the perinæum, and so on; or it communicates with the rectum, with the colon, with the vagina in women, or with the cavity of the belly, in which case there is always a fatal effusion of urine into it. Complete urinary fistulas are mostly consequent on retention of urine, tearing, injury of the bladder, or an incomplete internal or external fistula. These, which in men open into the rectum, frequently occur after the operation for the stone, as those connected with the vagina take place after difficult delivery, or after ulceration of the vagina. Cancer of the rectum and of the vagina may also produce urinary fistula.

Complete urinary fistula is characterized by the escape of urine, which is constant, if the fistula be from the bladder, but only whilst making water, if from the urethra; this escape, however, is not always present in complete fistula, as if the fistulous passage be very narrow, and the urethra not obstructed, the urine often passes by the latter alone, and in fistula of the bladder, if the canal be very narrow and curved, often only by straining, whilst emptying the bladder. It also depends on the condition of the fistulous canal, whether the probe introduced into it can be made to touch a catheter in the urethra or bladder. If the fistula communicate with the vagina or rectum, the urine escapes by these canals; or the opening of the fistula is felt by the finger introduced into it, or merely by the sound passed into the bladder. If the fistula be connected with the rectum the urine flows through it or is mixed with stool. Less constant are these symptoms, viz., hardening of the course of the fistulous canal, or in the whole extent of the perinæum, inflammation, unhealthy suppuration, proud flesh about the fistulous opening, loss of power, wasting, hectic fever, and the like.

948. The prognosis in urinary fistula depends on its situation and extent, on the constitution of the patient, and on other diseases connected with it. Complete fistulas, of which the internal opening is connected with little loss of substance, heal more easily than those which have it with greater loss of substance; fistulas of the urethra, under similar circumstances, heal more readily than those of the bladder. When the canal of the

urethra is considerably changed, greatly narrowed, or entirely obstructed, and cannot be reopened, the cure is impossible. Urinary fistulas communicating with the vagina or rectum are extremely difficult, and frequently not to be healed. A bad state of the patient's powers renders the prognosis very doubtful.

949. The cure of incomplete external fistula requires the general treatment of fistulous sores. Suitable pressure often assists the healing; often must the fistulous orifice be enlarged by a conical cut, of which the point is directed towards the urethra or the bladder, the source of the pus laid bare, every neighbouring passage opened, and care taken for the free flow of the pus. If there be callosities, dispersing bran poultices and proper digestive remedies must be employed. If caries be connected with this fistula or any general affection be connected with it, the treatment must be modified according to general rules.

950. Incomplete internal urinary fistula requires the introduction of a catheter, which often, if the urethra be narrow, must be preceded by the use of the bougie. The catheter must be of moderate size; otherwise it fills up the urethra too much, or the urine escapes by its side. If the fistula be old and the cure do not in this way take place, the incomplete must be changed into a complete fistula by a suitable cut, which is also necessary in extensive urinary infiltration, where several incisions often must be made,

in order to prevent the gangrenous destruction caused by the escape of the urine.

Stones frequently lie in the sac of a blind fistula, in which case cutting into it and the the removal of the stone is necessary, and afterwards the treatment is to be as in complete fistula. Compare also what is hereafter said about urinary stones exterior to the urinary passages.

951. Complete urinary fistulas communicating with the kidneys, or ureters, require no assistance, unless kept up by the pressure of a foreign body or by prevention of the flow of urine from the bladder, in which case perhaps the restoration of the natural area of the urethra, or the removal of the foreign body, may contribute to the cure.

952. Complete urinary fistula is situated either between the scrotum and the glans penis, or between it and the anus in the perinæum. The difference of the seat of the fistula depends on its course, and requires different treatment.

953. In the first case, (Fistula urinaria penis,) the fistulous opening is most commonly on the under side of the penis, varying in size, so that either all the urine and semen, or only part of it, escapes thereby. It presents different conditions, according to its cause and duration; it is often connected with surrounding hardness and copious suppuration, especially if it arise from stricture; often it forms an extremely minute and obliquely running aperture; often the skin and the neighbouring mucous membrane of the urethra, skin over, and do not suppurate; often is a large portion of the lower wall of the urethra destroyed, and the opening varying in size, surrounded with a hard scar, as in destroying ulcers or wounds with loss of substance. In narrow and obliquely running fistulas, the introduction of a probe, through the fistula, and of a catheter through the urethra, shows the seat of the internal opening.

954. If the fistula be accompanied with narrowing of the urethra, this must be first got rid of by bougies, and then by the continual wearing an elastic catheter, which should be properly fastened, the urine must be conveyed from the fistula. At the same time, any disease, standing in causal relation to the fistula must be attended to, and care taken for the cleanliness and diminution of the irritated condition of the parts surrounding the fistula, by warm hip-baths, leeches, poultices, and so on; and the patient's constitutional powers must be improved by attention to diet and tonic remedies. The cure usually takes place without further assistance, if the fistulous orifice be not too large, and its walls not too much changed.

