VESICO-VAGINAL FISTULA; 
♦ 
ITS 
HISTORY AND TREATMENT. 
BY 
D. HAYES 2GNEW, M. D., 
ABBISTANI LBCiURER ON CLINICAL SURGERY, ANT) DEMONSTRATOR OF ANATOMY IN THE UNIVERSITY 
OF PENNSYLVANIA; SURGEON TO THE PENNSYLVANIA HOSPITAL; SURGEON TO 
WILLS OPHTHALMIC HOSPITAL; MEMBER OF THE COLLEGE OP 
PHYSICIANS AND SURGEONS, ETC., BTC. 
PHILADELPH I A: 
Published at the Office of the Medical and Surgical Reporter. 
1 8 6 7. Dr. D. S. Lamb, 
7 PARK PLACE, 
V Street, west of Thirteenth. 
HISTORY AND TREATMENT 
OF 
VESICOVAGINAL FISTULA, 
Mauriceau, in his work, published in 1712) 
lays down the following aphorism; “L’issue in- 
voluntaire de Furine caus6e par une fistule qui 
s’est femme, est ordinairement incurable si elle 
duze plus si trois mois.” No operation does he 
propose, but only looks for a cure, when it does 
occur, as a purely natural or spontaneous result. 
There is much consoling in the thought that, 
An most of the diseases and accidents incident to 
the body, the sufferers are not debarred the so- 
ciety, sympathy, and entertainment of friends. 
Such considerations greatly mitigate and sustain, 
under the severest physical distress. But there 
is one accident liable to occur in the female—and 
that, too, in the exercise of the highest function 
of her nature—which dooms her to isolation and 
'seclusion, renders her presence intolerable to 
friends, and compels her to exist in an atmos- 
phere repugnant in the highest degree to her 
own sense. 
HISTOBY. 
Hoffman, in 1724, describes the accident, and 
refers it to the proper cause: “Quando enim 
librae sub diuturnoribus partus laboribus ad 
infantis capiti, ad os pubis compressae diu manet 
fieri deinde solet ut infiamentur, atque in ab- 
scessum abeant, aliquot denum a partu diebus 
consummandum; unde fluxus, et stillicidium 
urinae per vaginam tertio demum, vel quarto die 
contingit.” It is quite evident, too, the art of 
the Genevan embraced no means of repairing the 
accident. 
Until a very recent period, the unfortunate vic- 
tim of vesico-vaginal fistula was obliged to con- 
front her situation under the conviction that her 
case was absolutely hopeless, and has, in some 
instances, sought refuge from the mental suffer- 
ing by self-destruction. One of the grandest 
triumphs of American surgery—for it is all her 
own—has been to step in and lead such forth 
into the light of day, and restore them to the 
bliss of family and social life. 
Astruc, physician to the King of France in, 
1776, has no notice whatever of the affection in 
his work. 
Smellie, in his publication of 1776, although 
he describes an operation for this form of fistula, 
had evidently never performed one himself or 
even witnessed it performed, as he adds, “I wish 
the operation may not be found impracticable.” 
Antecedent to the discovery of the forceps, 
such accidents must have been of very frequent 
occurrence, although comparatively little is said 
in medical or surgical works on the subject, as 
such, were, by common consent, regarded to be 
beyond the resources of obstetric surgery. 
Denman alludes to ulceration and sloughing 
of the vagina after difficult labor, but suggests 
no remedy. 
Burns, in his work on midwifery, edited in 
1820, by James, describes the lesion, and advises 
a catheter to be worn for some time, under the 
conviction nothing else could be done. 
Hippocrates speaks of a discharge of urine 
through the vagina sometimes following difficult 
labors, with some unimportant remarks in re- 
gard to cleanliness; no hint is anywhere thrown 
out, leading to an inference that such cases ad- 
mitted of cure. Without disturbing the repose 
of ancient medical record, it may not prove unin- 
teresting to interrogate a few comparatively 
modern authorities. 
Conquest, in his Outlines of Midwifery, pub- 
lished in London in 1820, insists on the propri- 
ety of attempting a cure by an operation, but 
does not designate any particular method, nor 
does he intimate a knowledge of any cures hay- 
ing been effected. 
5 6 
James, in his System of Midwifery, of 1813, 
not only takes notice of this form of fistula, but 
advises the employment of an elastic catheter, 
and adds, perhaps it may heal. The same author 
also speaks of the use of caustic when the open- 
ing is small, and freshening the edges when it is 
large, conjoined with the use of the catheter. 
and while the subject of fistula in general is 
cussed, this form is not even mentioned. 
lleister mentions it as incurable. 
Samuel Cooper, in his Surgical Dictionary, 
speaks of dilferent kinds of fistula, but does not 
in any way allude to the one under considera- 
tion. In 1808, in the Ist volume of his Surgery, 
some methods of operation for the cure of such 
fistulas are described, but he evidently doubts 
their practicability. 
Ashwell, quite a prominent practitioner and 
writer in London, in 1828, has no allusion to the 
subject whatever. 
William Campbell, of Edinburgh, in 1833, 
appears to have given unusual attention to the 
subject. The opening is clearly described, and 
its most common location, near the neck of the 
bladder. In his experience, the catheter and 
recumbent position perseveringly employed has, 
wThen pronounced by others utterly hopeless, per- 
manently relieved cases: the phraseology, it will 
he perceived, will not allow the conclusion that 
such were cured. 
Mr. Liston asserts that an operation only makes 
the patient worse, by converting a small into a 
large opening, and adds, “There is little hope in 
a case of any size.” To the same conclusion tend 
the testimony of Mr. Earle and Mr. Lawrence, 
both of whom state a successful operation im- 
practicable. 
Chelius says the prognosis is always very un- 
favorable. 
Miller believes a favorable result by any 
means improbable. 
Gooch, in 1831, alludes to a case having got 
well by a gum-elastic bottle, with a sponge at- 
tached, being pressed into the vagina and kept 
opposite the opening. This solitary case of re- 
ported cure is treated as a very unusual and 
extraordinary event. 
Velpeau asserts of all the eases reported as 
cured, there were few free from doubt. 
Pirrie has not a word upon the subject. The 
subject is not introduced by name into the works 
of Dorset or Gibson. 
Desault, in his Treatise on the Urinary Or- 
gans, confines himself simply to the palliative 
treatment. 
The cases reported as cured by Lallemande, 
Phillips of Rheims, and Vidal, in 1834, Vel- 
peau most positively asserts were not cures. 
Dupuytren only hoped, by cauterization, to 
effect something. 
.Blundell, in his work published in 1834, dis- 
poses of the subject in a most summary manner 
by stating, a slough of the vagina may lay open 
the bladder. 
Mr. Earle, after thirty operations, succeeded 
in curing one case; no wonder he pronounced 
the operation the most difficult or unsatisfactory 
one in surgery. 
Ramsbotham, writing as late as 1841, does not 
treat of the subject. 
Nelaton, as late as 1854, talked of autoplastic 
processes and the cautery. These are hut a few 
of the names which might be introduced. 
Davis, in 1841, describes the manner in which 
such an opening is made, with the additional 
statement, “it is almost a universal fact, that 
they never do heal.” 
In 1839, Dr. Hayward, of Boston, succeeded 
in curing a case by freshening the edges, and 
approximating them with a thread suture. In 
1840, two additional cases were treated, with a 
similar result, and although twenty operations 
were performed in attaining these three cures, 
yet, in a prospective point of view, their value 
cannot be overestimated. 
Dewees, in his work on midwifery, makes no 
mention of it. 
Churchill, in 1844, speaks of all such open- 
ings as being perfectly hopeless. 
Simpson, in his work published in 1865 and ’66, 
when describing the result of long-continued 
pressure by the foetal head against the vesico- 
vaginal septum, speaks of the slough separating 
and leaving an incurable fistula. 
In 1847, Dr. Pancoast, Professor of Anatomy 
in the Jefferson Medical College, reported two 
cases, cured by a tongue, and groved incision, 
the wound being adjusted by his silk-thread plas- 
tic suture. In the same year, Dr. Mettauer, of 
Virginia, gave to the profession the history of a 
case successfully treated by vivifying the edges, 
and uniting the same with leaden threads. Such 
occasional cures doubtless tended to inspire a 
hope of the ultimate curability of this disgust- 
Revbard, in 1856, published a paper on the 
palliative treatment of this form of fistula, be- 
lieving the affection incapable of cure. 
Let us now interrogate a few of the eminent 
surgeons abroad and at home, and ascertain with 
what voice they testify on this subject. 
Ambrose Fare’s great work bears date 1582, 7 
granulation. A very singular case occurred in 
the East London Lying-in Institute, reported in 
the January number of the French Lancet for 
1838, of a woman who, in consequence of a 
chronic retention of urine, had acquired sufficient 
dexterity to catheterize herself. From some cause, 
being without the usual instrument, she extem- 
porized the catheter with the stem of a clay to- 
bacco pipe. On one occasion it was broken, a 
portion remaining in the bladder, and which, in 
time, not only passed into the vagina, but finally 
into the uterus, from which it was extracted. 
ing disease; but it was not, however, until about 
1852, when Dr. I. Marion Sims, then of Mont- 
gomery, Alabama, gave to the profession the fruit 
of his labor and observation, by which this oper- 
ation was removed from the category of proba- 
bilities, and crowned with a success which com- 
pared favorably with any of the established op- 
erations in surgery. For this he has placed the 
civilized world under a debt of gratitude. 
Among the causes inducing this lesion maj be 
enumerated: 
Causes. 
Third. Carcinomatous and other forms of ul- 
ceration.—Almost every work treating of the dis- 
eases of the female genitalia, furnish examples 
of malignant growths, involving the uterus, and 
gradually invading, by destructive ulceration, the 
vagina and rectum, until they become converted 
into a common cavity. Phsegedenic chancre may 
produce a similar result. Two cases of this na- 
ture came under my own observation in the 
wards of the Philadelphia Hospital, rendering 
the poor, unfortunate outcasts, objects of the pro- 
foundest commiseration. 
