In the superficial vesico-utero-vaginal fistulte the anterior lip of the os uteri is freshened and is united to the lower edge of the fistula, which is formed by the vesical or possibly the urethro-vaginal wall (Fig. 58 a); whilst in the deep vesico-utero-vaginal the post,erior lip of the os is to be united in the wound, thus making the woman sterile (Fig. 53 b) . Re cently, however, Hegar has several times succeeded in curing longitudinal fistula with the help of very small remains of the ant,erior cervical wall.
As A. Martin and K. Schroder remark, vesico-uterine fistulEe show a great tendency to spontaneous cure, though operative interference may be necessary when they have existed for a long time.
In vesico-uterine fistuhe, when we cannot, after dilating the cervix, close the vesic,a1 opening by energetic cauterization (see successful cases of Hildebrandt and of Kaltenbach), we must split the cervix bilaterally, and bring the fistula into eyesight by dragging down the anterior lip of the womb. The edges of the fistula are then to be excised, and the cut surfaces united by suture. R. Wilms has told me himself that he did this operation successfully long ago a number of times. A. Martin, Lossen, Muller (Oldenburg) and many others, have done it; and I have cured five of my patients in this manlier, (see below). In two of my cases closure was not complete immediately after removing the sutures;— but it soon ensued. In my first case I used silk, and I was unable to remove all the sutures, which had sunken deep into the uterine tissue. Several months later four of them encrusted with calcareous salts were evacuated by the urethra. If direct union fails, nothing remains but to freshen both lips of the womb and unite them together, performing hysterokleisis, first performed by Jobert.
L. Landau has recently proposed in cases of uretero-vaginal fistula3 to pass a long elastic catheter from the vagina into the upper end of the urethra, and then to pass the lower end out through bladder and urethra. Then the patient is to be placed in the knee-elbow position, and then the uncovered portion of the catheter to be covered with the vaginal mucous membrane and the lower ureteral wall. The catheter is to romain in situ for some time. If this does not succeed a long oval piece is to be excised from the vesical and va.ginal wall, and the direct uretero vaginal
fistula be thus changed into an ordinary vesico-vaginal fistula, into the uppermost point of which the ureter opens. Then the vesico-vaginal fistula is to be closed by deep sutures which pass through the vesical mucous membrane.
Simon, however, was led by his want of success in his early attempts to secure direct and indirect healing of uretero-vaginal fistula3 to teach in later years as follows: the vesical wall is to be pierced at the place of the fistula; a sound is to be passed from the bladder into the ureteral opening; and the uretero-vesical wall is then to be slit from the vesic,a1 surface for a distance of to I of an inch. The edges of the cut are to be daily separated with a large sound until cicatrization has set in. The vaginal fistula now lies at a distance from the new ureteral opening, and its 'edges can be freshened and united. A small portion of the adjacent vaginal vault could be denuded, and used to help the closure of the fistula. Simon regarded this proceeding as more certain than that of Landau.
Very recently L. Bandl operates as follows on uretero-vaginal fistulte. He passes a catheter into the bladder and then through an artificial fistula and into the ureter. Then he secures union over the catheter, which remains in place. Thus like G. Simon he entirely neglects the lower end of the urethra; nevertheless lie completely cured two patients in this way after many unsuccessful attempts. (See Fig. 54.) Schede thinks un favorably of Bandl's method on a,ccount of the subsequent cicatricial con traction and striction of the ureter. He first therefore surrounds the artificial vesico-vaginal fistula with vesical mucous membrane to prevent future contraction; and he so arranges it that the ureteral mouth forms the outer, posterior end of the artificial fistula. The double fistula is then so freshened that there remains immediately surrounding the fistula a strip of vaginal mucous membrane 1 to 2 lines in breadth. In this way the margins of the fistula are covered with mucous membrane; this pro truded into the bladder fornis the half of a deep tube entirely clothed with mucous membrane, into whose extreme end the ureter opens. Schede cured one patient in this way.