Reybaud (Lyons) closed the fistula with an obturator, introduced a sponge into the vagina, and fixed the whole with a T-bandage.
Fl.ron (Paris) used a pig's bladder for a considerable time as a col peurynter, and then a rubber pessary. The patient recovered, and had a child one year later without further injury.
Marm'..jouls cured a case by using a Gariel pessary, and was able to discontinue it after a few months.
Conradi cured a patient by using a golden button, the head being in the bladder, the neck in the fistula, and the plate in the vagina; in five years it fell out, and the patient was cured. Yemeni], Schup, F. Winckel, Depaul, Hildebrandt, Monod, Freund, and others saw the spon taneous healing of fistulte without any local or general treatment at all. Not only small, but very considerable &tulle have closed in this way (Guthrie, Marjolin, Hildebrandt), and we should always first endeavor t,o obtain it. Thus Palfrey, who formerly operated as soon as possible, 110W holds that by procrastinating many patients can be spared the neces sity of undergoing any operation at all. Two indications are to be ful filled, to effect a ready outflow through the urethra, and to prevent an outflow through the vagina. The former indication is met by placing a nietallic or elastic catheter in the bladder. Thus Fritsch (J. D. Von Heyne) plisses a drainage tube 4 inches long and 1 inch in diameter through the urethra in the bladder, and washes the viscus out through it. Every two days the tube is removed and cleaned. The c,arbolic in jections also exercise a mild cauterizing effect upon the edges of the fis tula. Two cases were cured in this way. If the catheter or drainage tube is not well borne, we must catheterize every 1 to 3 hours. The second indication is to be met by a careful tamponade of the vagina. The best material to use for this purpose is the ball of salicylated cotton covered with linen, which Esmarch has introduced into practice; for small portions of loose charpie and cotton can easily pass through the fistula into the bladder, and there form the nucleus for the formation of stone. The colpeurynter and sponges are not sufficiently antiseptic, nor do they fit well enough. If the amount that passes through the vagina is snaall, the tampon may remain in situ for several days; in other cases it must be renewed daily after evacuating the bladder with the catheter.
The healing of the fistula may be favored by placing the patient in an appropriate position, either lying on the side opposite to the fistula, or lying upon the abdomen. (See Winn.)
There are authorities who are opposed to the above method, and who claim that the catheter is not well borne by an irritable bladder, and that vesical spasm, abdominal pain, vomiting, and other symptoms are caused by it. Among them are Velpeau, West, Baker Brown and others. This is sometimes the cue; and then we can only pass the catheter every few hours, or perhaps not at all. The tampon will cause no trouble, and it may be tried both in recent and in old cases. So long as the patient im proves it is to be continued, for months if necessary.
If the fistula becomes no smaller, and the patient is no better, is opera tive interference indicated ? and if so, of what nature should it be? The answer to the first part of this question depends upon the size, seat, nature, and complications of the fistula. It depends also upon the ex perience of the surgeon; Simon has cured many a fistula which other sur geons have failed to remedy. For it is undeniable that as in recent times the operation by freshening the edges and suturing is more and more fre quently and successfully done, the more the other methods are neglected and cast aside. To Ed. F. Boma belongs the credit of having reintro duced among others the method of cauterization either alone or together with immediate union of the edges; for he rightly says that: " Les fis tiles vi,sico-vaginales dans leur grantle variete ne ripondent pas ti une settle indication, un seul de moyens therapeutiques connus; mais que tous sent appek.s rendre, dans un certain nombre de cas; des services 1 l'exclusion des autres et que tons par consi:quent mi.ritent d'etre Otudies un degr." Let us now consider cauterization as a means for the cure of urinary fistulm. Its object is to cause the formation of a more or less deep eschar at the edges of the wound, or in its neighborhood, and to close the orifice by the granulation and cicatrization which occur when the slough is cast off. Various caustics may be used; the red-hot iron, the galvano-cautery, nitrate of silver, acid nitrate of mercury (Ehrmann, Cousot), creosote (Emmert). sulphuric acid (Soupart, Du Moulin, van Wetter, Deneffe, de Lorge and others), chromic acid (Deneffe), the juice of euphorbia (Sou part), caustic potash (Deneffe, van Wetter), chlorine water, Vienna paste and others. They may be applied either frotn the vagina to the genital mucous membrane in the neighborhood of the fistula, or from the vesical surface, or finally to the fistulous tract itself.