First. The. Pessary.—When this instrument is 
out of proportion, and fitting badly, or corroded, 
or encrusted with saline matters, it may induce 
ulceration of the vagino-vesical septum. Profs. 
Beirards and Liseranc each relate a case of the 
bladder and rectum both being opened, by a pes- 
sary; one of the patients died of peritonitis 
[Jour. Nouv. Held. de Med., t. 1, page 263.) A 
case of Dupuytren, in the Hotel Dieu, is recorded 
in the Diet, des Sciences Med., t. vii., p. 47, of a 
young country woman, whose rectum, vagina, 
and bladder freely communicated in consequence 
of wearing a badly adapted instrument; both of 
these were produced by stem pessaries. A case 
of this kind is also cited by Desqrmeaux, a 
French physician. In most of them, doubtless, 
the ulceration was brought about by saline de- 
posit on the exterior of the instrument, the angu- 
larities of which matter would very soon produce 
destruction of tissue. Other cases might be in- 
troduced in illustration of the same point. In 
earlier times it is probable such accidents were 
common, when a great variety of extraordinary 
materials were employed, not only for mechani- 
cal support, hut as means of introducing remedial 
agents into the organs of generation; at present, 
improvements in the form and substance of me- 
chanical supports will not be likely to furnish us 
a case illustrative of the condition under consid- 
eration. 
Fourth. Wounds of the Vagina-vesteal wall in 
the legitimate and illegitimate use of instruments. 
Enderthe first maybe enumerated the careless 
employment of the obstetrical vectis or lever, 
bruising or lacerating the tissues by long-con- 
tinued efforts to modify a foetal position, or the 
slipping of a perforator in cases of craniotomy. 
The forceps has come in for a large share of ani- 
madversion, but they have little agency in pro- 
ducing such an accident; their earlier, and more 
frequent employment, particularly in educated 
hands, would have prevented many which have 
occurred. Under the second head may be ad- 
duced the violence committed by those ignorant 
scoundrels who flourish in every great city in 
their criminal attempts to procure abortion. 
Fifth. Pressure of the foetal head.—This, 
above all others, is the most common cause of 
vesico-vaginal fistula. It is probably not going 
too far to say 90 per cent, of such occurrences are 
due to the prolonged pressure of the foetal head. 
The testimony of almost all authors harmonizes 
in this particular. It was so regarded by Mau- 
riceau; yet singular enough, he was greatly 
opposed to the use of instruments, whereby a 
tedious labor might be brought to a close. This 
prejudice it is said was due to the failure of 
Chamberlayne to deliver a woman in Paris after 
a public boast. Not being aware of the existence 
of a deformed pelvis he had torn the vagina and 
uterus in several places in his ineffectual efforts to 
extract the child with the forceps of which he 
Second. Foreign substances in the bladder.— 
Under this head may be mentioned vesical-cal- 
culi, examples of which are by no means rare. 
Fa'bricius Hildanus relates an instance of this 
nature. Sir Benjamin Brodie another, in which 
the stone made its way into the vagina by ulcer- 
ation ; and a third is given by Sir Astley Cooper. 
Dr. Dunlap, of Norristown, in this State, exhib- 
ited to me a calculus as large as a hen’s egg, 
which he extracted from th’e vagina of a female, 
who had long suffered from the disease, and which 
had perforated the vesico-vaginal septum, A most 
interesting fact connected with this case, was the 
perfect restoration of the parts subsequently by 8 
was the inventor. Denman attributed the lesion 
to long-continued compression of the soft parts. 
Davis expressly declares that it does not result 
from the use of instruments, but delayed labor. 
Dr. Simpson stops to fortify a similar opinion by 
stating “these abnormal openings, if produced 
by instruments, should appear at once, while it is 
known they only occur several days after their 
use.” Smellie, Colombat, and Churchill, all 
describe the fistula to protracted pressure during 
labor, and an opinion of similar import is enter- 
tained by Professors Hodge and Meigs. Doctors 
Sims and Boseman, whose opportunities for ac- 
quiring accurate information on this subject have 
been extensive, testify to the same fact, and ex- 
cept in a single case my own observation accords 
with these gentlemen. 
Third. At the has-fond; the opening involving: 
the inferior fundus of the bladder. 
Fourth. Vesico-utero-vaginal; where the open- 
ing communicates with the bladder, vagina, and 
cervix, or body of the uterus. 
Fifth, Fortunately quite rare where the entire 
vesico-vaginal wall is destroyed, and it may be the 
urethro-vaginal also. 
The relative frequency of these varieties, as 
they have come under my own notice, is as fol- 
lows: First, at the vesical triangle; second, at 
the bas-fond; third, in the urethro-vaginal sep- 
tum; fourth, the utero-vesical; and last, the one 
attended with a destruction which includes the 
first four classes. This, I think, accords with the 
experience of most observers. Dr. Boseman, I 
believe, states, according to his observation, the 
vesico-utero-vaginal is the most common. I have 
never but in a single instance seen an example 
of this kind. 
If the foregoing statements be correct, what is 
the modus—the manner in which the lesion 
takes place? The head in passing through the 
pelvic cavity presses the anterior wall of the 
vagina toward and against the posterior face of 
the pubic bones. If in consequence of failure 
of the uterine expulsive efforts, or a dispropor- 
tion between the pelvis and the head, or a want 
of accord between the diameters of the two, the 
head long remains thus engaged, the vitality of 
the soft parts so compressed and bruised will be 
destroyed, either by the formation of a slough or 
by inflammation and ulceration. It is asserted by 
some that a fold of the vagina is caught and 
pressed against the pelvic bones until its death is 
insured; but it does not seem probable any such 
folds would exist when the canal is so greatly 
distended. The period when the opening occurs 
varies in different cases; in some as early as the 
fourth or fifth day, and in others the event may 
be prolonged—as in one which came under my 
own observation (case 4)—until the twenty-first 
day after confinement. When the parts are so 
injured as to induce ulcerative inflammation, a 
longer time is required to penetrate the vagino- 
vesical wall than where they are killed outright, 
and drop out as a slough. 
These fistules may be transverse, oblique, or 
longitudinal; determined, it may be presumed, in 
a great degree by the particular part of the foetal 
head impinging, or the exact manner in which 
the vaginal parieties may be caught. The trans- 
verse variety has most frequently come under my 
own notice. 
Direction. 
The configuration or form of such openings 
may be oval, round, linear, angular, and eliptical; 
the last most common. A careful study of the 
muscular component of the vagina will explain 
this. Its fasciculi are disposed longitudinally and 
circular; the former the most numerous and dis- 
tinct; and of these, those on the lateral parieties 
are so associated with the levatores ani that they 
contract less when divided than those occupying 
an intermediate position, and hence the ovidal or 
eliptical form of most fistula. The dimensions of 
the opening also vary from an aperture so small 
as barely to admit the introduction of an ordinary 
probe, to one through, which might be passed a 
good-sized egg. So far as the patient’s comfort is 
concerned, the small opening is quite as bad as 
the large one; in either case the urine will be 
constantly passing the vagina. 
Form, Size, and Condition. 
Classification. 
These fistula! may occur at any point from the 
middle of the urethra to the termination above 
of the anterior wall of the vagina, but practi- 
cally the classification of Sims or that of Dr. 
Boseman, the two differing very little, answers 
every purpose. 
The condition of the borders of the fistula—like 
its size and form—differ much. Sometimes they 
are, especially the upper one, thin, inverted, quite 
pale and smooth; in other instances thick, soft, 
spongy and vascular; and again of almost carti- 
lagenous consistence, inextensible and sparsely 
supplied with blood vessels. The mucous mem- 
brane of the bladder often projects through the 
opening, forming a red, erectile-looking tumor, 
First. Urethro-vaginal; the opening being be- 
tween the urethra and vagina. 
Second. In the trigone vesicate; the opening 
being situated at the cervix of the bladder. 9 
Dr. Gross gives a remarkable ease—in his work 
on the urinary organs—of the entire bladder es- 
caping through such a fistulous orifice into the 
vagina. The condition of the edges as to thick- 
ness, density, and vascularity, is a matter of great 
practical moment in the cure of disease. 
but the one on the side answers every end, and Is 
more in consonance with her feelings of modesty 
and propriety. With the aid of the speculum no 
doubt need exist; without it no examination is 
complete. I have been called to cases said to be 
vagino-vesical fistula;, but which on occular in- 
spection proved to be incontinence from defect in 
the muscular endowments of the vesical cervix 
allowing the urine to find its way back into the 
vagina after escaping passively from the urethra. 
Diagnosis. 
It is not usually a difficult matter to ascertain 
the existence of this affection. If inquiry be 
made as to the state of the bladder immediately 
succeeding the labor, the patient or her attendant 
will state that for two or three days there was an 
inability to evacuate its contents, with some pain 
or uneasiness, requiring perhaps the use of the 
catheter; after this a stillicidium of urine through 
the urethra; or this last condition may have been 
present from the first. At some period, however, 
varying from five to twenty days from the labour, 
the incontinence is complete, the urine escaping 
entirely from the vagina. The patient sometimes 
describes this state as being preceded by a sense 
of something giving away. The labile, inner 
surface of the thighs, perinmum, and the buttocks 
being constantly bathed in the secretion become 
red, inflamed and covered with a crop of pustules, 
which sometimes form ulcers of considerable 
depth. The genitalia and surface of the vagina 
frequently become encrusted with a saline deposi- 
tion (urates)', and a strong urinous odor is emitted 
from her person and clothing. These may be re- 
garded as the rational signs of the disease. Al- 
though they do not in themselves establish or 
justify the conclusion that a fistula exists, they 
form a strong presumptive proof of the fact. 
Only upon a physical exploration of the parts 
can we ascertain with certainty the accident. 
