Finally, 13. CretW and Zweifel cured uretero-uterine fistulte by ex tirpating the kidney of the side involved.
In ease the opening of the vesico-vainal fistula is very considerable, COurty gradually closes it by successive incomplete operations done at intervals of 1 to 2 months. If the defect in vesico-utero-vaginal fistula is exceedingly large, Jobert first taught us to loosen the urethra under the pubic arch by the so-called vestibular-incision, so that the urethra could more easily be drawn upwards. Later, however, he abandoned the pro cedure. G. Simon used it in case No. 2, which had been unsuccessfully operated upon by Bozeman in Heidelberg; at the same time he divided the commissures of the os uteri to the depth of half an inch in order to render the anterior lip mobile. Ho succeeded in closing the large fistula; but the patient could only completely control her water when lying upon her back; when she stood or walked it began to dribble after I or an hour. Future cases must inform us whether this faulty result was due to the short urethra (I an inch), or whether the loosening caused it; and if the vestibular incision can be successfully used at all to re-establish continence.
There occur cases, however, in which the loss of tissue is too great to be closed in the manlier described; and cases in which the edges of the fistula have become attached to bone, so that there are not sufficient soft parts to be freshened up; cases where the abnormal opening is situated so high up that there is danger of wounding tho peritoneum; cases in which repeated unsuccessful attempts at closing have been made, leaving the fistula larger than it was before. In all these instances there remains but one hope for the patient. That consists of closure of the vagina below the fistula, the transverse obliteration of the vagina, or Simon's kolpokleisis. (Fig. 53).
Vidal, and after him Wutzer, B6rard, and Dieffenbach, had proposed in the severest cases to close the vaginal opening; but they none of them succeeded in the operation, small clefts or fistulous tracts being always left. Schuppert of New Orleans is said to have been the first to secure complete closure by means of the so-called episiostenosis, without, how ever, entirely curing the incontinence. It is very evident that this proceeding, which prevents cohabitation as well as conception, is only to be employed in the most desperate cases, and is always to be done, if at all, as high up as possi'ule. Recently Bozeman, Bouqu6 and others have claimed that transverse vaginal obliteration has been done oftener than is really necessary. Simon has cured such cases in the ordinary way
after dividing the cicatrix. The indications for the operation are to be accepted with great hesitation.
Kolpokleisis is done by selecting portions of the anterior and posterior vaginal wall in the neighborhood of the fistula which will fit to one another, and then marking with the point of the scalpel the limits of the area of tissue to be freshened. (Figs. 55 and 56.) One assistant then with forceps or hooks puts tension upon the part, whilst another pushes it out by means of a catheter lying in the bladder. After smoothing the edges of the wound and stopping the hemorrhage, two needles threaded upon one thread are used to pass the suture through the entire thickness of the denuded surface. The sutures pass from above downwards through the lower, and from below upwards through the upper border. The union should be especially exact at the corners. It is not necessary that the sutures should pierce the vesical or the rectal wall; but there is no harm done if this does occur. They should be passed at distances of about one lino from each other.
After the operation is finished the new closed reservoir must be t,ested by means of injections through the urethra. Everything else is to be carried out exaetly,. as in vesico-vaginal fistuhe. If uniou is incomplete, pregnancy may ensue even though the opening be very small. As a rule the product of conception is not carried to term; it may make its way into the bladder, or, by enlarging the orifice, pass out by the vagina. (Cases of de Roubaix, R. Line, and the author, No. 6.) If there be extensive cicatricial stenosis of the vagina, the opemtion should be done below the sears. In a ease in which there was a cherry-sized fistula in the right vaginal vault, Simon obliterated the vagina obliquely, so that the vagina retained its full length, and only half its vault was closed off (see 5:). In another case of kolpokleisis at the level of the urethra the same operator later loosened the post,erior vaginal wall from the wall of the rectum, and, covering the latter with a flap, lengthened the vagina an inch. Both operations are by no means devoid of danger. In the first one Douglas's pouch may be opened; and in the second injury to the rectum and re-establishment of the incontinence may easily occur. And the result to be attained is but a small one.