At your request I send you a brief notice of a newr mode of operation for the cure of urethra and vesico-vaginal fistula, which I have successfully employed in two cases, a more detailed account of which I propose hereafter to present you with. The two operations above alluded to, were respectively on patients of Professor Meigs, and Dr. Condie. In one t case, there was a complete destruction of a cross section of the whole urethral structure, at its juncture with the neck of the bladder ; in

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... e other there was an elongated orifice in the bas fond of the bladder, which would more than admit the end of the finger. The peculiarity of the operation consists virtually in attaching the two sides of the anormal opening (irmly together, on the principle of the tongue and groove, so as to get four raw surfaces in contact, and thus increase the probabilities of union by first intention. For this purpose it is necessary that the margins of the fistula should have considerable thickness ; and when not found in this state, they are to be thickened by repeated applications of lunar caustic, or, better still, of the actual cautery. Having exposed the fistulous orifice as thoroughly as possible with a Charriére's speculum from which the sliding blade has been removed, an assistant at the same time drawing the vestibuluni well up towards the front of the pubis, my first object in the operation is to split the most posterior margin of the fistula to the depth of half an inch, with a sharppointed, sabre-shaped bistoury. I next pare off the edges of the other lip of the fistula, so as to bring it into a wedge-shape ; first reverting it as much as possible with a small blunt hook, and trimming off the mucous membrane on the side next the bladder with the curved scissors or scalpel, and then detaching, in like manner, the vaginal mucous membrane, to the breadth of three quarters of an inch, along the whole extent of the lip. This is a very difficult but most important part of the process ; and great care should be taken to obtain a sufficient extent of raw surface, at the two angles of the fissure, where the lips will rest merely in apposition. Having checked the bleeding by the use of astringent applications, my next object is to insert the raw wedge or tongue into which one of the lips of the fistula has been converted, into the groove which has been cut in the other, and bold them in close connection. This I accomplish, by the means of a peculiar suture that might be called the plastic, and in the same way that 1 have described its application in reference to some plastic operations, in my Operative Surgeiy, and in the American Journal of the Medical Sciences, for October, 1842. The suture threads are to be passed with short, sharp, curved needles, held in Physick's artery forceps with the handles made of twice the ordinary length. When the sutures are knotted firmly, the tongue or wedge will be found immovably imbedded in the groove. The sutures 1 leave for two weeks or more, or until they become loose. A gum catheter should be kept in the bladder to prevent the accumulation of urine. To keep the The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at SAN DIEGO (UCSD) on June 28, 2016. For personal use only. No other uses without permission. From the NEJM Archive.