With this view let the patient be placed in bed, 
on her side, with the limbs well drawn up, and 
the hips on the edge of the same, before the win- 
dow, with a good light. Introduce the duck bill 
speculum into the vagina, and draw the perineum 
well back toward the sacrum until the entrance of 
the air distends the vaginal cavity. If the lesion 
exists it will most likely be at once detected, un- 
less it should be so small as to escape observation. 
That it be not thus overlooked, a pocket-case 
probe should be introduced into any suspicious 
pockets or depressions, and moved carefully about 
until their nature and extent are determined. 
Where the aperture is so sfhall as not to be readily 
found, it has been advised to inject through the 
urethra into the bladder some colored liquid, dis- 
tending its walls, and carefully noting if any can 
be discovered passing into the vagina. Some 
prefer having the patient on her elbows and knees, 
others on the back in making the examination, 
Complications. 
tinder this head may be enumerated stricture 
of the vagina, recto-vaginal fistula, obliteration of 
the urethra, and malignant disease of the uterus 
or rectum. 
Treatment. 
The treatment of vesico-vaginal fistula includes 
the preparation of the patient, the operation, and 
subsequent management. 
Preparation. No woman can be in the best 
condition to undergo an operation for her cure, 
until after the lapse of at least eight or ten weeks 
from her confinement. I have operated as early 
as the fifth week, and with complete success, but, 
nevertheless, do not think so early a date should 
be fixed as a rule in practice. It requires at least 
two months before the system has completely 
recovered from the perturbating influences of the 
parturient act, and her secretions duly established. 
The moral and physical suffering induced by the 
existence of the fistula tend to put the woman 
out of health. If we find her pale, feeble, with 
loss of appetite, and harassed by a train of ner- 
vous symptoms, it may require several months of 
preparation; during which time a carefully regu- 
lated nutritious diet will be demanded, fresh air, 
attention to the intestinal and other secretions, 
conjoined with the use of tonics, such as the pre- 
parations of iron or infusions of the bitter vegeta- 
ble class. It is certain, no one familiar with the 
treatment of this form of fistula, will be rash 
enough to subject his patient to the inconveni- 
ence of such an operation, before attending to 
these preliminary measures. 
There is no operation in surgery which de- 
pends so much for its success on healthy consti- 
tutional conditions as the one under consideration, 
nor must we overlook the local treatment. All 
inflammation must have subsided, the connective 
tissue component of the parts must be well ma- 
tured, and sufficiently dense to withstand the 
traction of the sutures, the edges of the opening 
should have considerable thickness and a good 
supply of bloodvessels. All this will be favored 
by due attention to cleanliness, injecting tepid 
or cold water, with the addition of a little palm 10 
soap, or a decoction of*oak bark into the vagina 
every day. Should the edges continue pale and 
thin, they must he subjected to a special treat- 
ment, with a view to make them more volumi- 
nous. This is best accomplished by making a 
few shallow' incisions parallel to their long diam- 
eters, and rubbing into each a little nitrate of sil- 
ver. The caustic should be used about every third 
day. In the course of a few weeks, the requisite 
change will have taken place. The saline mat- 
ters, which so commonly encrust the margins of 
the fistula and other parts of the genitalia, pro- 
ducing much uneasiness, may be counteracted by 
the internal administration of nitro-muriatic acid, 
as a good tonic. The excoriation due to the uri- 
nous stillicidium, is best relieved either by an 
ointment of the precipitated carbonate of zinc, or 
by a mixture of the black wash and glycerine. 
Attention must also be given to her catamenial pe- 
riod, three or four days after its accomplishment 
being the most fitting time for the operation. If 
done during the latter half of the month, the 
irritation of the parts, together with the prolonged 
etherization, are prone to produce premature men- 
struation. The day previous to the operation, a 
gentle cathartic should be administered, after the 
action of which, one grain and a half of opium, 
in pill, should be given to quiet all intestinal irri- 
tation. 
is effected by either graduated bougies or sponge 
tents. I have practised each method, and am 
confident the last is the most certain and least 
painful. 
This is divided into the palliative and radical. 
If, in consequence of extensive destruction of tis- 
sue, or the presence of malignant disease, an oper- 
ation is contra-indicated, we may resort to some 
means to palliate the distressing situation of the 
patient. These chiefly point to the collection of 
the urine so as to defend her person against ex- 
coriation, and offensive emenations. There is 
no task so difficult, and unsatisfactory as this. 
Many recepticles, and obturators, and other con- 
trivances have been devised; such as a bag of 
gum elastic worn partly within, and partly with- 
out the vagina, styled by Colo meat the “ iron d' 
enfer” of Feburier; or a gum bottle with a 
sponge on its anterior face, introduced into the 
canal; or tampons of fine linen, or soft sponge so 
adjusted as to occlude the opening. Of all these 
devices the metallic shield of Prof. Meigs answers 
the best purpose, yet it must be confessed, all are 
but sorry contrivances, and will be soon aban- 
doned. A rigid attention to cleanliness, by fre- 
quent ablutions, and the use of an inter-femoral 
napkin or diaper, will perhaps give the most sat- 
isfaction. Fabricius Hibdanus, as related by 
Colombat, furnishes an instance of a case which 
was cured, after eight months, by vaginal injec- 
tions, consisting of barley-water, and the mucil- 
age of quince seeds; the following passage, in 
his quaint style, narrates the event, “Ilia autem 
continue usa medicamentis (ut dixi) conglutinan- 
tibus, et per intervalla etiam purgantibus, intra 
menses octo, non sine admiratione omnium eorum 
quibus res cognita plane curata fuit, adeo nunc 
Dei optimi maxima gratia ne guttula quidem 
urinse involuntarise affluat, sed a vesiefi colligatur, 
retineatur et excernatur non aliter ac si antea 
nunquam male affecta fuisset.” 
Treatment. 
Should the fistule be the result of carcinoma- 
tous ulceration, any operation will be futile, as 
everything tends to a fatal termination. When 
it co-exists with a recto-vaginal opening, the 
escape of purulent matter into the vagina will be 
unfavorable to healing; yet, if the peristaltic 
movements can be sufficiently controlled by 
opium or some of its preparations, there is no 
reason why the vagino-vesical fistula should not 
be closed, before undertaking that, between the 
vagina and intestine. 
The complication most commonly met with is 
stricture of the vagina, and, as the opening is 
usually above it, nothing can be done for its re- 
lief until the dimensions of the canal are properly 
restored. Three methods may be employed for 
this purpose. First. Incisions of the stricture 
through the mucous and submucous tissues, fol- 
lowed by dilatation. Second. A submucous di- 
vision of the contracted bands, and subsequent 
dilatation; and third, dilatation alone. Choose 
which we may, there is a strong tendency in the 
stricture to return. If incision be selected, the 
reformed parts have the same vicious tendency to 
contract, and although this is true of dilatation, 
it is less so than either of the others, and should 
be selected as best adapted for our purpose. It 
Radical treatment.—lt was only about the be- 
ginning of the present century any attempts for 
the cure of this distressing malady were thought 
of, and only within the last fifteen years that any 
encouraging results have been attained. At pre- 
sent we approach the management of a case of 
vesico-vaginal fistula with the same degree of con- 
fidence as that of stone, or hydrocele. The his- 
tory of the various methods practised for its cure— 
although most of them have passed into history— 
will be presented, as they furnish the most re- 
markable example of untiring, undismayed perse- 
verance in the face of the most unpromising re- 
sults, and of a fertility of professional resource to 11 
be found in no other department of medicine. 
These methods may he arranged under the follow- 
ing heads: 
ATo., 1824. Colombat speaks favorably of this 
plan, provided the edges be first cauterized. It is 
probable any such cases reported as cured, recov- 
ered, not from the but from the perse- 
vering use of the catheter. The could 
exert no influence whatever in pressing together 
the sides of the fistula, but just the reverse, by 
unfolding the rugae or plications of the canal by 
distension. Let any one notice how a fistule gaps 
when the speculum is introduced, and the canal 
distended with air, and then, in withdrawing, how 
the sides collapse, and the demonstration will be 
clear. 
Ist. By the catheter. 
2d. By the catheter, conjoined with the lam- 
poon. 
3d. By cauterization 
4th. By the uniting apparatus. 
sth. By galvanism. 
6th. By transplantation. 
7th. By the suture. 
First. By the Catheter.—-It is important to as- 
certain, at the earliest moment, the existence of a 
fistula, as a little well-timed attention may pro- 
cure a cure without an operation. There are 
cases in which there exists a strong tendency to 
to spontaneous cure, and advantage should be 
taken of this, and a catheter placed at once in the 
bladder, and worn for three or four weeks, the 
patient being confined to the recumbent position, 
and due attention to cleanliness observed. A 
number of such cases terminating successfully 
have been placed on record, by Fabricxus Hilda- 
nus, Blundell, Ryan, Sedillot, Campbell, of 
Edinburgh, Nelaton, and others; and I doubt 
not similar ones may be recalled by many prac- 
titioners extensively engaged in obstetric medi- 
cine. 
Third. Cauterization.-—Of this, Colombat said, 
“It is the best method we can oppose to vesico- 
vaginal fistula.” The agents employed were 
either the nitrate of silver, or the actual cautery. 
The former was conveyed to the fistula by fixing 
a stick in a porte-crayon, and conducting it to 
the opening through a fenestrated speculum in- 
troduced into the vagina, and repeated every four 
or five days, followed by emollient injections to 
relieve pain. After the edges begin to assume a 
swollen, or raw appearance, a catheter, according 
to Colombat, should be placed in the bladder. A 
few successful cases by this mode of treatment 
have been reported by Dupuytren, Delpech. 
