Nor could better results be obtained by changing the materials used for suturing. Gilded, silver, steel, straight or curved needles, insect needles, or the use of silk, golden, iron or silver threads were of no avail. Three men have done more than all the others combined for the operative cure of urinary fistulte; these are Jobert de Lambslle in France, 1839, Gustav Simon of Darmstadt, and Marion Sims of New York.
In 1853 Simon showed that the gist of the operation lay in an exact freshening and a careful suturing. He simplified the operation, and de serves credit for taking it out of the hands of a few specialists, and placing it in those of a large number of surgeons and gynecologists.
The operation may be done at all ages and at any time. G. Simon did it in 1866 in a girl eight years old. (Case No. 9.) It has been done after sixty. It has been performed successfully during menstruation, and during pregnancy, though premature delivery has been seen to occur in consequence. (Schwartz.) Excepting carcinoma of the uterus or vagina, the only contra-indication is such excessive weakness as to render speedy death probable, as in a case suffering from a rapidly progressing cheesy pneumonia. In such cases no operation should be undertaken, since the pain, loss of blood, uncomfortable position, and the use of chloroform, might cause the patient to die upon the table.
The best time for operation was formerly the subject of much discus sion. Neaten, Verneuil, Sims and West placed it at 6 to 9 months, Kiwis* Baker Brown, Bozeman, Simon and Ilegar at a few weeks after the occurrence of the fistula. Recent statistics show us that it is not wise to postpone the operation more than 6 to 8 weeks after delivery. I have repeatedly cured large fistulte by freshening and suture, during the first 6 weeks um; and Hegar always obtained a good result by a first operation done 6 to 8 weeks after birth. Hegar rightly elainis that the treatment of other co-existent maladies is much simplified by the operation. Most patients themselves desire to have it done as soon as possible. Even if the edges of the wound are not yet entirely cicatrized, they can be thoroughly freshened; and besides, being unthinned and unfixed by cica tricial tissue, they are more succulent and vascular than they will be later. Gravidity is not in itself a contra-indication. Pregnant women stand the
operation well, and quickly recuperate when the continence of the bladder is re-established, as the cases of Cohnstein, Rogowicz, and Schlesinger prove. Kroner, however, cites 5 cases, in 4 of which premature delivery took place after the fistula operation. In the case of fistuke caused by calculi and pessaries, the croupous cystitis and colpitis must first be cured and the wound become clean, before any operation can be attempted.
The exact time of operation will depend upon whether any preparation for the operation is necessary. In most eases it is not; especially if there are no extensive cicatrices, and no vaginal awl vulvar ulcerations. And even if such measures should be necessary, it is better to combine them with the operation, rather than to draw them out for days beforehand, as some surgeons do. Thus Bozeman gradually dilates cicatricial bands by cutting, and subsequently by using rubber tampons. Thus the pus and urine was directly applied to the cuts, and colpitis, cystitis, and if the pelvic connective tissue be opened, abscesses may occur, as also parame tritis and pelveo-peritonitis, endangering the patient's life. This occurred twice to Simon and Bozeman. (Cases 3 and 4.) Simon himself admits that incision is difficult and requires considerable experience. Very re cently Bandl, von Massari, and Pawlik have obtained very good results by Bozeman's method of preparatory treatment, in sufficiently operable fistuhe. The vulva and vagina are first cleansed of urine by means of sitz-baths and lavements of hot water, and the sore spots are brushed over with a 10 per cent. solution .of nitrate of silver. The incised cicatricial bands are also brushed over in the same way, and the dilating instruments introduced. In this manner Bandl, Massari, and Pawlik have always thus far been able to avoid kolpokleisis.
As a rule, vaginal injections, a warm bath, as much nourishment as possible, and repeated and exact examinations of the patient, are all the preparatory treatment that is necessary. Repeated examinations are necessary to determine the size, seat, and complications of the fistula, to determine in which position the fistula can be best exposed, and to decide beforehand upon the metlicx1 of operating.