stemmed slightly curved sharp hook, and brought into a suitable position; a line is then to be drawn with the point of a fine pointed scalpel around the fistulous opening, and from three to four lines distant everywhere from it. The portion of the mucous membrane of the ragina between the line and the fistulous opening is then to be seized with the hook somewhat raised, and gradually removed about the whole extent of the opening as thinly as possible, to the breadth of three or four lines, by a saw-like motion of the scalpel, and the bleeding which ensues is to be checked by the injection of cold water.

By DIEFFENBACH, the patient is put in the same position as in cutting for the stone, a silver catheter is introduced into the bladder and held by an assistant, and a two-armed speculum vaginæ passed, in order to see the fistula distinctly. If the fistula be not high up, one of its edges may be seized after another, with a hook, or with a pair of hooked forceps, gently drawn down, and removed with a proper bistoury or pair of scissors. If the fistula be high up, DIEFFENBACH, after introducing RICORD's speculum, passes one pair of hooked forceps into the wall of the ragina, above the fistula, and a second pair of hooked forceps beneath it; the speculum is then removed, and the vagina gently drawn with double hooks, if there be considerable tension, by an assistant, to one side, till the edges of the fistula are apparent between the nymphæ. About the edges little hooks are to be introduced, and both double hooks and one pair of forceps removed; the other pair is held by an assistant, and the little hooks by another person. A small scalpel is now thrust through the mucous membrane of the vagina and bladder, distant a line from the fistulous aperture, and a strip, a line broad, is to be removed around the opening, and the hooks again introduced into the bleeding edges. The edge of the bladder is now to be taken hold of with a fine pair of hooked forceps, and a portion, two lines wide, removed with the knife, so that the wounded surface, which was only one line wide, is now four lines. In small fistulas, where the separation of the two walls is not possible, a funnel-like piece should be removed.

HOBERT (a) refreshed the edges by touching with lunar caustic.

Peculiar instruments for refreshing the edges (NAEGELE'S bistoury with a covered edge, LALLEMAND's hook-shaped knife, and so on) are unsuitable and unnecessary.

977. For uniting the refreshed edges, the twisted, the glover's, the interrupted and the running stitch have been proposed, and with different modifications employed; the twisted and the interrupted are most convenient. The latter is easier of application; soft threads only and not hard metallic threads being employed, the threads are easily withdrawn; on the other hand the twisted suture renders the union much closer and does not allow the urine to percolate so easily; therefore WUTZER prefers it, in a quiet intelligent patient, for a narrow vagina and soft fistulous edges. In using the twisted suture, the insect-needles should be fresh sharpened and pointed, just before the operation, but they must not be too fine. The needle in the needle-holder should be introduced at such an angle as suits generally the position of the fistula; its point should not project further than necessary. It may be requisite, in order that the movements of the needle be not prevented, to grip it with the needle-holder close to the head. The tip of the forefinger of the left hand is to be placed near the edge of the fistula, and so directed that the entrance of the needle

(a) London Medical Journal, 1825, Dec. p. 439.

should be as advantageous as possible. In transverse fistula it is best to pierce the hinder (upper) lip of the wound first, but in longitudinal fistula that next the left side of the pelvis. The left forefinger then presses the corresponding lip of the wound against the point of the needle, till it pretty well holds it. The other needles are to be introduced in a similar way, and the distance between the several needles should be no more than two and at farthest three lines asunder. The tying of the threads is to be effected with the two forefingers, but if they cannot reach, with the forceps. In the application of the interrupted suture, the curved needle, properly fastened in the needle-holder, and supported by the left forefinger is to be thrust through both lips of the wound at proper points; for which purpose, frequently the edges of the wound must be fixed with a sharp hook, as otherwise they easily give way. As soon as the needle is introduced through both lips up to its eye, an assistant frees it by turning back the screw of the needle-holder; the eye and the thread are then to be oiled, the holder withdrawn, and the point of the needle seized with the forceps, and about eight inches length of thread introduced. Both ends of the thread may be advantageously used for arranging the edges of the wound whilst applying the other stitches. If several threads have to be introduced, it is convenient that they should be of different colour, so that they may be more easily arranged. The needle threads must be first tied and drawn together with the fingers, or if deep, with the forceps. If the first tie loosen before the second is drawn together, it must be kept tight with forceps by an assistant. The threads must be cut off an inch from the knot. In introducing the needle it should be remembered, that the edges of the wound are to be taken hold of so far from the needle, that they may be penetrated without ever piercing the mucous membrane of the bladder. By this treatment the two wounded surfaces are applied to the height of three or four lines, and their free edges at the same time turned inwards towards the bladder, permit the urine to come in contact with the seam only in the most untoward cases. In this way, according to WUTZER, the very difficult separation of the bladder from the wall of the vagina, which here and there, from the great thinness of the tissue, must be quite impracticable, is superfluous. DIEFFENBACH draws with curved needles seven threads from the hinder to the front end of the fistula when drawn down, of which only one holds the edges of the vagina and the other, those of the bladder. The threads which have been passed are to be properly tied with the fingers, their ends brought out and fastened in the mons Veneris with sticking-plaster.