McDowell, of Kentucky, Liston, Colles, and 
Ferrall, When the cautery was used, a bean- 
shaped stillet, heated to a white heat, was applied 
to the opening, a fenestrum shielding the vagina 
being first introduced—and the parts lightly 
touched so as to induce a superficial slough. The 
advocates for caustics have been Chelius, Yacca, 
Berlinghien, Czeekiersky, Ehrman, Monteggia, 
Guthrie, and Colombat ; for the hot iron, Dupuy- 
tren, Delpech, Bellini, McDowell, Liston, 
Blasius, and Dieffenbach. The caustic treat- 
ment was somewhat modified by Lallemand, 
principally, who conjoined with it a uniting ap- 
paratus. This surgeon was so particular as to 
take an accurate cast of the fistule with a very 
plastic wax. After the edges were made suffi- 
ciently alive by the caustic, he adjusted his in- 
strument, one portion of which acted as catheter, 
and through its openings hooks were made to 
protrude, penetrating the posterior lip of the fis- 
tula on its vesical surface. A roll of lint, or 
charpie, was next placed against the under surface 
of the urethra, and pressed upward toward the 
vagina by a moveable plate connected to the an- 
terior extremity of the catheter, the object being 
to press the lower lip of the fistula toward the 
other or upper lip impaled by the hooks. Dupu- 
tren attempted the same thing by a peculiarly 
constructed catheter. Langenbeck very properly 
Second. Catheter conjoined with the Tampon. 
This is usually described as the method of De- 
sault, although it more properly belongs to 
Boyer—the name of the former having doubtless 
become connected with it in consequence of the 
truss-like apparatus which he devised to sustain 
and retain the catheter. 
A large-sized elastic catheter is introduced into 
the bladder, and its end slipped through an open- 
ing in a curved rod, one end of which is to be 
opposite the urinary meatus, and the other se- 
cured to an oval plate which rests on the pubes, 
and is in turn securely attached to a truss-spring 
surrrounding the pelvis. This controls the cathe- 
ter, by which means the urine is removed as 
rapidly as deposited. The margins of the fistula 
were next pressed toward each other by a round 
tampon, or plug, made of fine linen filled with 
lint, well oiled, and pressed into the vagina. It 
does not appear, of the many cases thus treated 
by Boyer, more than a single one recovered. 
With a very slight modification of the vaginal 
plug, others—as Baines, Guthrie, Young, and 
Barnes—have reported cures, the treatment con- 
tinuing from six to twelve months. Those, cu- 
rious to peruse these cases, will find most of them 
in the Med. Chir. Trans., Vol vi., page 582; and 
the Edinburgh Med. and Surg. Journal, April 12 
pronounces such devices as complicated, and de- 
void of practical value. 
was kept constantly in the bladder during the 
treatment. In one case the growth of hair, the 
follicles of which were in the flap, induced a vagi- 
nitis, and also interfered with the execution of 
the conjugal act.' In one case the material to 
form this fleshly obturator was taken from the 
buttock and thigh, and proved altogether success- 
ful in effecting a permanent cure. The results of 
four cases reported, furnish us with one cure, two 
failures, and one death. Where a large part of 
the vaginal-vesical septum has been destroyed, 
the operation of Jobert might answer a valuable 
purpose. 
Fourth. The Uniting Method.—Laugier, in 
order to bring the edges together, invented a pair 
of claw-forceps, the blades of which could be in- 
troduced separately, and after being implanted 
on opposite sides of the fistule, secured together, 
by which the coaptation was effected. Quite re- 
cently, an instrument, acting on the same princi- 
ple, has been invented by Dr. Betancourt, while 
pursuing his studies in the University of Pennsyl- 
vania. 
Fig. 1. 
Seventh. By Suture. The introduction of the 
suture marks an important epoch in the history 
of vaginal fistulas. It was a step in the right di- 
rection. The credit of its introduction is due to 
Roonhtjysen, a distinguished obstetrician at Ams- 
terdam, who proposed its use in 1663. It was 
violently opposed long after by the celebrated 
Petit, who asserted that incising and introducing 
a thread in parts so situated was a task almost 
incapable of execution. 
The operation of Roonhuysen consisted in fresh- 
ening the edges by means of a knife, scissors, or 
cutting forceps, operating through a speculum, 
then pushing across the opening needles, formed 
from the quill of the swan, and binding the parts 
together by winding about these novel pins, 
thread as we apply the twisted suture. Lews- 
inski, long after, in 1802 proposed the suture. It 
formed the subject of a thesis before the Faculty 
of Medicine in Paris. His instrument for placing 
the ligature was a catheter, carrying a needle 
which had a spring attached, and bearing a 
thread. This instrument was passed into the 
bladder, the spring pushed forward, making the 
needle to pierce the posterior wall, afterward the 
anterior wall, and securing by a serre-noeud. 
Mg. 1 is two light metallic plates connected by a hinge ; their 
margins are scalloped, and support sharp hooks, designed to 
sieze the margins of the fistula. In one plate are two eyes, and 
in the other, two moveable posts with shoulders, which are 
intended to pass through the eyes and hold the plates together. 
These processes, unlike the others, act on the 
vaginal surface of the opening. As to their value, 
it may bo said of all of them, what Langenbeck 
pronounced of Lallemand’s mode, “ they are theo- 
retical, and devoid of practical value.” 
Lallemand, as far as I can ascertain, never re 
ported more than a single case of cure, and even 
this Velpeau declares proved a failure. Laguier 
confesses he had not succeeded in a single instance 
with his uniting forceps. 
Yolter recommended after pairing the edges 
to coaptate by the interrupted suture. To exe- 
cute this he used curved needles, threaded with 
waxed silk, and passed them at short intervals 
through the margins of the fistulas, securing each 
by tying in a knot. 
Fifth. Galvanism.—The attempt to cure this 
malady by galvanism, is due to Mr. Marshall, of 
the University College, London. The impression 
was to be made by bringing the poles of a battery 
in contact with the sides of the opening, and was 
only another phase of the cautery. It only serves 
to demonstrate the straits into which men are 
thrown when they resort to such chimerical expe- 
dients. 
Xagele’s method consisted in removing the 
circumference of the opening with a knife or 
scissors, the edge of which was guarded by a 
shield, moveable at pleasure; then introducing 
the thread sutures by a peculiar needle, one end 
of which was supported on a ring, through 
which the finger could be slipped, and near to 
the other extremity or the point was an eye for 
the thread. The point was guarded by the finger 
while being carried to the fistulas, and after the 
sutures were passed the parts were drawn to- 
Sixth. Transplantation.—A very ingenious 
operation was devised and executed by Jobert; it 
was by transplantation of tissue. The circumfer- 
ence of the fistula being drawn down, was fresh- 
ened, a flap was raised from the inner surface of 
the labium, and being turned into the opening, 
was secured by a number of stitches; a catheter gether, by twisting their ends together and allow- 
ing them to hang out of the vagina. Not the 
least important part of his plan was the use of 
the silver catheter; but singular enough its utility 
was destroyed in a great measure by the attach- 
ment of a stop-cock, only allowing the urine to 
flow at particular times. The same authority 
proposed the use of gilt or silver pins, and around 
them silk threads. He employed likewise the 
glovers suture: and for stitching a watch-spring, 
with a needle point, and concealed in a la forest 
catheter. 
retained by twisting the wires. To keep the 
bladder empty an elastic catheter was worn, and 
the patient requested to lie on the b) east. It is 
worthy of notice here that this surgeon, in execut- 
ing his operation placed, his patient on her elbows 
and knees. 
Kilian separated the walls of the vagina with 
blunt hooks; used a silver catheter, curved, simi- 
lar to the male instrument, to bring the fistula 
forward for incising; and with curved needles, 
directed by a Wutzer needle-holder, passed the 
requisite number of threads, which were secured 
by Desault’s knot tightener. 
Flamant manifested most concern about par- 
ing the edges of the fistulas, to accomplish which 
he advised the use of a knife guarded at the 
point to protect the adjoining parts. The atten- 
tion of Le Roy was most directed to the same 
subject; and hence we find him proposing differ- 
ent forms of cutting instruments, and also a 
fenestrated speculum, with hooks to unite the 
sides, as a substitute for the suture. 
Blasius advised a grooved suture. The mar- 
gins of the fistula were fashioned with a sharp- 
pointed knife, as follows: Taking hold of one side 
with a hook or forceps, It was split longitudinally, 
or parallel with the long axis of the opening; 
then seizing the other and everting it, the knife 
was applied to its surfaces in such a manner as 
to give it a cuneiform or wedge-shaped form; nee- 
dles armed with thread sutures were next passed, 
drawing the wedge-shaped side into the gutter or 
slit of the opposite, constituting a tongue and 
groove (as he calls it) adjustment. He claims for 
this a more extended apposition or contact of raw 
surfaces. 
freshened the edges with a pair of 
curved scissors; deposited wax threads by means 
of curved needles, supported on a needle-holder, 
and made them secure by introducing the ends 
through a rosary of small wooden balls or beads, 
and making them fast by tying over a little cross- 
piece. The same surgeon used the glovers suture. 
Lewzisky’s operation consisted in inserting 
the stitches by means of a canula, traversed by a 
watch-spring, supporting a needle bearing a 
thread. This instrument was carried into the 
bladder, and the needle made to project from the 
canula, puncturing the septum from the vesico 
toward the vaginal side. By repeating this pro- 
cess above and below the opening, the ends of the 
sutures were all brought into the vagina, and se- 
cured on that side. This operation is similar in 
■most respects to that of Nrgle, and includes the 
entire thickness of the vesico-vaginal wall. 
Luke employed a bivalve speculum to expose 
the parts, angular knives to incise the borders of 
the fistula, hooks to draw it down, and curved 
needles to deposit the sutures. 
Malagodi used a leather thimble, which he 
placed on the left index finger, and hooking it 
under the margins of the openings pared the 
edges when thus stretched, the approximation 
being made by silk threads introduced by curved 
needles, manipulated in the grasp of a needle- 
holder. To prevent urinary infiltration a ca- 
theter was worn in the bladder, and the vagina 
stuffed with lint or chapie. 
Colombat furnishes us with an operation much 
more remarkable for its ingenuity than utility. 
