and may take a couple of years, but, as a rule, the malignancy of the tumor reveals itself by its rapid growth.

The

prognosis as to a complete cure is very doubtful, as this affection has great tendency to relapse even after complete extirpation. Symptoms. In adults they are insignificant in the beginning. Later there are leucorrhea, hemorrhage, dysuria, and sensation of pressure. The tumor ulcerates and discharges a sanious fluid. The neighboring organs become implicated, and the general health is undermined. In children the symptoms referable to pressure on the organs in the pelvis soon become pronounced.

Diagnosis. The diagnosis from fibroid and carcinoma can only be made by microscopical examination.

Treatment. — Circumscribed tumors are extirpated like sessile fibroids. The diffuse form may be kept in check for a time by curetting and cauterization with thermo- or galvano-cautery, or chloride of zinc as in cancer of the uterus.

5. Carcinoma.-Primary carcinoma of the vagina is a rare disease. As a rule, it is secondary, either propagated by continuity from neighboring organs, especially the cervix uteri, or appearing as metastatic deposits from carcinoma in remote parts.

It is found in two forms, either as a circumscribed papillary growth,

and then it is epitheliomatous in structure, or as a diffuse carcinomatous infiltration, which again may have the medullary or scirrhous type. The diffuse form affects sometimes the shape of a ring.

The cause is unknown. The disease is rarely found before the age of thirty years.

Cancerous tumors develop rapidly. The center ulcerates while the periphery spreads over the neighboring tissues. In consequence of the central breaking down, fistulous communications with other canals may be formed, the most frequent of which is a recto-vaginal fistula. The lymphatic glands in the pelvis and at the groin soon swell.

The chief symptoms are the sanious, dirty, ill-smelling discharge from the ulcer, hemorrhage and pain, to which may come the common symptoms due to pressure and obstruction, dyspareunia, dysuria, dyschezia, and dystocia.

Diagnosis. The broad basis, the friable substance, and the hemorrhage caused by touch are characteristic. The friability, the ulceration, and the hemorrhage serve to distinguish the papillary epithelioma from simple papillomatous vegetations (p. 277). From sarcoma carcinoma can only be distinguished by means of a microscopical examination. The distinction between primary and secondary carcinoma is of great importance in regard to treatment. Bearing in mind that the vagina is rarely the original seat of carcinoma, we must carefully examine all neighboring organs from which it may have spread, and even other organs from which germs may have been detached and carried to the vagina.

Prognosis. The disease, as a rule, has made so much headway before it comes under treatment that a radical cure is impossible. Even after seemingly complete extirpation relapse is common. The whole body is gradually infected, and the disease soon ends in death.

Treatment. If there is any possibility of operating in healthy tis sue, the whole tumor should be extirpated and the wound closed by sutures, which both will arrest hemorrhage and bring about union by first intention. In this respect it is advised not even to abstain from excising parts of the bladder and the rectum, the edges having good tendency to unite if properly brought together by sutures. Of late it has even been demanded that under all circumstances the uterus should be removed.1

In most cases only a palliative treatment can be attempted, but life may be prolonged and sufferings alleviated by a judicious use of the sharp curette, thermo- or galvano-cautery, chloride of zinc, or bromine, applications or injections of chloride of iron, creolin injections, tonics and narcotics, in which respect the reader is referred to the chapter on Carcinoma of the Uterus.

6. Tuberculosis.-Tuberculosis of the vagina is much more common

1 Mackenrodt, Centralbl. f. Gynäk., 1896, vol. xx. No. 5, p. 129.

than that of the vulva, but is still rather rare. It forms ulcers on the posterior wall of the vagina, owing to stagnation of infecting material from the uterus, the disease in the vast majority of cases being only found in connection with tuberculosis of that organ. Miliary nodules, ulcers, and caseous masses are visible in the vagina and on the vaginal portion of the uterus, and the microscopical examination shows the presence of bacillus tuberculosis. Tuberculous ulcers form easily fistulæ opening into the bladder, the urethra, or the rectum. The tuberculous nature of these fistula is revealed by the presence of nodules and bacilli around their opening.

