Treatment.—Many of these fistul.i occurring post partum contract down and close spontaneously. We are in a position to appreciate the ease with which this may occur in uncomplicated cases, from our experience with the difficulties in keeping open a fistula created artificially for draining the bladder for cystitis.
All those cases which do not close spontaneously call for operative treatment, which consists by one device or another in uniting the edges of the bladder in such a manner as to close the defect with the least possible tension and without injury to the ureters.
It is not long since Dr. J. Marion Sims closed these fistulae exclu sively with silver sutures, and believed that the success in their treat ment was chiefly due to the special form of suture used. Bozeman and Emmet have laid the greatest stress upon the preliminary prepa ration of complicated cases, by incising scar tissue and dissipating it by pressure. The tendency to-day, however, is in almost all cases to proceed at once with the repair of the defect.
Dr. Nathan Bozeman, of New York (New York Medical Journal, Oct. 1st, 1887), urges the use of hard or soft dilators. The former are introduced and left in the vagina, where they are held by an external attachment. The soft dilators are made of strips of sponge covered with oiled silk. By means of the pressure exercised by these dilators scar tissue is stretched and dissipated.
In all cases where the vagina contains necrotic sloughing tissue, where the edges of the fistula and the neighboring parts are raw and granulating, and where incrustations are found at the margins of the fistula and on the vaginal walls, these complicating conditions must be removed before proceeding to an operation for closing the fistula. This will be attained by exposing the parts and removing as much of the dead tissue and incrustation as can readily be taken away, and after this using daily warm irrigations, either solutions of borax or weak carbolic-acid lotions, and every four or five days touching the raw surfaces with a solution of nitrate of silver, varying in strength from three to five per cent.
While thus treating these associated conditions, it will be well also to incise bands of scar tissue in several places, loosening up the margins of the fistula, or opening up the vaginal canal, so as to make the fistula more accessible. By such preparations a difficult ope
ration will be rendered more easy, and success attained where the re sult of an immediate operative procedure would have been a failure. I hold, however, that with the improved technique of our opera tions to-clay, the same amount of elaborate preparation, more par ticularly that dealing with the scar tissue, is not so necessary as in zhe days of our immediate predecessors.
A skilful operator will not be embarrassed by finding a marked stenosis of the vaginal orifice, for this can be at once extensively divided with the knife, on one or both sides, carrying the incision down beside the rectum, giving all the room necessary to get at the fistula. Scar tissue radiating out from the edges of the fistula can also at the time of operation be freely incised, or even cut out entirely, with the result of loosening up the margins of the fistula so that they can be approximated.
In one of my cases, the edge of the fistula was pinned down to the left descending pubic ramus and was extremely awkward to get at, besides leaving no room for applying sutures on the side of the scar. I overcame this difficulty successfully by introducing a deli cate sharp lance on the vulvar surface about 3 cm. (11 in.) distant, and carrying it along under the mucous membrane freed in this way the margin of the fistula from the bone without puncturing it. The hemorrhage from the little opening made by the lance gave no trouble. The fistula was then successfully closed.
Where the fistula is of moderate size, 2 cm. in diameter or smaller, and its edges can be approximated by traction, the best plan of pro cedure is a denudation of its margins on all sides bevelled from the vaginal surface down to the mucosa of the bladder. It is not neces sary to remove more than the very edge of the mucous membrane. On the vaginal surface, however, the denudation must be from 5 to 6 or 8 mm. in width. If the fistula is small and round, not more than 2 mm. in diameter, the denuded surface has a distinctly funnel shape. When the fistula is larger the denudation simply exaggerates the shape of the fistula.