The chief novelty of his method consists in using 
a spiral needle, not unlike a corkscrew, (Fig. 2.) 
Ehrman recommended scarifying or cauteriz- 
ing the edges, and then bringing them together 
with sutures, passed by curved needles, managed 
with a porte-aiguille. When he used cauteriza- 
tion a tube was inserted into the vagina, and 
through it a brush, dipped in a mineral acid, was 
carried up to the fistulous opening. The specu- 
lum he employed was a tri-valve, and his sutures 
were inserted by curved needles. 
Fig. 2. 
Colombat Needle. 
having a steel-point, with an eye for the thread. 
At the other extremity, where it combines with 
the handle, there is a second eye, through which 
the ends of the thread are passed, after being 
wound about the spiral of the instrument. After 
vivifying the edges with a pair of cutting forceps, 
the needle is made, by a rotatory movement, to 
pierce one side of the fistula; then the other, 
Gosset, surgeon at one time to Newgate, Lon- 
don, operated successfully in 1884 on a case by 
the following method: The edges were carefully 
pared; metallic threads, well gilded, were intro- 
duced by curved needles, passed with a needle- 
holder, and the sides brought together and so 14 
and so on, just as one would bore a gimlet, until 
its entire length was traversed, when by reversed 
turns it was removed, leaving the thread in its 
track, as represented in Figs. 3 and 4. This is a 
Dieffenbach, to expose the fistula, used a hi 
valve speculum; seized the margins with a hook 
or long forceps while they were being pared, and 
united them with the interrupted suture. The 
position which he preferred having the patient 
for the operation, was on the back, and the cathe- 
ter was used continuously to drain the bladder. 
In his hands, the results were most discouraging. 
On one woman he operated eighteen times, and 
then failed to effect a cure. So great was his 
interest in the subject, that he had gathered 
wards full of women afflicted with this malady, 
from all parts of the country, but, as he states 
himself, making very few cures. 
Fig. 8. 
Fig. 4. 
Glover’s suture. The ends of his threads were 
twisted together and secured with sealing-wax. 
Dieffenbach very facetiously remarks, this in- 
strument only needs a clockwork attachment to 
go right. 
Beaumont, after paring the edges, introduced 
double threads; through the loops on one side 
was inserted a cylinder of some round substance 
parallel with the border of the opening, and 
along the other side a second, over which the free 
ends of the sutures were tied, forming a quilled 
suture. 
Deybers employed a wooden catheter, intro- 
duced through the urethra, to control the edges 
of the opening, while being subjected to the 
knife. The stitching he effected by means of a 
curved tube enclosing an eyed stilet for the 
thread, and which was controlled by a spring 
protruding or withdrawing the point at pleasure. 
The sutures he used were either silk or lead-wire. 
Thus far the fistula under consideration has 
proved more than a match for the skill of the 
ablest of the old world, and now we turn to 
American surgery to have our hopes revived and 
faith strengthened. 
In 1839, Dr. George Hayward, of Boston, re- 
ported a case, (see p. 7,) which he had succeeded 
in curing. His patient was a lady, aged 34 years, 
in excellent health, and who had been delivered 
15 years previous with instruments after, being in 
labour three days, during which time no urine 
had been drawn from the bladder. A slough was 
the consequence, opening a communication be- 
tween the vagina and bladder. Attempts had 
been made with the catheter, and also by cauteri- 
zation to close this fistula, but without success. 
Dr. Hayward operated on the 10th of May. The 
patient was placed on the edge of the table, upon 
her back, very much as in the position for lithoto- 
my ; the parts well dilated, (he does not state how); 
a large bougie passed into the bladder, and carried 
back to the fistula, by which he was able to bring 
it into view. Thus fixed, an incision was made 
round the opening with a scalpel, and after the 
bleeding ceased, the membrane of the vagina was 
dissected away from the bladder to the extent of 
three lines. Three silk threads were next intro- 
duced by curved needles through its sides, drawn 
together and knotted firmly down; a short silver 
catheter, prepared for the purpose, was placed in 
the bladder, and the patient put to bed. In five 
days she was examined, the stitches cut away, 
and the parts found to be solidly united. In 1851, 
Dr. Hayward published an account of eight 
additional cases, making in all nine cases, three 
Roux fixed the edges with a long pair of for- 
ceps while they were being incised; passed 
across them silver pins, and drew the wound to- 
gether by winding about them threads similar to 
our twisted suture. 
Wuther incised the fistula with either curved 
scissors or a sickle-shaped knife, fixing it first 
with a hook, and used sometimes long-stemmed 
needles, sometimes short curved ones passed with 
a needle-holder like that of Roux’s; and at other 
times insert-pins, surrounded with threads to 
bind the edges together. His patients during the 
operation kneeled, or were kept on their hands 
and knees, and the vagina exposed by introduc- 
ing a hook speculum—really an instrument simi- 
lar to the Sims’ speculum. In order to defend 
the wound against the action of the urine, and 
keep the bladder empty, the organ was opened 
above the pubes, a catheter introduced, and the 
patient kept upon her belly, buckled to a leather 
cushion in which a hole was cut out. On the 
sixth day, his ligatures were removed, injections 
of cold water having been thrown into the 
bladder, through the catheter, and the vagina, 
through an oesophagus tube, every half-hour. In 
eighteen operations, three cases were reported 
cured; a success pronounced extraordinary, and 
greater than than that of any other surgeon. 15 
of whom had been cured after twenty opera- 
tions. 
There can be little doubt that Dr. Sims reached 
this important combination of improvements, 
quite independent, perhaps, of foreign aid ; yet, 
by reference to the historical enumeration of 
methods which I have detailed, it will be found 
almost all have been conceived and executed by 
predecessors. In illustration of this, let them 
be examined in detail. 
In these cases of Dr. Hayward there was 
nothing new, unless it was the peculiar catheter; 
it had often been practised before, but in his 
hands was crowned with a success, calculated to 
inspire confidence in the curability of the affection. 
In 1847, Prof. Joseph Pancoast succeeded in 
effecting two cures. The posterior or upper lip 
of the fistula was exposed by a Charriere speculum, 
and split one half inch deep in a longitudinal di- 
rection ; with a pair of scissors and bistoury, the 
lower lip was next pared into a wedge-shaped 
form, and this tongue of raw tissue, drawn into 
the grove in the upper border, by what he called 
his plastic suture. The bladder was kept empty 
by a gum elastic catheter, and after the second 
day, injections of zinc were thrown into the 
vagina to give tone to the parts. On the fourth 
day a solution of the nitrate of silver was applied 
over the line of apposition, to favor union by 
granulation, where that by the first intention 
failed. In this method, we have a repetition of 
the plan of Blasius. 
First, the position. This was recommended 
and practiced both by Chelius and Walter; the 
later of whom employed a blunt hook for open- 
ing the vagina, which executed in a good mea- 
sure, the office of the duck-bill speculum. 
Second, the suture apparatus. In 1834, Gos- 
set, of London, emplo}md the metallic thread; 
Devber, also; the former gilded wire; the latter 
lead. Beaumont carried his sutures around lit- 
tle cylinders, placed one on the other side of the 
fistula; thus resembling the clamps. 
Third, the self-retaining catheter. Dr. Met- 
taper employed, in his case, a short instrument 
which was worn in the bladder during the cure, 
so that really all these novelties, have, at some 
time or other, engaged the notice of surgeons, 
during the long years of experiment and device 
which have marked the history of vaginal 
fistula. Still, however, the undivided honor of 
combining, modifying, and utilizing, all belongs, 
and only belongs to Dr. Sims. 
In the same year, Dr. John P. Mettauer, pub- 
lished in the American Journal of Medical 
Sciences for July, the history of a fistula, which 
he cured by inserting leaden sutures, after par- 
ing its circumference. The bowels were kept 
closed for eight days, and the stitches allowed to 
remain thirteen days, during which time a short 
catheter was worn in the bladder. The metalic 
thread used by the operator in this instance, was 
undoubtedly the procuring cause of so fortu- 
nate a result. Just at this point commence the 
most important facts in the history of our subject. 
Position of the Patient. A table is selected, 2j 
by 4 feet, covered with folded comfortables; on 
this the patient is placed, resting on her elbows 
and knees, the latter separated six or eight inches, 
the pelvis being elevated, and the shoulders 
depressed. An assistant on either side placing a 
hand in the fold between the nates, the fingers 
extending quite to the greater labite, simultan- 
eously draw them asunder. The viscera gravita- 
ting toward the thorax, and the air rushing into 
the vagina on the separation of the walls of the 
vulva, distend the canal so as to offer a very com- 
plete interior view. To increase its capacity for 
a more thorough exploration, the Sims speculum 
(Fig. 5) is next introduced, and drawn back to- 
Dr. Sims’ Operations. 
In 1852, Dr. J. Marion Sims, of Alabama, 
solved the whole difficulty, and placed this vexed 
and perplexed operation, on a solid and substan- 
tial foundation. The discoveries which he ad- 
vanced as peculiary his own, were the following: 
Ist. A method by which the vagina could be 
thoroughly explored, its capacity greatly in- 
creased, and the fistula made readily accessible. 
2d. The introduction of a suture, which would 
remain a long time, without inducing either irri- 
tation or ulceration. 
Fig. 5. 
3d. A mode of keeping the bladder drained of 
the urine. 
The first was accomplished by placing the 
patient on the knees and elbows, the hips being 
elevated, and using a speculum, which from its 
form is called the duck-bill speculum. The 
second, by substituting the ordinary thread with 
a metallic (silver) one, aided by leaden clamps; 
and the thin, by a self-retaining catheter. 
Vaginal speculum similar to Sims’—Bozerman’s pattern. 16 
ward the sacrum by one of the assistants. (Fig. 6.) 
along, sharp-pointed bistoury is applied (Fig 8) 
vesical mucous membrane concealed the margin 
of the fistula, interfering with its proper manage- 
ment, a soft sponge should be passed through 
the opening into the bladder, and allowed to re- 
main until the stitches are ready for adjusting. 