955. If, when the urethra have attained its proper size, the cure of the fistula do not take place, or if there be scarcely any diminution in the size of the stream of urine, the cause of the obstinacy of the fistula is its callous or some other condition. Then, if the fistula form a canal, it must be divided and filled with lint to promote the development of granulations; or the edges of the fistula, especially if they be callous, must be touched with caustics, as lunar caustic, nitric acid, (A. COOPER,) a solution of caustic potash, or with tinct. canth., (DIEFFENBACH,) because this is less destructive than irritative. In the application of the caustics, a moderately thick bougie should be introduced into the urethra, the cauterization repeated after the separation of the slough till good granulations are produced, the scarring of which may be assisted with lunar caustic. After the narrow or oblique fistula has been dilated, DIEFFENBACH recommends the cauteri

zation of the whole fistulous canal, by means of a pencil, three times within six or eight hours, a wax bougie being in the urethra, after which an elastic catheter is to be introduced and fastened; next morning the slough is to be removed by introducing a fine piece of sponge into the fistula, and the cauterization repeated after suppuration has been set up, till good granulations are developed. The catheter should always be changed twice a day. In two or three months the cure of a tolerably large fistula may be effected, rarely however is the healing thus produced, and although the external opening be closed, it may be again burst open by a large stream of urine or during connexion (DIEFFENBACH.)

If the cauterization of such fistulas do well, it may not merely be confined to the callous edges, but may be extended to the immediate neighbourhood, as ROSER especially has done, and my own practice has assured me.

956. For closing these urethral fistulas, the suture of various kind, has been used, the interrupted stitch, (A. COOPER, DIEFFENBACH and others,) the glover's stitch, (ZANG,) the twisted stitch with five insect-pins, (DIEFFENBACH and others,) the quill stitch, (FRIEMANN,) and the splint stitch, (DIEFFENBACH,) which resembles it. The result has been, however, rarely satisfactory, because the thin edges of the skin afford insufficient points of union, and are little disposed to adhesion, which is also easily destroyed by the trickling urine, in spite of the catheter which has been introduced. The patient should be placed, as in the operation of cutting for the stone, and after a catheter has been introduced, the edges of the wound should be made raw, in small fistulas with caustic, or by shaving off the skin with a thin knife, and in larger openings a thin slice must be removed. According to the different size of the fistulas are a sufficient number of threads to be introduced with a fine needle, or sufficient insect-pins to be passed into the bottom of the fistula, and the union effected by tying together the threads, or twisting the silk around the pins. If much tension of the skin arise in consequence, a longitudinal cut must be made into the skin, half an inch from the wound and stretching beyond it, in order to relieve the tension, and to prevent the pins tearing out.

957. In fistulas not of large size, if surrounded with healthy skin and not immediately behind the glans, DIEFFENBACH has proposed and proved the running stitch as the most efficient. A catheter is to be introduced and the fistula frequently pencilled with tinct. canthar. On alternate days the blisters which have been produced are to be removed, and a short tolerably thick elastic bougie introduced into the urethra. A thick, double-waxed silken thread is now to be passed, with a curved needle, a quarter of an inch from the edge of the fistula, so that the threads may lie deep, without injuring the urethra. As the needle cannot be at once thrust through the whole extent, it must be thrice passed through, and introduced again through the same punctures, till in the end it comes out through the first puncture and the threads are drawn after it. Both ends of the thread are now to be tied with the double knot, so that the threads lie deep in the cellular tissue. The bougie is then removed, and no catheter introduced. A slight swelling of the penis occurs; towards the seventh day, the threads become loose and can be somewhat drawn out; they may then be cut through and the part covered with sticking plaster. If a slight fistulous orifice remain, it may be touched with tinct. lyttæ, or the operation repeated.

958. In those fistulas which have much loss of substance, various experiments have been made to close them by grafting skin (Urethroplasty.) A. COOPER, EARLE, ALLIOT, Delpech, RicoRD have formed the covering flaps from the skin of the scrotum and groin twisted round; but COOPER and ALLIOT alone have obtained any satisfactory result. The ground of this frequent disappointment is easily perceived, and DIEFFENBACH has proposed for such cases a corresponding operation by transplanting by means of removing the skin.

959. In fistula near the scrotum, after the catheter has been introduced into the bladder, the edges of the fistula are to be seized with a pair of hook forceps, and so drawn out that a transverse wound with two sharp points stretching on each side of the penis is formed. A longitudinal fold of the skin of the scrotum is to be then raised and cut through to the extent of two inches, so that a transverse wound, parallel to the former, is produced, and the bridge of skin which has been formed by it is detached from its base by cutting horizontally, then drawn forwards and fastened with five or six twisted stitches to the edge of the skin of the penis. Beneath the hinder edge of this bridge of skin, an elastic bougie two inches long is to be introduced to the aperture in the urethra, in order to divert the urine pressing out by the side of the catheter. After some days the threads are to be removed, and the union to be sustained with sticking plaster.