The twisted suture is proposed by NAEGELE to be made with curved needles; Roux employs the common hare-lip needles; SCHREGER uses the glover's needles and suture. EHRMANN (a) first introduces on the inner side of the fistula some cross threads, then scarifies, and brings it together by tying the threads. KILIAN So introduces the needle near the front angle, three lines from the edge, that its convex surface is directed towards the operator, pushes it backwards in the direction of the length of the fistula, and again passes it out at the same place, draws it out with the forceps, and brings back the threads to this side. In this way the threads are introduced on the other side, by which the first thread may be employed for drawing down the fistula. The several opposite corresponding threads may then be tied.

The conveyance of the needle with the fingers, or, where necessary, with a needleholder, is preferable to the long stemmed trocar-like needle, from the eye of which the ligature is drawn out with a pair of forceps. (NAËGELE, LALLEMAND, DEUBER, and

(a) Répertoire Générale d'Anatomie et de Physiologie Pathologiques, vol. v. pt. ii. p. 172. FRORIEP'S chirurg. Kupfertaf. ccxxxv.

others.) The drawing together of the threads, by passing them through several rosary beads, and tying upon them, (SCHREGER,) or with the ligature tyer, is improper.

For the cases in which, on account of the thinness of the fistulous edges above described, the separation of the vagina from the bladder is not possible, DIEFFENBACH recommends the running stitch, in which without previously refreshing the edges, a very thick thread is carried by a curved needle circularly around the fistula, some lines distant from its edge, through the cellular tissue connecting the vagina with the bladder, in which the needle must be passed in and out three or four times through the same opening; the thread is then to be firmly tied. (Compare par. 957.)

978. For the purpose of carrying off the urine with greater certainty from the wound thus brought together, puncture of the bladder above the pubes should, according to WUTZER, be performed. The patient must be removed from the position upon her belly to that on her back, and should be allowed some rest. She is then to be brought to the edge of the table, the thighs raised towards the belly, and after the still remaining urine is drawn off with an elastic catheter, the curved tube of the trocar furnished with a fishbone-plug, and oiled, is to be introduced through the urethra into the bladder; the round head of the plug is then placed against the front wall in the direction towards the arch of the pubes, pressed pretty firmly on the hind surface of the lower notch of the synchrondrosis, and there kept some time constantly close to the pubic symphysis, raised along it from below upwards, till at last it can be felt through the abdominal coverings immediately above the pubes, and directly in its middle. The operator then firmly retains the tube in his right hand, in the position just mentioned, places the tip of the forefinger and thumb of his left hand on either side of the projection artificially made above the pubic symphysis, and endeavours so to assist in fixing the extremity of the tube there pressed up; an assistant then withdraws the plug, and in its stead introduces a curved stilette into the tube, so far upwards till the two handles completely meet to each other, and the point of the stilette at the same time protrudes through the upper opening of the tube. At this important moment the operator with his right hand takes hold of the handle of the tube with that of the stilette, and with strong pressure thrusts the stilette in a corresponding direction upwards and forwards, through the front of the bladder and the wall of the belly. The accompanying tube he takes hold of at the same time, with the two fingers of the left hand conveniently disposed, keeps it steady, and then allows the stilette to be withdrawn by an assistant, who also immediately carefully removes the handle of the tube, by gently drawing them apart. The operator now changes both hands, draws the tube with his right hand out of the belly till the hinder extremity directed by the left hand enters the cavity of the bladder, between the orifices of the ureters, which can be ascertained by the careful introduction of the oiled tip of the finger into the vagina. For the purpose of keeping the tube in this position, it must be fixed immovably by means of wing screws, in the cleft of a previously well-fitted belly-girdle, after which the patient should be carefully conveyed to a bed previously prepared, placed on her belly, upon suitably cut out leather cushions, and properly buckled in it with suitable straps. In the gap of the bolster and beneath the point of the tube a basin should be placed to receive the urine flowing from it.

For the arrangement of the trocar and bed, see WUTZER, above cited, pl. iv. and v. 979. The after-treatment must have special reference to the prevention of inflammation. According to DIEFFENBACH, besides rest and antiphlo