To remove the blood from the parts during the 
freshening of the parts. The lining membrane of 
the bladder he does not disturb, unless it pro- 
Fig. 6. 
Fig. 8. 
Exhibits the speculum in situ, with the relative position 
of the organs. 
If the illumination is not sufficient, a mirror 
(Fig. 7) may he used to reflect the light into the 
canal. 
Fig. 7. 
Mirror to throw the sunlight into the vagina. 
Paring the Fistula. For this purpose, a small 
sharp hook, or tenaculum, is passed iuto the cir- 
cumference of the fistula, and while thus brought 
into proper position, and made sufficiently tense 
Tenaculum fastened into the fistula, and the bistoury 
applied to its circumference. 17 
trades through the opening in excess. When the 
fistula was very small he hooked the tenaculum 
through both sides, and raising it up, cut out a 
circular portion with the bistoury. During the 
operation, little mops (Fig. 9) should be on hand. 
These are readily made by securing small bits of 
sponge to whalebone or rods of wood. 
across the wound, and bringing it out half an 
inch above the raw margin of the opposite side; 
taking care not to include the mucous membrane 
of the bladder. As the needle passes through the 
distal side, the tissues will require support, that 
they press not away from the instrument; and 
thus counter-pressure is supplied by a blunt hook 
behind the needle (Fig. 11.) 
Application of the Clamp Suture. This may 
may be divided into three stages: the introduc- 
tion of the silver wires; the attachment of the 
clamps; and the approximation of the wound, 
with the securing of the apparatus. 
Fig. 11 
First. Introduction of the Sutures. In the ex- 
ecution of this he passed a silk thread through 
the eye of along, awl-shaped needle (Fig. 10), and 
Fie. 9, 
Fig. 10. 
The blunt hoolv between the needle and tissue 
to favor its passage. 
A sponge mop. 
Needle for passing sutures. 
entering it half an inch from the freshened edge 
of the opening, carried it downward, and forward, 18 
thread the wire is towed into its place-, the 
threads being only designed to favor the insertion 
of the wires. In this process a difficulty very 
naturally occurs, that of the thread, or the wire 
as it may be, cutting into, or even tearing out of 
the tissue, on the distal side of the wound, as 
they are pulled upon. To counteract this he 
employs a crescent-shaped fork to push the suture 
above the orifice while traction is being made 
(Fig. 13.) The silver sutures being all passed, 
As soon as the needle emerges, and the thread 
comes fairly into view, a long tenaculum is hooked 
into the loop, and one end drawn through (Fig. 12), 
Fig. 12. 
Fig, 13. 
Exhibits the tenaculum drawing the thread through. 
after which the needle is withdrawn, leaving the 
suture in its track. In this manner the requisite 
number of threads are deposited across the wound. 
The next step consists in substituting the silver 
threads for the silk, which is readily accomplished 
by binding the end of the former into a crook or 
link, and making fast to it the distal end of the 
latter. By drawing on the proximal end of the 
A silver thread secured to the silk one, with the fork in situ 
to favor the passage through the upper puncture. 19 
the second stage of the process consists in the 
Attachment of the Clamps. Two little bars of 
silver or lead, a trifle longer than the fistula, are 
perforated with a number of holes, corresponding 
to the number of sutures. Through these the 
upper end of each wire is passed, and fastened 
by winding it about the bar, or passing it through 
a shot. (Fig. 14.) This completed, the lower 
the apparatus in position,* a perforated shot is 
passed down each wire, and being pressed against 
Fig. 15. 
Fig. 14. 
Tig. 16. 
Both clamps on the wires, and per- 
forated shot behind the proximal 
one. 
Upper clamp attached. 
The adjusting fork. 
ends of the wires are drawn upon, when the 
clamp will be carried into the vagina, and take 
its place above and parallel with the upper bor- 
der of the wound. During this adjustment, a fork 
of another kind (Fig. 15) is used as a pulley, to 
prevent the wires cutting into the flesh. In the 
same manner, the other ends of the wires are 
passed through the second clamp. (Fig. 16.) 
the clamp, is then fastened by compression with 
a strong pair of forceps. (Fig. 17.) The wires 
are next cut olf short, and bent over the shot. 
Fig. 17. 
The Adjustment. The proximal ends of the 
wires being drawn upon, and the clamp pushed 
up with the fork at the same time, the raw sur- 
faces are brought in contact with each other, in 
doing which, care and judgment are requisite 
that they be pressed together sufficiently tight to 
prevent gaping, and yet not so forcible as to en- 
danger strangulation or ulceration. To maintain 
The appearance of the wound, when adjusted, 
Shot compressor. 20 
with the suture apparatus in position, is repre 
sented in Fig. 18. 
Dr Sims’ Later Operation. 
Fig. 18. 
To the clamp there are objections, and these 
were soon discovered by Dr. Sims, and the opera- 
tion so modified as to add greatly to its simplicity 
and perfection. The modifications consist in the 
introduction of the metallic threads without those 
of the silk, and dispensing entirely with the 
clamps, adjusting the wound and securing the 
wires by twisting alone, which he accomplishes 
by drawing, with a pair of forceps, the ends of 
the wire through the slit at the end of his ad- 
juster, (Fig. 20,) and then, while thus firmly 
held, the forceps, by a rotary movement, twirls 
the wires about each other, so as to make them 
secure. 
Fig. 20. 
Exhibits the wound adjusted with the suture apparatus. 
The After-Treatment. The operation being com- 
pleted, the patient is placed in bed, on the back, 
a self-retaining catheter placed in the bladder, 
(Fig. 19,) and a full dose of opium administered; 
Fig. 19. 
to be repeated as often as 
may be necessary to keep the 
bowels quiet. The diet is to 
consist of crackers, and coffee 
or tea. During the progress 
of the case, the vulva and 
other portions of the external 
genitalia are to be bathed 
with cold water, a bed-pan 
being placed under the nates, 
to collect the fluid as it runs 
from her person. The urine 
is to be received on old cloths, 
as it drops from the catheter. 
On the ninth or tenth day, 
the clamps and sutures are 
to be removed, and if well, 
the patient required to wear 
the catheter for several days 
longer. About the twelfth 
or fifteenth day, the bowels 
should be opened by some 
mild cathartic. 
fcelt-retaluiDg cauueusr 
of Sims. 
Such are the general features of Dr. Sims’ ope- 
ration, and from this dates the successful surgical 
management of vesico-vaginal fistula. 
Sims’ method of coaptating and securing -wires by an adjuster 
an.t forceps. 21 
Operation of Dr. Nathan Bozeman, 
Formerly of Alabama. 
done, the requisite number of silk threads are 
introduced with short, straight, spear-pointed 
needles, from half an inch to one inch in length, 
grasped in the jaws of a needle holder. (Fig, 27.) 
The needle is entered some distance from the 
freshened border, and carried obliquely through, 
first the proximal side of the fistula, penetrating 
as deep as the vesical mucous membrane, and 
then, after being adjusted to the needle-holder, 
through the distal side, being drawn through with 
a pair of long forceps, counter-pressure being- 
made with a blunt hook, similar to Sims! in- 
strument. The threads being all passed, each 
one is securely fastened by its lower end to a sil- 
ver wire, and as the one is drawn out, the other 
The name of Dr. Bozeman is well known, 
both in this country and abroad, in connec- 
tion with vesico-vaginal fistula. Several pa- 
pers from his pen have appeared on the subject, 
all proving unusual dexterity and success as an 
operator. The chief novelty in his method is 
what he terms the button suture, (Fig. 21,) eom- 
Fig. 21. 
Bozeman’s lead button. 
posed of a piece of thin lead cut to fit the opening, 
and having in it small holes answering to the 
number of wire sutures employed; also leaden 
crotchets to secure the button. The patient is 
placed in the position recommended by Sims- a 
duck-bill Bozeman speculum introduced; and 
M hile the parts are controlled by a long tenacu- 
lum or forceps, the edges are pared by straight 
and curved bistouries; sometimes using the 
curved scissors. See Figs 22, 23, 24, 25, 26? This 
Fig. 27. 
Fig. 22. 
Fig. 23. 
Fig. 24. 
Fig. 25. 
Fig. 26. 
Bozeman’s needle hold- 
claws °nig?*tem’ with*wo 
with n lts extremity, 
7““ a. canula to slide up 
and down, closing and 
opening the jaws. Also 
examples of the Bozekik- 
needle. 22 
takes its place, a fork being used, as in Sims’ 
method, to guide the sutures and support the soft 
parts. 
on wires and button. The operation is finished 
by cutting off the wires a short distance above the 
crotchets, and turning an end down on either side. 
(Fig, 32.) The patient is placed in bed, on her 
back, the catheter introduced, the bowels kept 
closed by opium, and an unirritating diet al- 
lowed. 
The next step consists in passing both ends 
of each suture through an instrument called 
an adjuster, (Fig. 28,) and drawing on the 
wire, as it is run down, the wound is brought to- 
Fig. 28. 
Adjuster. 
Fig. 29. 
The sutures alter being passed through the adjuster. 
Fig. 30. 
Bozeman’s instrument, having an angular and concave extremity, 
to model the button to the surface of the vesico-vaginal septum. 
gether and a set given to the thread, which 
contributes to so maintain it. (Fig. 29.) The wires 
are next passed through the perforations in the 
lead button, and the latter pressed down upon 
the line of approximation, and made to conform 
to the surface against which it rests by means of 
an instrument represented in Fig. 30. 
To secure the button firmly in place, pieces of 
lead or crotchets are run down the wires (Fig. 31) 
and compressed, by a pair of strong forceps, both 
Operation of Dr. J. Hunter McGuire, 
Formerly of Philadelphia. 
The patient being placed in the position re- 
commended by Sims, the edges are to be pared 
with a long-handled bistoury, and brought to- 
gether with the instrument delineated in (Fig. 33.) 
