The vaso-motor disturbances are often the most annoying. The phenomena of the “flushes” consist of a feeling of heat over the whole or a part of the body, followed by sweating and the sensation of cold or a slight chill. The flushes may occur frequently during the day, sometimes several times during an hour. The treatment of the menopause should be directed to the maintenance of the general bodily and mental health. The diet should be carefully regulated. Too much nutritious food should be forbidden. Purgatives should be administered whenever necessary. The woman should have plenty of fresh air and the proper amount of exercise. Mental depression demands a change of locality and surroundings. CHAPTER XXXVI. GENITAL FISTULÆ. Fistulous openings may exist between the different portions of the genital tract and the neighboring structures. Such fistulæ are the result of childbirth, operative or other form of traumatism, congenital defect, cancer, syphilis, or suppuration. The accompanying diagram (Fig. 180) shows the chief varieties of fistula that occur. [Illustration: FIG. 180.--Diagram illustrating the chief varieties of genital fistula: _v. u._, vesico-uterine fistula; _v. v._, vesico-vaginal fistula; _u. v._, urethro-vaginal fistula; _r. v._, recto-vaginal fistula.] =Vesico-vaginal Fistula.=--The most frequent form of fistulous opening occurs in the septum between the bladder and the vagina. The condition is usually caused by sloughing, the result of prolonged pressure from the fetal head at labor. In some cases such an opening is made for therapeutic reasons by the physician, for the cure of cystitis. Intelligent midwifery and the prompt and proper use of the obstetrical forceps have greatly diminished the frequency of vesico-vaginal fistula. It was formerly a very common disease. At the present day it is but rarely seen, at least in those parts of the country where women have competent attendance at labor. The vesico-vaginal opening may be situated at any portion of the septum. It varies very much in size and shape. It may be a small hole barely admitting a fine probe-point, a median slit, or a large irregular opening involving the whole base of the bladder. The appearance of the fistula varies according to the time that has elapsed since the receipt of the injury. The margins of the opening, which are at first irregular and ulcerated, become in time thin and firm from cicatricial contraction, and the size of the opening becomes similarly diminished. The first symptom of vesico-vaginal fistula is the involuntary escape of urine from the vagina. If the condition has resulted from pressure at parturition, the incontinence of urine does not appear for five or ten days after labor, when the slough has separated. When a direct laceration of the vesico-vaginal septum has occurred, the urine will escape immediately.