In vesico-vaginal fistula the reforma tion of the bladder-wall is the essential point for cure. After the separation of the flap around the fistula four double threads are passed, thin ends knotted and lying outside the vagina (two only are shown in Fig. 1). A pair of curved . forceps is passed through the urethra up to the fistula, and the four pairs of threads are brought together and their knotted ends placed within the grip of the forceps. If gentle traction is made upon these, as is seen in Fig. 2, the cir cular flap is inverted into the bladder "in such a way that mucous membrane will face the bladder, while the raw con nective-tissue surface will face itself and come easily together at the level of the bladder-wall, while the innermost edges project as a tube into the bladder cavity." While traction upon these threads is gently maintained, and before the frill is inverted, a fine-silk suture is carried round it just above its extremity; this passes through the connective tissue, but must carefully avoid the mucous mem brane. This is now cut short, the frill inverted, and the guiding threads di vided and drawn out through the ure thra. In Fig. 3 the repaired fistula is seen from the vaginal side.
The advantages are: (1) absence of tension upon the uniting surfaces; (2) mucous membrane is alone opposed to Fig. 1.—The flap has been separated and turned into the vagina; two guiding threads are shown in position, and the first uniting thread, which passes only around through the connective tissue and muscular coat, avoiding the mucosa. A pair of bent forceps is passed
through the urethra, its point entering the vulva through the fistula. The guiding threads will be turned up into the vagina and their knots placed between the jaws of the forceps. (Stan wore Bishop.) the action of the urine; (3) the cubic capacity of the bladder is not much de creased, as in other operations for a simi lar purpose; (4) the sutures are sepa rated from the bladder-contents by the mucous membrane in its entire thickness. Stanmore Bishop (Trans. Med. Soc., vol. xx, p. 123, '93).
In the second class of cases not only must the vaginal opening be closed, but the abdomen must be opened and the source of offense removed, whether it be organ or tissue. In sonic eases the moval of this source of offense will fice, and the vaginal fistula may be closed by a subsequent operation should it fail to heal after the irritating cause has been removed. In either class of cases a series of operations may be required, and great patience and skill will be demanded if a cure is to be accomplished.
Tumors of the Vagina.
The tumors of the vagina, like those of other organs, may be benign or malig nant. They may be classified as fol lows:—