Fig. 33. 
Fig. 31. 
Fig. 32. 
Button and crotchets 
adjusted, wires cut and 
turned down. 
Exhibits the crotchets being 
passed down the wires. 
Representing McGuire’s instrument for yesioo- 
yaginal fistula. 23 
This consists of a plate of silver, having a hole 
near each extremity, and three needles, slightly 
curved; soldered to its front surface a second 
silver plate, of the same size and shape as the 
first, having fastened to each end a thread-screw? 
and three holes corresponding in position to the 
three needles on the other plate, and lastly, two 
female screws. 
Fie. 34. 
Fie. 35. 
Fro. 36. 
Application. With a strong pair of forceps 
the plate supporting the needles is grasped, their 
points passed through the posterior lip of the fis- 
tula, and brought out through the anterior one. 
Through the perforations at either end of this 
plate are next passed the thread-screws of the other 
plate, and through its perforations the extremities 
of the needles. The female screws are next run 
down the thread, forcing the clamp together, 
until the edges are in close contact. 
Operation of Dr. J. Y. Simpson, 
Of Edinburgh. 
The operation of this distinguished Scotchman, 
certainly one of the representative medical men 
of the age, differs chiefly in substituting, for the 
Bozeman button, a wire splint, prepared as fol- 
lows : He takes ten or fifteen strands of metallic 
thread, and twists them into a cord, the ends of 
which are then doubled over each other, and 
plaited round into the form of a circle, which 
may, being very flexible, be pressed into any 
figure desired. With an awl, or any sharp- 
pointed instrument, the required number of holes 
may be made, by passing it through among the 
wires. These perforations are for the iron thread 
sutures. For the introduction of the sutures, Dr. 
Simpson uses an ingenious needle (Fig. 34), to- 
gether with a crotchet (Fig. 35), and a hook 
(Fig. 36.) 
The needle consists of a hollow tube, with a 
needle point, one opening being near the end, 
and the other near where the handle and shank 
join. 
The mode of using is readily understood. The 
wire thread being pushed within a short distance 
of the upper orifice, the needle is carried through 
both sides of the fistula, after which, the thread 
is thrust forward. As soon as it appears, it is to 
be seized with a pair of forceps, and held while 
the needle is being withdrawn, thus leaving the 
suture in situ. By a repetition of this process 
the requisite number are introduced. He prefers 
the iron wire, as more easily managed than 
silver. His sutures are next passed through the 
Dr. Simpson’s needle, -with a wire inserted. 
Simpson’s crotchet and hook. 24 
openings in the wire splint (Fig. 37), the latter 
being pressed down over the line of apposition, 
and the wires secured by twisting with his wire 
The ends of the metallic threads are next clip 
ped off close to the splint (Fig. 40), and the after- 
treatment conducted on the same principle as 
that of other operators. 
Fig. 37. 
Fig. 40. 
Simpson’s splint adjusted, wires secured, across the lower bar. 
For paring the fistula he uses straight and an- 
gular knives; for the passage of the metallic 
sutures, Simpson’s needle; and for securing the 
threads, little crotchets or clamps of lead, run 
down, and compressed with a strong pair of for- 
ceps. Flis operation dates 1860. 
Operation of Dr. Isaac Baker Brown. 
Simpson’s wire sp nt, the threads being carried through 
the openings in it. 
twister (Fig. 38), constructed on a plan which 
was suggested by Dr. Coghill. 
Fid 369. 
Fig. 38. 
Operation of Dr, Robert Battey. 
The peculiarity of Dr. Battey’s method con- 
sists in a metallic (lead) button (Fig. 41), having 
Fig. 41. 
Battey’s button. 
a series of holes on one border, and on the other 
a corresponding number of slits. The upper ends 
of the wire after being inserted are passed through 
the holes, the other ends forced into the slits, and 
both fastened by twisting them about each other. 
He claims for it a water-tight adjustment. 
Operation of Collis, 
Of Dublin. 
This method, described in 1862, consists in 
splitting the vesico-vaginal septum along the en- 
tire circumference of the fistula; turning the 
vesical side toward the bladder, and the vaginal 
side toward the vagina; the sutures he employs 
are silk, and introduced as double threads, with 
Liston’s needles secured on long handles. When 
the threads are all inserted, there will be a row of 
loops on one (the upper) side, and two free ends 
on the other side of the fistula. A vulcanized 
quill is next passed through the loops above, and 
a second placed along the lower border of the 
opening, and the approximation effected by tying 
the free ends of the threads firmly around it; it is 
a quilled suture. 
Simpson’s "wire twister. 
The same, with the wire in, and partly twisted. 25 
Operation of Dr. Alfred Meadows, 
Physician-Accoucheur to the General Lying-in Hospital, London, 
think its exhibition more imperative than in va- 
ginal fistula. The position and exposure are cal- 
culated to shock the feelings of any female pos- 
sessed of ordinary sensibility, and I have in all 
cases administered this agent with the most sat- 
isfactory result. 
The novelty of this method consists in allowing 
the patient, after the parts are pared, and closed 
with silver threads, to rise and go about as usual, 
dispensing altogether with the catheter. He 
publishes two cases, which it is alleged were 
treated successfully in this way. I should not 
feel disposed to subject a patient to such a treat- 
ment without some further accumulation of data. 
Assistants. There will be required four as- 
sistants ; one for the sponges, one for each lower 
extremity, and one for the anaesthetic. As such 
an operation is rarely completed in less than 
half an hour, and may be prolonged to even two 
hours, the assistant having charge of the anaes- 
thetic, should be perfectly familiar with his duty. 
Agnew’s Operation. 
Having presented the various operations in his- 
torical succession, I proceed to state the plan of 
treatment practised by myself for several years, 
with results the most satisfactory. Nothing ori- 
ginal is claimed for the method. Except in a few 
particulars, it does not differ from modes pursued 
by others. 
Time to Operate. As a good sunlight is all 
important to the successful execution of this ope- 
ration, the forenoon of a clear day should be se- 
lected, and a room whose windows have an east- 
ern or southern exposure. 
Arrangements for the Operation. Among the 
first things to be attended to is the bed on which 
the patient is to lie. This should be a firm mat- 
tress ; but should the circumstances of the pa- 
tient be such as not to command this, a feather 
bed may be well beaten down and covered with 
two or three comfortables, so as to give it a cer- 
tain degree of solidity. Over that part where 
the hips are to rest there should be spread a strip 
of oil-cloth, and over this a folded sheet, the ob- 
ject being to protect the bed. A low stool should 
be procured and turned upon its side, over 
which should be placed one or two folded blan- 
kets, and over these again a piece of oil-cloth, 
the whole to be secured by a few turns of a 
roller. (Fig. 42.) This forms an excellent sup- 
port, across which the patient is to be turned. 
Instruments. The instruments which have been 
and are still being invented for this operation 
constitute a most formidable armamentarium. 
I shall content myself by presenting a list of 
such as compose my own case, and which I have 
found to answer every purpose. 
A duck-bill speculum (Fig. 43); two long-han. 
died scalpels (Fig. 44); one pair of long rat- 
toothed forceps, slightly curved, with an attach- 
ment at the end of the handle, embodying the 
adjustor, for running down the wires and the 
crotchet to favor by counter-pressure the passage 
of the needle through the distal side of the fis- 
tula (Fig. 45); a needle-holder which can with 
one hand be detached from the needle, or again 
made to grasp it, and by which the needle can be 
introduced at any angle (Fig. 46); one pair of 
long scissors, curved a little on the flat (Fig. 47); 
a shot compressor (Fig. 48); this instrument, to 
be efficient, should have strong handles, and the 
articulation less than half an inch from their ex- 
tremities; a shot perforator (Fig. 49); two sig- 
moid self-retaining catheters (Fig. 50); the open- 
ings in which should be very small, otherwise 
the mucous membrane of the bladder will insinu- 
ate itself through them, and become strangulated, 
rendering its withdrawal impossible without tear- 
ing the incarcerated portions; one dozen of nee- 
dles; these should be -constructed with great 
care, seven-eighths of an inch in length, slightly 
curved for one-fourth of an inch at the extremity, 
the cutting-edge confined only to the extent of 
the curve, and sufficiently wide to allow the 
proximal part to pass without tugging and pull- 
ing, as is too often the case. The eye should be 
well sunken, so as to bury the thread, and the 
whole so tempered as to bend, rather than break; 
fine silver wire; some No. 3 shot, and twelve or 
Fig. 42. 
Stool covered, over which to place the patient. 
There will be required two basins, one bucket for 
cleansing, and another for the bloody water, sev- 
eral mops or sponges; readily formed by securely 
tying small pieces of soft clean sponge to the 
ends of sticks or pieces of whalebone; a six or 
eight-ounce syringe, and some pieces of ice. 
There is some difference of opinion as to the ex- 
hibition of an amesthetic. In no operation do 1 26 
Fig. 43, 
Fig. 44. 
Fig. 45. 
Fig. 46. 
Fig. 47. 
Fig, 48. 
Fig. 49. 
Fig. 50. 27 
fourteen inches of light gum-elastic tubing, to 
slip over the end of the catheter, and thus convey 
the urine to a bottle or other vessel, placed be- 
tween the patient’s limbs. 
over to assistants. The operator now takes the 
speculum, smeared with oil, and introducing 
it into the vagina, commits it to one of the assist- 
ants having charge of the limbs, who draws it 
firmly toward the rectum, when the air, entering 
the vagina, expands the tube in the most satisfac- 
tory manner. (Fig. 51.) The surgeon now takes 
his seat in a position to command a full view of 
the fistula, and seizing its lower margin with the 
forceps, enters the knife from three-eighths to half 
an inch from the opening, bringing it out just 
short of the vesical mucous membrane, and by 
successive sawing movements, paring away, until 
the entire circumference of the fistula has been 
freshened. Should the mucous membrane of the 
bladder protrude, a piece of sponge may be press- 
ed through the opening to keep it out of the way. 
