Cauterization of the neighborhood of the fistula from the vagina was first practised by Chelius in 1844. He cauterized with nitrate of silver in substance a broad tract of the vaginal mucous membrane around the fistula, and about half an inch from its edges. The method was espec ially favored by Soupart, Du Moulin, van Wetter and Deneffe in Belgium; and Soupart modified it by converting the simple perifistular cauteriza tion into a perifistular centripital cauterization, making each successive application ne,arer and nearer to the fistula, yet without touching its edges.
He used sulphuric acid as well as the actual cautery and the galvano cautery. A second cauterization is undertaken as soon as the eschar caused by the one is cast off and the wound is cicatrized.
An older method was the so-called intermediary or intra-fistular one of Desault, which consisted of cauterizing the inner surface of the fistulous canal. The actual cautery, and lunar-caustic in holders from which it could be projected, were especially used. Dupuytren, LaRemand, G. Simon, Soupart, and others have cured cases in this way. Sometimes the vesical mucous membrane near the fistulous opening was cauterized at the same time. Dupuytren and Velpeau described instruments carry ing a piece of lunar caustic bent to a right angle, which could be projected and used to cauterize the vesical mucous membrane for a certain distance from the orifice.
This procedure has been improved upon by Soupart, Deneffe and Bouga, so that an intra-vesie,a1 cauterization may be conducted as fol lows: in a hollow sound shaped like a uterine sound, but thicker, is a mandril, to which a small sponge soaked in chromic acid or a piece of lunar caustic may be attached. The fistula is then fixed by the left index fin ger in the vagina, and the bladder being empty the sound is passed to the neighborhood of the fistula through the urethra, the caustic holder projected, and with the help of the finger in the vagina, is swept over a vesical surface surrounding the fistula and some inch distant from it. The cauterizations per vaginam and per vesicant are not always concen tric, and the uneven cicatrization leads to a more rapid reduction of the size of the fistula.
These three methods of cauterization may be used singly or combined, on urethro-vaginal, vesico-vaginal, and vesico-uterine fistulce: it is appli cable not only to small fistulte, but to those also which measure 2 to 3 inches in 'diameter (Neaton, Passamonti).
It may be urged as an objection to the cauterization method that the cicatrices it causes in the neighborhood of the fistula diminish the chances of a snbsequent cutting operation; but this has not been found to be the case. It must be conceded, however, that severe intra-fistular cauteriza
tion may occasionally cause enlargement of the fistula.
Cauterization has been recommended for a number of fistula3 in which a bloody operation is contra-indicated; namely those situated high up in the anterior vaginal vault, and those in which the peritoneum is liable to be wounded, though peritonitis from the latter cause is hardly ta be feared now that we use systematic antiseptic precaution& It has also been recommended for vesico-uterine fistulte, so as to prevent union of the lips of the os and sterility, though the process itself is liable to cause atresia. It was not to be thought of for uretero-uterine and uretero-vaginal fistuhe, on account of the danger of closing the ureter, with subsequent unemia.
As to the most suitable time and method for cauterization, there is con siderable difference of opinion. Some authorities, as Neaton, Yemeni], Treat, West, Sims, Schuppert, would wait six to twelve months, to give time for as great as possible amount of cicatrization of the original wound; others, like Velthem, Baker Brown, and especially Nottingham, with Bozeman, Wright, Warner, etc., recommend cauterization as soon as pos sible. Nottingham relates that he found only small fistulte in a woman 3 months after confinement; but that 3 months later, probably in conse quence of coitus, they were 3 times larger than before. The length of time required for cure by this method is in favor of early cauteriza tion; according to Bouque, when done less than 1 month aft,er the injury it was 41.1 days; 1 to 2 months after, 75.6 days; later than 2 months, 115.8 days, and the average. The average time for all cases cured by cauterization was 77.5 days.
There is also no agreement of opinion concerning the length of time that should intervene between single cauterizations. If we wait for complete cicatrization we may have to wait for months, though my ex perience confirms the opinions of Soupart and BouquO in that two to three weeks is usually enough. Only very considerable losses of substance and ureteral fistula3 contra-indicate cauterization. It may be employed in pregnant women; sulphuric acid has been freely used in such cases by Deneffe and Botiqu6 without doing any harm to the patient.