Treatment.—A cure will sometimes result spontaneously; but, if so desirable an issue is wanting, the cure can only be obtained by surgical measures.
Two classes of cases may be con sidered: those in which the fistula alone is to be regarded and obliterated and those in which this procedure alone will not suffice, the organ, or abscess, or tis sue having communication with the va gina requiring separate treatment or re moval.
In the first class may be mentioned the fistulai communicating with the bladder, rectum, and ureter, and some of those which connect with the uterus, intestine, and pelvic connective tissue. In the sec ond class are those which connect with the tubes and ovaries, intestine, appen dix, and pelvic tissue. For the first class of cases the lines of treatment have been clearly defined by many writers. They require that the vaginal mucous mem brane he carefully and broadly denuded, the adhesive attachment between the vagina and the other injured organ being usually maintained. The denuded tis sues are then brought into such accurate apposition that no leakage can occur. For suture material in such eases I be lieve that nothing has been discovered which is equal to fine pliable silver wire. Each suture is carefully twisted so as to furnish an adequate splint to the tissues during the process of healing, but care must he taken that it be not twisted too tightly, thereby defeating the very ob ject of uniting the denuded surfaces.
The sutures are to be retained from seven to ten days, and then carefully re moved. In vesico-vaginal fistula it has always seemed to me rational and useful to keep a catheter within the bladder for constant drainage as the wound remains unhealed.
Personal operation in vesico-vaginal fistula is as follows: 1. A crescentic incision separating the muscular and mucous coats from the vagina is made around the posterior two thirds of the fistula, and the bladder de tached from the supravaginal cervix all the way up to the peritoneum, and widely on both sides, by a blunt dissection.
2. Next a strip is denuded around the remaining anterior third of the fistula on its vaginal surface, the denudation being carried down to the mucosa of the bladder and the urethra.
3. Two flexible urethral catheters 2 V, millimetres in diameter are passed through the urethra across the fistula, and one conducted into each ureter and pushed up above the brim of the pelvis.
4. The part of the bladder freed from its attachments behind is now easily drawn forward and accurately applied to the immovable anterior third, to which it is united by interrupted fine silk-worm-gut sutures. Each suture catches the under surface of the mus cular coat of the bladder so as to turn the cut edge up toward the newly formed bladder. The urethral orifices fixed on this edge are in this way turned into the bladder, and escape transfixion or compression by the sutures through the presence of the catheters, which make their position plain. These urethral catheters may be left fit situ for a few days, thus draining each kidney directly through its ureter and preventing any urine from entering the bladder. H. A. Kelly (Johns Hopkins Hosp. Bull., Mar., '96).
Six cases of complicated vesical fistula operated upon successfully by the method described by Freund. Douglas's pouch was opened, the fundus uteri drawn down through the opening, and after freshening the edges of the fistula and the posterior uterine wall near the fundus the latter was sutured to the bladder, so as to close the fistula.
It is unnecessary to make an opening in the fundus for the escape of men strual discharge as suggested by Freund. Rollin' and Kahn (Centralb. f. Gyniik., No. 9, '97).
Forty-four cases of fistula were ob served in the hospital at Saratoff among 1004 gynaecological cases (4.36 per cent). As regards the results of operative inter ference, 47.74 per cent. were cured by a single operation; 6.S1 per cent. by two; 18.1S per cent. were relieved by diminish ing the size of the fistula; episiocleisis was successful in one instance; eight pa tients were not relieved. The denuded surface was always quite extensive, and was made so that the edges could be approximated with the least possible tension. Silk sutures were generally used (rarely silver wire), which were re moved on the sixth or eighth day. A catheter was left in the bladder for nine or ten days, after which time the patient was allowed to leave her bed. Anes thesia was rarely used. Rouzmine (Bob.n Gaz. Botkina; La Gynec., Apr. 15, '98).