gistic diet, injections of cold water every half-hour, with a large syringe, through the catheter lying in the bladder should be made, and by an œsophagus tube into the vagina; cold applications on the region of the pubes, and according to the state of the constitution, blood-letting; if pain come on, leeches to the region of the bladder, and even in the vagina; emulsions with aqua lauro-cerasi and castor oil, with mucilaginous drinks. About the sixth day the ligatures are to be carefully removed with forceps and long scissors, and injections made with lukewarm chamomile tea. If the union succeed and there remain only a little opening in place of the early cleft, or one of the needle-holes, we must endeavour to close it, by touching with tincture of cantharides, and the like, or by the loop suture. According to WUTZER, the symptoms of inflammation coming on moderately, may be opposed by frequently drinking cold water, and careful injections. In more careful examination of the patient, together with the application of leeches, some doses of calomel, rubbing in gray mercurial ointment on the insides of the thighs, and the frequent introduction of small pieces of ice into the vagina may be sufficient against severe inflammatory symptoms. The latter remedy employed with a cautious hand, will be especially advantageous and diminish the still burning pain. In increased inflammatory symptoms, blood-letting, calomel followed with infusion of senna, and injections of luke-warm oil into the rectum are to be employed. When, however, there is no danger of threatening symptoms, constipation for four or five days is rather desirable, and if there be disposition to diarrhæa, it must be checked with opium. If the puncture of the bladder have not been made, or if the tube have again slipped from the bladder, a thin elastic catheter must be introduced through the urethra every hour or two, or even oftener, with frequent pressure to discharge the urine; WUTZER considers it most advantageous when the patient herself can do this; but if not, the introduction of the catheter must be carefully performed by an assistant; and only when neither is possible, should the catheter be allowed to remain permanently. When, however, not merely the disposition to inflammation of the bladder is much increased, but also, by the continued irritation, the mucous secretion in the bladder is so great, that particularly after the third day, the catheter is frequently stopped, against which injections are not sufficient, this instrument must often be changed. The sutures should be first examined three days after the operation; if about this time a needle or a thread be near cutting through it, must be removed. After the third day, the examination must be made daily, that according as suppuration comes on, the several threads or needles may be removed. In successful cases the scar acquires the desired strength in four days. After the removal of the threads or needls injections only of lukewarm water or of weak lead wash should be used.

980. The cure of vesico-vaginal fistula by transplantation, was first attempted by JOBERT, in a case where previously two attempts with suture had failed. By means of MUSEUX's forceps or a hook, he drew down the hinder edge of the transverse fistulous opening, pared it, and then did the same with the front edge. He next separated an oval piece of skin from the mucous membrane of the right labium, so that the flap at the edge of the vaginal aperture formed, by closing the cut, a neck of four lines broad. With a female catheter, he introduced a loop of thread through the urethra, up to the fistulous orifice in the vagina, and drew the one end of the loop out of the vagina, and the other by the catheter, out of the urethra. The

turned back flap was so folded, that its mucous surface touched itself, and through its double edge the end of the thread hanging out of the vagina was passed spirally with a needle twice, and so a plug of flesh formed with a raw surface. By drawing the end of the thread hanging from the urethra, the fleshy plug was pulled between the fistulous edges and properly pressed up with the finger. An assistant continued to draw the urethral end of the loop, whilst the operator, after refreshing, drew a thread forwards which had been introduced into the upper edge of the fistula, for the purpose of bringing it into contact with the flap of flesh. An elastic catheter was then introduced into the bladder, the ends of the thread fastened to a bandage, (or with sticking plaster on the thigh,) and the wound covered with agaric. The patient was benefited, but not cured.

In another case, in which the transplantation was made from the labium, hair subsequently grew upon it, which excited inflation of the mucous membrane of the vagina, and obstructed coitus.

Subsequently JOBERT made the flap from the fold between the thigh and buttock; after ten or eleven days the patient could pass her water without the catheter, in the usual manner. After four or five weeks the flap was cut through, an inch from its base, whereupon it became black, which however it ceased to be, after throwing off a small slough. After two months the successful result is no longer to be doubted. For similar experiments on transplantation see WUTZER, above cited.

981. DIEFFENBACH endeavoured to close large fistulas by drawing the mucous membrane together. Without introducing a speculum, and after having returned the wall of the bladder through the fistula, and having introduced a sponge into the cleft, to prevent its reprotrusion, he seized one edge of the opening with the hook-forceps, drew it towards him, and supporting it with another hook, cut off a narrow slip from the edge, and also cut off the edge of the bladder, some lines distant from the edge of the vagina. He then, by means of his own palate-needles, carried two leaden threads through the edges of the vagina, without including the bladder, and drew them together till there was considerable tension, upon which he thrust the knife in upon the posterior and lateral part of the vagina, and drew it down in a straight line to the nympha, and then treated the opposite side in the same way, so that the breadth of the thus isolated part of the vagina was about a fourth of its whole width. In making this cut the finger was introduced into the rectum to prevent injuring it, and to make the cut sufficiently long and deep. The leaden thread being then drawn tighter till great tension was again produced; the edge was drawn forward with a hook, or with hook-forceps, and the cellular tissue connecting the vagina to the pelvis cut through with scissors or a knife, first on one and then on the other side, but without coming too near to the bladder. By continuously drawing the leaden threads, the edges were loosely brought together, so that no further tearing apart was to be feared, and the edges of the wound were united with the interrupted suture, made with a curved needle, and when the hindmost stitch could not be made with the hand alone, it was made with a needle-holder. When the whole cleft was closed the leaden threads were drawn close together, and cut off so that only two turns remained. A catheter with large openings on the sides was introduced, and the after-treatment conducted as above described.

In moderately large fistulas, when a small neighbouring fold of the bladder lies in the opening, and has already become adherent, DIEFFENBACH recommends that the edges should be inflamed, by frequently touching with tinct. lytte, and that the mem