. The diagnosis of diseases of women . eat the present writing a case under observation in which the vesico-vaginal fistula was caused by direct violence during the attempteddelivery of a child. It is seldom, however, that fistulse are causedby direct violence in the use of forceps. More often, as Kellyputs it, they are due not to the use of forceps, but to the too longdelay in using them. 620 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM Carcinomatous invasion of the vesicovaginal septum is second inpoint of frequency. Other causes are vesical calculi, injuries sus-tained in vaginal operations,
. The diagnosis of diseases of women . eat the present writing a case under observation in which the vesico-vaginal fistula was caused by direct violence during the attempteddelivery of a child. It is seldom, however, that fistulse are causedby direct violence in the use of forceps. More often, as Kellyputs it, they are due not to the use of forceps, but to the too longdelay in using them. 620 DIAGNOSIS OF DISEASES OF THE URINARY SYSTEM Carcinomatous invasion of the vesicovaginal septum is second inpoint of frequency. Other causes are vesical calculi, injuries sus-tained in vaginal operations, and ulceration from the pressure ofan ill-fitting pessary. Forced catheterization during labor mayperforate the bladder. Finally, pelvic abscesses may perforate bothinto the bladder and vagina, thereby forming a vesicovaginal fistula. The diagnosis of vesicovaginal fistula is made by the history of apossible cause, the complaint of incontinence of urine with its dis-agreeable consequences, and, finally, by direct inspection. Fig. 217. Vesicovaginal fistula. A communication is established between the base of the bladder andthe vagina at a midpoint in the anterior wall of the vagina. It is unusual for a fistula developing after labor to manifest itselfbefore the end of the first week, though it is possible for urine toescape through the vesicovaginal septum during labor. The symptoms are quite characteristic. Before the urine escapesthrough a fistula there are usually symptoms of cystitis, bloodyurine, and rise of temperature. A foul-smelling vaginal dischargeindicates the sloughing of the vaginal wall, and this is soon fol-lowed by a dribbling of urine into the vagina. The vagina, vulva,perineum, and inner aspect of the thighs soon show the irritatingeffect of the urine in the form of vulvovaginitis and local distress and inconvenience of the dribbling lowers the vitality DIAGNOSIS OF DISEASES OF URETHRA AND BLADDER 521 of the patient, and she may become extremel
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