Now as to the patient's position. Dieffenbach, Jobert, Baker Brown and others prefer the simple dorsal or lithotomy position. Deep fistula3 can be well exposed in it, amesthetization is easy and rapid. But fis tube seated high up c,annot be well-exposed from the inclination of the pelvis. Simon has, therefore, introduced the dorsal position with the pelvis so elevated that it lies somewhat above the level of the abdomen and chest. The thighs are flexed upon the abdomen, and the legs are extended. Thus the field of operation is free, assistance can be rendered with certainty, the use of several specula and retractors at the same time, is possible, and narcosis is well applied. Nevertheless the patient's posi tion, even when the head is supported by a cushion, is unpleasant and tiresome, and some patients feel sick for days after being in it The lateral position is much more convenient for the patient, and the side corresponding to the fistula should be selected. Less assistants are needed, it is unconstrained, anmsthetization can be easily affected, and the height of the buttocks can be varied for higher or lower fistulle. For those unused to it, the exposure of the fistulEe and the use of instruments will prefient some difficulty in this position. Sims is its chief advocate.
His pupil, N. Bozeman, has, however, selected the knee-elbow position, which Schreger, Wutzer, and Simpson had already employed. Bozeman uses a special speculum (see Fig. 28) consisting of two lateral blades united by a metallic bar, which bears the screw; when dilated to a cer tain extent, the blade for the posterior vaginal wall can be inserted. Simon was convinced, by seeing one of Bozeman's operations, that with his position and speculum the fistula can be admirably exposed, and the result of every cut and every stitch can be seen during the entire opera tion. But he believes that it is very difficult to handle the instruments, since Bozeman used the scissors in fistula which were easily exposable and took off considerable tissue, while Simon for various reasons prefers the knife, and spares the substance of the septum as much as he can. However that may be, the accompanying illustration from Neugebauer (Fig. 29) plainly shows that the knee-elbow position is the le,ast convenient of all for tho patient, is the worst for anwthetization, is the most com plicated in the apparatus it requires, and is the most annoying for the operator, since the legs are here more in the way than in any other posi tion. These are serious objections; and since Bozeman in the competitive operations attained no better result than did Simon with his position, Simon's or Sims's positions are always to be preferred.
After the patient has been placed in one or other of these positions, she must be held in it by the assistants. Since patients often make vigorous
movements while narcotized, I have repeatedly tried.by means of broad padded leather pelvic girdles, to fasten the patient's pelvis to the table, and prevent motion. But the girdle always pressed upon the abdomen between the anterior superior iliac spines, and several unpleasant cases of asphyxia while under chloroform occurred; so that I bad to give up the use of the girdle.
Narcosis is not always necessary. After the patient has been placed in the proper position, we may proceed to expose the fistula. Jobert and Simon drag down the uterus, while Bozeman and Sims do not displace the fistula, but operate in situ. All operators first lift up the posterior vaginal wall with a blade or plate, and then draw asunder the two sides with retractors. (Fig. 31, a, b, c.) If the patient is in Simon's or the lateral position, and the anterior vaginal wall falls down under the fistula, it must be elevated with one of Simon's vaginal retractors, or it may be lifted with a sharp hook. If the upper edge of the fistula is high up near the uterus, it may be made more accessible by drawing down the os with a hook, or by passing a couple of strong silk threads though* it, knotting them, and giving them to an assistant to hold. If the uterus is fixed by einatricial bands, or if a precedent inflammation renders the existence of Adhesions probable, the uterus is not to be dragged down. If the loss of tissue is not great, and the vesico-vaginal wall is movable, displacement Pi— of the uterus is entirely unncessary. It is of especial importance t,o ex actly explore and expose every edge and corner of the fistula; for it has happened to the most practised operators, as to Simon in No. 4 of the competitive operations, not to fully close the fistula, but to forget to freshen and unite the edges of some bidden comer. Various means have been recommended to prevent such errors. Chassaignac has constructed an instrument to be introduced from the vagina (Fig. 30), which contains six hooklets to be projected by a piston, and, the hooks catching the edges of the fistula, to stretch it apart. Similar to this, but not so good, is the instrument that Roser has described (Fig. 32.) Antal (Budapest) uses a rubber ball to evert the edges of the fistula and render them tense. It can be dilated to various sizes, is introduced closed into the fistula, and blown up through a rubber tube fastened with a stop-cock. To cut off the edges of the fistula we must accurately grasp each portion; for this purpose long-hooked forceps, like that of Simon and Matthieu (Fig. 33, a and b) , or that of Simon and Roger (Fig. 34, a and b) , or sin gle or double hooks (Fig. 34, c) are all that is necessary. They are to be preferred to more complicated apparatus.