Probably for the same reasons the various complicated speculte intro duced with the object of diminishing the number of assistants, have not found general acceptance. Marion Sims's instrument is shown in Fig. 36; the Amerie,an and that of Spencer Wells in Figs. 37 and 38; and the com plicated apparatuses of Neugebauer, Ulrich, and Bozeman in Fig. 35. For we cannot vary the tension and position of the fistula with them as minutely as may be necessary during the operation. If cicatricial bands prevent the full stretching of the fistula, they must be incised, or divided.
The edges of the fistula being fully exposed, we now proceed to fresh en them up. Different instruments are used by various surgeons for this purpose. G. Simon and Sims employ only long-handled straight or elbow-bladed knives, with blunt or sharp points; while Bozeman only transfixes the edges of the fistula with his knife, and completes the abla tion of the edges with the scissors. Simon made the objection to the scissors that it was liable to contuse the tissues and cause considerable loss of substance, and that in vesico-vaginal fistulie situat,ed near the urethra it might easily endanger continence, although he admitted that the operation could more easily be done with the scissors than with the k nife in the deeper cavities. But he says that when we come to.the suc cessive ablation of the edges, to be continued until we reach perfectly healthy tissue, the knife is far preferable to the scissors for the preserva tion of tissue. We endeavor, of course, to obtain broad, smooth, vascular edges, free from cicatricial tissue; it has therefore been disputed whether it is preferable to freshen along the surface of the vagina, and spare the vesical mucous membrane as much as possible (the American method), or to freshen perpendicularly from vagina to bladder (G. Simon). The former method will probably enable us to avoid vesical hemorrhages with greater certainty. Hegar employs the flat funnel-shaped freshening when the edges still contain cicatricial tissue, claiming rather inconsequently that he thus sacrifices less tissue than he would if he freshened perpen dicularly outside the area of scantissue.
It is necessary before incising to mark out with the point of the scalpel the line of incision upon the vaginal mucous membrane; thus enabling us to keep at an even distance from the borders of the fistula. In doing this we must take into consideration the best direction to cut, so as to secure coaptation of the edges. The invaginated vesical mucous mem bmne which projects through the fistula must be replaced and held back before the cutting begins. This may be done by a sponge attached to a thread and passed into the bladder, or by an assistant holding back the tissue by means of a sponge attached to a sponge-holder. But the intro duction of a good-sized catheter into the bladder will suffice to crowd the fistula from the vesical side against the instruments of the operator, and thus make the requisite tension. It will do so best, of course, with small
fistulEe.
The lowest edge of the fistula is now transfixed about half an inch from the orifice, and the freshening of the edges is proceeded with evenly along the line marked out. Meanwhile the assistants carefully sponge and irrigate the wound with a 3 to 5 per cent. carbolic acid solution. Spurting arteries must either be seized with an artery forceps, or twisted, or tied. There is most danger from the large arteria vesico-uterina, which runs along the side of the cervix uteri, and is sometimes as thick as a crow-quill. If it were cut, the threads of the ligature might be passed out through the wound, Simon having proven that this does not necessarily disturb healing by first intention. The smaller arteries which. may be cut will be included in the subsequent stitches.
There is no doubt that the ureter may be cut through whilst freshen ing the edges of such a fistula, especially if it be large and is laterally placed. It may be recognized by noticing the urine flow from a small orifice, into which a sound can easily be passed for a considerable distance upwards and backwards. We must then endeavor to bring the cut end into the bladder. It is to be fixed in the edges of the wound, slit up for a certain distance towards the bladder, and then a broad, flat surface freshened for it to unite t,o. The openings of the ureters in the bladder according to Simon ' correspond to a point in the vagina about I of an inch outside the outer edge of the os uteri, and about -6- of an inch in front of it. Simon has operated upon quite a series of cases where the fistula was at this place or extended to it; but he never observed a symp tom which he could with certainty refer to closure of the ureter. In all these cases the ureter was either not included, or if it was the thread cut through the ureter so quickly that no marked interference with the flow of urine ensued. If the ureter is seen to project into the fistula, it can be pushed away into the bladder. Pawlik in every fistula operation intro duces an elastic catheter through the urethra into each ureter, only re moving them after the operation is finished. If this precaution, however, has not been taken, and if after the operation there occur symptoms of interference with the flow of urine, colicky pains originating in the kidneys and radiating along the course of the ureters, with vomiting, etc., the sutures must be at once removed. Finally, before putting in the stitches we must be certain that the bleeding surface is everywhere smooth and clean; all projections, etc., may be snipped off with the scissors.