Cauterization has the advantage of not requiring any special prepara tion of the patient; though the same remark applies to Simon's operation. Any position may be employed, and the fistula must of course be as thoroughly exposed as for any other operation.
After-treatment is very unimportant. As a rule, narcosis is not ne cessary. After using neutralizing or refrigerating applications to prevent any possible injurious effect of the caustic upon neighboring organs, the patient e,an get up and go about her usual business. It is unnecessary to use the catheter at all. The believers in cauterization declare tam ponade of the vagina to be useless and harmful. If there is pain after the operations, sponges and cloths wrung out in cold or ice-water may be introduced into the vagina; or lukewarm sitz-baths, with injec tions of belladonna and opium, may be employed.
In this connection we may mention a method first proposed by Naegele V. in 1812, and which consists of union' of the edges of the wound by for ceps, serrefines or even stitches, after cauterization. While the first instruments used were voluminous and heavy, those of Tellinucci, Mon teros, Deneffe and van Wetter are not heavier than those used by Boze man, Simpson, Atlee, Battey, and others. It is of course necessary that the edges of the fistula can be drawn together without any too great ten sion; and granulation along the edges of the cut must be active before hand. Bougn6, who believes that this procedure deserves far more atten tion than it has hitherto received, says: the larg-er the freshened surfaces, the greater the chances-of healing. He found 35 published cases which had been treated in this way, 25 were cured, 4 improved, and 3 died. BouquCs list of 639 operations with the knife ' give a percentage of suc cesses of 72 per cent.; the above 25 cases give a percentage of successes of 74.4 per cent.; and he believes it may compare favorably with the more common mode of operation. I confess that I have been led to form an exactly opposite conclusion; I believe it takes longer time, gives much more pain and trouble, and has results which are not so good.
Altogether I must remark that in spite of the many successful results of the method of cauterization, the ideas of the Belgian authors whom Bouqu6 represents are opposed to those of the German school. Bouqu6 says: For most practitioners the immediate union of the fistula will re commend itself on account of its simplicity and ease of execution, and many other advantages; and there is no reason why we should not first try the value of the various cauterizing agents in any given case. But
these attempts should be methodical, and should be persevered in for a sufficiently long time. We need not have recourse to a bloody operation until we have sufficiently proven the uselessness of caustics. The Ger man authorities on the other hand believe that the cauterization of large fistulre is entirely useless; that severe cauterizations, especially by the actual cautery, often do direct damage, enlarging the fistula and trans forming its walls for a considerable distance into hard, unyielding cica tricial tissue; further, that a succbssful result from cauterization can only be expected under certain well-defined conditions, those conditions being that the fistula is small and has broad, granulating edges, as recent fistulm in the puerperal period, or small fistulm left after other operations. If eauterization is not rapidly successful, it is soon abandoned in Germany, since by persevering in it we only spoil our chances of a future operation. (Hegar, 1. c. p. 351.) That they are not rapid is shown us by the above statistics; while hundreds of fistulze have been entirely cured in a few days by a bloody operation in the hands of skilled, and even unskilled surgeons.
Indeed l'rofessor D. G. Boddaert van Cutsem of Ghent has personally as sured me that he, as well as tint majority of the Belgian surgeons, de cidedly favor operative union, and only exceptionally employ cauterization. Since cauterization by no means always cures these fistulfe, the very earliest authors have sought to devise measures to secure a direct artificial union. Roonhuysen proposed in 1663 freshening of the edges with sub sequent continuous suture. Fatio, a Switzer, is said to have cureti the first case by suture in 1752. It was then forgotten until Naegele in 1812 again recommended it. At once many various stitches were proposed by Naegele, Roux,Wutzer, Schreger, Ehrmann,Blasius,Colombat, Beaumont, Dieffenbach, Esmarch. They did no particular good, partly because the fistulfe were imperfectly exposed, and partly because the freshening of the edges consisted either of a superficial scarification, or the removal of a band a line in width.