The edges of the fistula being now fully prepared, we must decide upon the material to be used for the sutures. Each surgeon naturally advo cates the kind he uses himself; Simon likes Chinese silk, whilst Sims, with Bozeman and Hegar, prefers silver wire. I have used silk, silver wire, and iron wire, and in one case where there was but very little tension upon the elongated fistula, even catgut, and have had successful results. Simon objects to wire because he says it is very liable to become the nucleus of a calcareous deposit. But this happens just as often with silk, (see Simon's 17th case,) and silk cannot remain as long in situ as can the wire. When there is much tension, when the loss of tissue is great. when the stitches have to remain in 8 or 10 or more days, silver wire or iron wire is decidedly preferable. Only recently I removed some iron wire from the vesico-vaginal septum which had lain there for 10 weeks without causing a trace of local irritation. Silkworm gut or Fil de Florence is a very excellent material, and I have used it almost exclusively in fistula operations for the last 7 or 8 years. The best plan is to use the materials most suitable for each case, and sometimes to use more than one kind at an operation. Pippingskjeld uses alternate iron and copper or iron and silver threads at distances of of an inch, and claims by this galvanic suture to have obtained union when he could not have done it in the ordinary way.
The needles (Fig. 42), are either curved ones of various sizes used with a Simon (Fig. 43) or Rose (Fig. 44) needleholder, or they are long and hollow like those of Simpson (Fig. 45) or Salter (Fig. 46) or Neuge bauer (Figs. 47 and 48); Hagedorn's needleholder may also be used. It was formerly the custom to put the stitches at different distances from the margins of the wound; and Simon and Kfichler used the so-called double suture, the more distant a inch) threads being designated tension, and the nearer ones uniting sutures. Latterly Simon himself gave up these tension-sutures (compare Fig. 49) and passes all his sutures one or two lines from the edge of the wound. When the edge of the freshened surface is considerable it is not necessary to transfix the vesical mucus membrane; Simon usually did so, but not always (comp. Fig. 49), whilst Sims and others avoid it. About lines should be left between adja cent sutures. But before the surfaces are united the entire surface of the wound must be wiped, and washed with cold water to remove coagula and other foreign bodies from between the surfaces to be united. When the stitches are tied, union may occur transversely, or longitudinally or obliquely. The first is the best, causing the least tension. Simon rightly
always united the edges in the direction of the longest diameter of the fistula. Triangular fistulw, whose base is at the urethra whilst their apex is al the oe uteri, and large square openings he even closed thus T and thus A, and cured them. He regards it as a disadvantage of Bozeman's method that from the lateral tension upon the vagina the fistula had always to be united transversely. (Comp. Figs. 49, 50, 51.) In deep-seated fistuhe, aud such as cannot easily be dragged down, it is not easy to tie the knot of a silken suture, and the thread is very liable to break in the operation. This cannot occur with wire. Bozeman lays a leaden plate upon the wound before twisting the sutures, and presses this plate against its edges by the wires. He then passes the wire through split shot. The whole proceeding is too complicated to find general ac ceptance, nor does it ensure any better results than a simple knot in silk sutures, or twisting wire sutures directly over the wound. Bozeman uses very thick wire, and places his sutures 1 of an inch apart.
After all the sutures are tied, and their ends cut off short, the bladder should be emptied with the catheter and washed out with a weak solution of salicylic acid. This enables ne to decide if our union is perfect, or if any fluid still exudes. A neglect of this precaution has necessitated Simon himself repeating the operation more than once.
The after-treatment has been greatly simplified by Simon. The patients are allowed to urinate at will, and can get up at once if they feel strong enough to do so. On the fourth or fifth day, if silk sutures have been used, otherwise later, the stitches are to be removed. The catheter is only employed when the patients cannot micturate spontaneously. Bozeman on the other hand leaves an elastic catheter permanently in the bladder, washes it out several times daily, and gives large doses of opium. My own experience is decidedly in favor of Simon's simpler plan.
Vaginal injections are only necessary if there is any foul-smelling secre tion. Easily digestible food and regular daily evacuation of the bowels are necessary.
The removal of the sutures is to be done, as we have said, on the fourth to the sixth day in the case of silk, after the eighth day in the case of wire. Sore spots are to be cauterized with the solid stick.
Any little openings which may be left can be closed by means of caustic applications; if this does not suffice, it will be necessary to operate again in 2 to 4 weeks time.
This is the mode of procedure in nrethro-vaginal and vesico-vaginal fistula. Some special additional precautions are, however, necessary for vesico-uterine and uretero-vaginal fistulte.