960. In large fistulas in the middle or fore part of the penis, the transplanting of the skin may be effected in various ways. In great deficiency of the urethra in the middle of the penis, with destruction of the skin, so that the edges of the latter cannot be drawn over the opening by lateral incision and setting free the bridge, the edges of the skin about the aperture must be set free, without separation, so far as may be easily done, then a longitudinal incision must be made on each side of the root of the penis, so that the wound occupies two-thirds of the extent of the penis. The outer skin of the prepuce is then to be drawn somewhat back, the skin of the first incision raised on the opposite side of the penis, behind the corona glandis, in a large longitudinal fold, and here also two-thirds of the skin of the penis cut through. The covering of the penis included between the two incisions and usually forming a bridge of skin two inches broad, is now to be separated, the edge raised with a pair of forceps, and the cellular tissue divided with a pair of sharp eye-scissors. The skin is now to be drawn completely down, so that the sound skin of the back of the penis descends and completely covers the hole in the urethra. Any tension of the skin is relieved by lengthening the incision. To prevent the collection of blood between the skin and the penis, the bleeding must be carefully stanched, and then the retraction of the skin to its old situation prevented, and its union promoted by some stitches and by some narrow strips of well sticking adhesive plaster. From the hinder edge of the wound, on the under side of the penis, a piece of elastic bougie is pushed beneath the skin, towards the hole in the urethra, in order to conduct externally the urine dribbling by the catheter. Erections must be especially prevented, and on their occurrence the strips of plaster must be cut through. After four or five days, if the skin be grown together, the threads may be cut, but the application of the sticking plaster must be continued. The bougie is only to be left off after the most complete healing.

961. According to DIEFFENBACH, if there be a hole close behind the prepuce, the external layer of the prepuce should be transplanted backwards as an entire ring, the outer layer of the prepuce being raised up before the fistula and cut through, so that the wound may occupy more than two-thirds of the circumference of the penis. Behind the fistula a corresponding incision is formed by the oblique division of a longitudinal fold, so that the two cuts join at their extremities, and thus an oval island is formed, having in the middle the fistula which has been prepared by some strokes of the knife laid flat. The edge of the wound in the prepuce is now raised with a pair of hook forceps, the cellular tissue connecting the outer and inner folds of the prepuce, divided with eye-scissors, the frænulum cut through, as well as the outer fold of the prepuce, where connected with the glans, and thus an opening is formed of half an inch for the introduction of a small bougie, for the escape of the secretion of the wound and the prevention of urinary effusion. The hinder edge of the outer layer of the prepuce is to be drawn back and united to the corresponding wounded edge of the skin of the penis by seven or eight stitches and the connexion supported by narrow strips of plaster crossing in the back of the penis. In very narrow prepuce both its layers must be divided to the corona.

962. In large openings immediately behind the glans, if the prepuce be deficient, DIEFFENBACH recommends the removal of the callous edges, so as to form a transverse cleft, and then by depressing the glans the edges of the wound are brought together and united by two interrupted stitches, the one end of which is to be cut off and the other carried by a blunt needle through the fistula to the mouth of the urethra. The neighbourhood of the fistula and the whole under surface of the glans is then to be set free, to the extent of a line with a pair of hook forceps and a small scalpel. The extent of the cut must be bounded by penetrating perpendicular incisions, and the wound have the shape of a half oval, of which the rounded part is to be directed towards the orifice of the urethra, its straight part backwards and its two angles reaching up to the back of the penis. The skin is now raised in a longitudinal fold, at the hinder and under part of the penis, and cut through obliquely, so that the ends of the cut are directed upwards and forwards. This bridge of skin, so entirely separated that it remains connected only on the back of the penis, is drawn forwards over the surface of the wound and over the fistula, and connected with the edges of the wound of the glans by fine interrupted stitches. The hinder surface of the wound is covered with soft lint and sticking plaster, and beneath the hind edge of the ring of skin, a piece of bougie is introduced in order to carry off the urine somewhat escaping by the side of the catheter. Inflammation is to be prevented by cold applications and subsequently lukewarm lead wash, and the threads projecting from the urethra, as well as the catheter, are to be drawn out when they have cut through the edges. In one case DIEFFENBACH had a favourable result; in another the cure was frustrated by erection and discharge of the semen.

Upon Urethroplasty compare

COOPER, A., above cited.

DELPECH, Chirurgie Clinique de Montpellier, vol. ii. p. 581.

BLANDIN, Autoplastic, p. 180.

DIEFFENBACH, Ueber die Heilung widernatürlichen Oeffnungen in den oorderen Theile der männlichen Harnrohre; in Hamburger Zeitschrift, vol. ii. pt. i. ZEIS, Handbuch der plastischen Chirurgie, p. 506.