Such fistulæ must be cut out in a wide circumference. Operations for their closure offer scant hope of success. For further information the reader is referred to what has been said about the same affection in the vulva (p. 288).

CHAPTER XIII.

FISTULE.

Definition. A fistula is an abnormal opening leading from the genital canal to the urinary tract or the intestines.

In a more limited sense the word is only applied to such openings the edge of which is covered with epithelium, leaving out fresh wounds extending from one canal to the other, or ulcers eating their way through the partition between them.

Pathological Anatomy.-According to the nature of the extraneous matter that finds its way through the fistulæ into the genital canal they are divided into urinary and fecal fistulæ.

A. Urinary fistulae are again divided, according to the organs through which the fistula goes, into (1) vesico-vaginal, (2) urethrovaginal, (3) uretero-vaginal, (4) vesico-uterine, (5) vesico-utero-vaginal, (6) uretero-uterine, and (7) uretero-vesico-vaginal.

There may be one or more fistulæ, and in size they vary from a scarcely perceptible aperture to an opening measuring two inches in diameter.

1. Vesico-vaginal Fistula.-The most common urinary fistula is the vesico-vaginal variety. The following description applies, therefore, more particularly to it, and the peculiarities of the rarer forms will be mentioned later on.

Etiology.-By far the most common cause of fistula is childbirth. The mechanism may be twofold. The abnormal communication may be due to a tear, and appear immediately after delivery, or it may be due to pressure with consequent necrosis, and not be developed before several days or even weeks have elapsed since parturition took place.

Tears are especially found in old primiparæ or after the use of ergot or in cases in which the forceps was applied before the cervix was sufficiently dilated. Pressure is due to a disproportion between the child and the genital canal, a distended bladder, a loaded rectum, a stone in the bladder, abnormal presentations, etc. In this connection it must be noted that the tissues withstand much better the same degree of pressure if it is exercised for a shorter time. Fistulæ from pressure are, therefore, as a rule, not due to the use of forceps, but to improper delay in their use. As soon as the presenting part becomes impacted and does not move to and fro during and between labor-pains, artificial help ought to be given immediately. In consequence of the improved midwifery and the much more frequent use of the forceps fistulæ have become much rarer now than they used to be, and come mostly from remote localities where proper assistance is not available.

Fistulæ are sometimes due to operations, not only the bungling attempt of the ignorant abortionist, but also in legitimate operations performed by skillful operators. Thus the formation of a vesicovaginal fistula is a not uncommon accident in vaginal hysterectomyi. e. the removal of the uterus.

In rare cases foreign bodies, such as a pessary in the vagina or a stone in the bladder, have gnawed a hole through the partition between the urinary and genital tract.

A pelvic abscess opens sometimes in such a way as to give rise to a urinary fistula.

Symptoms.-The chief symptom is the more or less constant dribbling of urine from the vagina, but this does not suffice for a diagno sis, as the same takes place if the sphincters of the urethra are lost or paralyzed, and, on the other hand, if the urinary fistula is situated high up, the urine may be retained for a long time in the erect posture, and in urethro-vaginal fistula it may be entirely retained except during voluntary micturition.

In spite of the utmost cleanliness fistula patients have a disagreeable ammoniacal odor. If the fistula is large, it may be felt by digital examination.

In most cases it can be seen by introducing a speculum and placing the patient in different positions, especially Sims's, the genu-pectoral, and the dorsal with elevated pelvis (p. 197).

Sometimes, however, the opening is so minute that it cannot be discovered, or it may be hidden by a projecting cicatrix. By injecting a colored fluid-for instance, milk-into the bladder the presence of a vesico-vaginal fistula may be established. A good way to find a minute opening is to cover with a piece of linen the space within which the opening is supposed to be. Urine will go right through it and make the linen wet (Bozeman). Sometimes the opening cannot