If the edges of the opening cannot readily be brought together, any restraining bands of tissue in the vaginal walls should be divided with scissors. If these bands are slight and superficial, they may be divided at the time of operation for closure. If, however, they are extensive, preparatory treatment devoted to the liberation of the edges of the fistula must be practised. All restraining bands should be freely divided, and after the vagina has thus been opened up, it should be distended (to prevent subsequent contraction) by introducing a vaginal plug or dilator (Fig. 181) or a rubber bag packed with sponges. Bleeding is generally controlled by the pressure of the plug. The vaginal plugs of glass or of hard rubber are made of various sizes. They should be long enough and thick enough to stretch the vagina without producing sloughing. The plug is retained by a T-bandage. After this operation the woman should be kept in bed for a week or ten days. The urine should be drawn with the catheter without removing the plug. When suppuration begins the plug will become loosened and may be removed. Emmet says: “It is remarkable how much absorption of the cicatricial tissue takes place in a few weeks when judicious pressure has been maintained by this instrument.” After removing the plug, vaginal douches should be resumed until healing is complete. It will be seen from this consideration that the preparatory treatment may be severe and may extend over a long period. Such extensive treatment is not by any means always necessary; when, however, it is required, it is useless to proceed to operation without it. _Operation._--The operation consists in freshening the edges of the fistula with the knife or scissors and bringing them into apposition with the interrupted suture. Different forms of suture have been used by various operators. If the parts are in a healthy condition and are properly denuded and approximated, it makes no difference in the result what form of suture is used. As in all forms of plastic work, I prefer silkworm gut shotted. The operation is most easily performed with the woman in the Sims position, the vagina being exposed with the Sims speculum. The lithotomy or the genu-pectoral position is preferred by some operators. The edge of the opening should be seized with the tenaculum or with tissue-forceps, and a continuous strip of tissue should be removed all around the fistula, extending from the mucous membrane of the bladder out upon the vaginal surface for a quarter or three-eighths of an inch. The vaginal mucous membrane usually retracts somewhat as soon as it is liberated from the fistulous margin, so that the raw surface is broader than the strip removed. It is advisable to avoid any injury to the mucous membrane of the bladder, as free bleeding may take place from this structure. The denuded surface should extend as near as possible to the mucous membrane of the bladder without involving it.