Should the opening be large, the best results follow when the fistulous tract is dissected out and the rectal and vaginal surfaces united by separate tiers of sutures. This operation necessitates an attempt at primary union which so often fails in this region of the body. Care should be taken to have the parts thoroughly clean by emptying the intestinal canal, a day or two in advance of the operation; after which two cleansing enemas should be followed by an injection of eight ounces of peroxide of hydrogen, which is allowed to remain in the bowel.

A bivalve rectal speculum should be introduced and the margin of the rectal wall dissected free, removing as little tissue as possible. The circumference of the rectal wall is then separated from the vaginal wall for a distance of about one-fourth of an inch. The aperture in the rectal wall is then closed vertically. Silk gut is used for suturing and the sutures should pass through the entire rectal wall and be placed about a quarter of an inch from the margin. These sutures should be close enough to invert the mucous membrane toward the vaginal wall and hold it in apposition to the inverted vaginal wall. Beyond the angles, additional sutures should be placed at a distance of a quarter of an inch to protect the wound.

Before and after approximation of the wound, it is well to swab the whole area with pure iodine to ensure sepsis, if within the range of possibility. The vaginal portion is cleansed and sutured in the same manner as described for the rectal part of the operation. A rectal tube is introduced and kept in the rectum for three days, but should be taken out each day. cleaned and reinserted. Before the bowels are allowed to move olive oil should be injected into the rectum in order to secure a soft and easy stool. In a week the sutures should be removed, although the vaginal suture may be left for two weeks if nonirritating

Liechtenstein’s Operation for recto-vaginal fistula is as follows: The fistulous tract is denuded to the rectal mucous membrane from the vaginal surface. Sutures are then introduced from the vaginal side through all the tissue, including the recto-vaginal, excepting the rectal mucous membrane, and the entire wound closed by interrupted wire sutures. Care should be taken that the sutures are introduced so as to bring the parts into a position without too much tension, the direction in which the wound is drawn together being of no consequence. Make no effort to close the opening into the rectal mucous membrane. The sphincters should be dilated and a rectal tube introduced and the patient constipated for a period of four or five days.

Cinematography Complete excision of the fistulous tract may be combined with cinematography It is an operation which is a modification of that for the repair of the sphincter and is attended with success where aseptic measures can be instituted, but the experience of many has been, that, should it fail, the patient is really worse off after the operation. A modification of this technique, employed by Cuttle, has proved a success by bringing down a piece of the mucous membrane, and attaching it to the anal margin, thus preventing direct infection from the rectal contents. The perineum is then brought together with three or four deep silver wire sutures after the technique of Emmett The technique as given by Cuttle is as follows:

"The sphincter muscle should be thoroughly but gently stretched; the perineum is then completely incised from the vagina into the rectum up to. but not including the fistula. A probe is then passed through the fistula and the latter together with all its cicatrice tissue is dissected out en maze The mucous membrane of the rectum is trimmed off from the edges of the wound for about one-half an inch up to the level of the fistulous opening, and above this it is loosened from its attachments until it can be brought down to the margin of the anus. The perinea septum is then brought together down to and including the sphincter muscle with a continuous chromite catgut suture. Three or four deep silver wire sutures are then passed through the perineum after the manner of Emmett Before the latter are fastened the mucous flap in the rectum is brought down and sutured to the skin at the margin of the anus. The wire sutures are then drawn together and made fast by twisting or by perforated shot, and finally the edges of the mucous membrane in the vagina are sutured with plain catgut and sealed over with formalized collocation" The operation consists in doing practically a Whitehead operation upon the anterior wall of the rectum combined with a complete cinematography

Recto-vesicular Fistula;. This communication is more frequently met with than the recto-urethral fistula. The opening is most commonly at the trig one of the bladder, on account of the close relation with the rectum and bladder at that point, and seems to be simply a perforation, the result of ulceration or traumatize Other causes are pelvis-rectal abscess, malignant disease, tuberculosis, and non-specific ulceration of the rectum.

Treatment. Much can be accomplished by the use of a permanent catheter and rectal tube in order to empty the bladder and rectum to prevent further irritation or infection. This method has proved successful in a number of cases.

Should this happy result not follow, the sphincters should be stretched by means of a rectal speculum, the margin of the fistulous opening vivified and deep sutures placed carefully so as not to include the bladder wall. The sutures should extend well beyond the extremities of the wound. After this, the catheter and rectal tubes should be introduced as suggested above. Care should be taken to remove the catheter at the end of twenty-four hours, to avoid over-irritation of the bladder. Afterward, it may be passed at short intervals to keep the bladder empty.