The greatest difficulty in executing this part of 
the operation will be experinced at the angles, 
or commissures of the opening; and too much 
care cannot be observed, that no point be over- 
looked. If it is properly done there should be at 
least three-eighths of an inch, or more, of oblique 
raw surface, visible everywhere around the fistu- 
lous opening. The tendency to inversion of the 
vagino-vesical septum is so great, that unless a 
considerable extent of tissue is removed, there 
will be danger of not having a sufficient amount 
of raw surfaces apposed to secure adhesion. There 
will be cases and situations in this freshening 
process, where the scissors come in more advan- 
tageously than the knife; such will naturally 
occur to the surgeon as he proceeds. Where the 
fistula is very small, receiving, for instance, only 
the end of an ordinary probe, some advise trans- 
fixing with a long awl-shaped instrument, and, 
raising the sides, by a single stroke of the knife 
cut out a sufficient amount of tissue. There is a 
very ingenious instrument (the author of which 
I cannot recal), (Fig. 52), with a conical ex- 
tremity standing at an angle with the shank, the 
The patient having removed all her clothing, 
save a chemise and night-gown, lies down upon 
the bed, and is brought under the influence of 
the anaesthetic, nothing having been communi- 
cated to her about the position in which she is to 
be placed. When sufficiently unconscious, the 
stool, prepared as directed, is placed across the 
foot or side of the bed, and the patient carefully 
lifted, and placed over it, resting on her abdomen, 
two or three pillows being laid under her breast 
and head in such a way as to form an inclined 
plane. The head must be turned on one side, 
and a free access of fresh air admitted to her face. 
The person having charge of the anaesthetic must 
take his position so as to have a full command of 
the pulse and countenance, keeping her perfectly 
passive, without profoundly impressing her. 
There are periods in the operation when very 
little need be given, as when the surgeon is wait- 
ing for the bleeding to cease; and again, when 
the apposition and adjustment are being effected 5 
at such times very little pain is inflicted. The 
legs, being next flexed upon the thighs, are given 
Operation. 
Fig. 51. 
Fig. 52. 
base of which is surrounded with sharp teeth, 
designed for controlling the edges of such fistulas. 
The apex of the cone is inserted into the opening, 
and pressed through; then, by withdrawing it, 
the teeth become fixed into the circumference, 
when the knife may readily excise at a stroke 
the included tissue. 
Exhibits the -woman resting on her abdomen oyer the stool 
placed across the bed, and the assistants supporting the limbs, 
one of them also holds the speculum, which has been passed 
into the yagina. 
There is another instrument, (Mr. Hilliard’s, 
of Glasgow,) designed to secure the edges of 
large fistulas while being pared, and which con- 28 
gists of a long shank, with a small thread at its 
extremity, on which may be secured yarious 
sized forks for transfixing, and on this shank a 
sliding rod, bearing a bar which may be pushed 
forward, and then drawn back between the forks, 
so as to compress and secure the included tissue. 
Figs. 53 and 54, exhibit the instrument and its 
application. There is no objection to having all 
as the following, will indicate such an apposi' 
tion; as when the fistula runs to any great extent 
longitudinally; or when it is low, and either so 
great a loss of substance, or so unyielding a char- 
acter of tissue, as to make too much traction when 
brought together on the lower wall of the urethra, 
endangering a subsequent incontinence of urine. 
Fig. 53. 
Fig. 54. 
Introduction of the Sutures. This is regarded 
by many as the most difficult part of the operation. 
The needle bearing the wire is placed in the 
grasp of the needle-holder, and whilst the proxi- 
mal border of the fistula is steadied by the for- 
ceps, is entered at the middle of the wound, 
three-eighths of an inch from the freshened sur- 
face, brought out at the mucous membrane of the 
bladder, (not including it,) carried across the 
opening, made to enter the opposite side, and 
emerge the same distance above its raw surface. 
The needle-holder is now disengaged from the 
needle, by simply pressing the upper blade of the 
instrument while the spring is being pressed for- 
ward by the thumb, made to seize the extremity 
now through the upper border of, the fistula, and 
while the parts are supported, by applying to 
them the hook at the end of the forceps, (Fig. 
55,) the needle is drawm through, turned and 
Fig. 55. 
these instruments, if the taste and the circum- 
stances of the surgeon allow it; but that such 
are essential, or even necessary to the proper exe- 
cution of the operation, is certainly not correct. 
Arrest of Hemorrhage. The bleeding which 
follows the foregoing process is not generally 
very profuse, stopping under the application of 
cold water, or a lump of ice inserted into the 
vagina, or even under the styptic influence of the 
atmosphere; but occasionally cases will be met 
with where the discharge of blood proves both 
copious and persistent. To control such irregu- 
larities, I have found a small stream of cold 
water, steadily directed on the parts from a large 
syringe, singularly efficacious. Should this not 
succeed, the stitches should be inserted, and the 
edges drawn firmly together, when it will cease, 
just as the approximation in a case of hare lip 
arrests the hemorrhage. 
The Direction of Approximation. Most ope- 
rators favor an approximation of the sides of the 
fistula transversely, yet there are no reasons 
why they may not be closed longitudinally, 
base 15 is an example in point. Such conditions 
Needle in the grasp of the needle-holder carried through the 
fistula, and the hook at the end of the forceps placed between the 
tissues and its point, to favor its passage by counter-pressure. brought out of the vagina. When the sides of 
the opening- are too wide apart, the needle cannot 
be made to penetrate both at once, and therefore 
it must be drawn through them in succession. 
In this manner the requisite number of threads 
are inserted, the distance between them being a 
trifle less than one-fourth ol an inch, (1 ig. 56.) 
drawn, the blood sponged away, and the patient 
placed on her back, on the bed prepared for her 
reception, after which the catheter is to be intro- 
duced into the bladder, and carefully watehed, to 
see if the urine flows freely through its canal. 
In order to keep the clothing of the patient and 
the bed perfectly dry, a light piece of gum elastic 
tubing may be drawn over the end of the cathe- 
ter, and its other extremity inserted into a bottle, 
which shall lie between the patient’s limbs; or a 
small earthen vessel or cup may be placed be- 
neath the instrument, and receive the urine as it 
drops from its extremity. 
Fig. 56. 
After Treatment. Too much importance can- 
not be attached to the after management of the 
case, as on this will depend, in a great degree, 
the success of the operation. The nurse should 
understand the manner of introducing and re- 
moving the catheter; if she does not, five min- 
utes instruction, by showing her the mode, will 
suffice to enable her to do so, unless she be un- 
usually dull of apprehension or imitation. It 
should be examined frequently to see that no 
obstruction exists, that it does not become mis- 
placed, and that the urine drops freely. This is 
imperative, for it often happens for the first 
twelve or twenty-four hours, that small coagulse of 
blood are expelled from the bladder, and which 
may obstruct the instrument. Two catheters 
should be always on hand, so that one may be 
introduced immediately on the withdrawal of the 
other. After thirty-six or forty-eight hours, 
twice a day will be sufficient to change the in- 
strument, in the morning, and at bed time; and 
it can best be cleared of mucus, and other mat- 
ters, by inserting the nozzle of a syringe into one 
end, and forcing through it a stream of water. 
If the bladder is kept perfectly empty, the col- 
lapsed state of its walls will prevent all tension 
on the sutures, and diminish greatly the chances 
of urine getting between the edges of the wound, 
an accident which will almost always defeat the 
union. The position best suited to the patient is 
that on the back, although there are no objections 
to her turning for a short time on the side to re- 
lieve a sense of weariness or discomfort. 
As each is deposited in its proper place the needle 
is to be removed, the ends of the wire twisted 
together, and given in charge of one of the assist- 
ants supporting the thighs. 
Exhibits the threads passed. 
Adjustment. In the important stage of adjust- 
ment, the wire first inserted is separated from the 
others, and the ends passed through the hole of 
the adjuster at the end of the forceps. As the 
latter is slid down, the wire is drawn upon until 
the edges of the wound are brought into accurate 
contact. The set which the wire thus obtains, is 
sufficient of itself temporarily to maintain the 
apposition. All of the threads are subjected suc- 
cessively to this process, and while being done, 
care must be observed that the edges be properly 
everted, so as to secure the contact of raw sur- 
faces, and also, that no clot be permitted to lie 
between them. 
The next step is to secure the sutures perma- 
nently, and for this purpose it has been my 
almost uniform practice to use perforated pellets 
of shot. These are run down the wires, then 
seized with the strong compressing forceps, and 
while the metallic threads are being drawn upon, 
pressed firmly against the line of adjustment, 
and then compressed so as securely to maintain 
their position. The sutures are next cut off, close 
to the shot, leaving no projecting ends to irritate 
the soft parts, (Fig. 57,) the speculum with- 
The next important thought is to lock up the 
bowels, and keep her free from all pain and un- 
easiness. For these ends we have no better agent 
than opium. One or two grains should be given as 
soon as she is adjusted in bed, after which, from 
a third to half a grain, three times a day, for five 
or six days, will answer. From this, until the 
removal of the stitches, the fourth of a grain, 
morning, noon, and night, will maintain the 
effect produced. Ido not think there is any ad- 
Fig. 57. 
Exhibits the edges of the wound apposed, the shot com- 
pressed on the wires, and the latter cut off. 30 
vantage in exhibiting this drug, beyond what is 
just sufficient to keep the bowels quiet; more 
than this tends to impair the digestion, disturb 
the secretions, and destroy the appetite. Occa- 
sionally the patient will be seized with an un- 
controlable desire to bear down, or an involuntary 
contraction of the bladder, often driving the ca- 
theter from the urethra; in such conditions we 
must resort to enemata, consisting of two or three 
tablespoonfuls of flaxseed tea, or starch-water, 
with forty drops of laudanum, repeated once or 
twice in the twenty-four hours, if necessary. 
No injections of Avater into the vagina should be 
practiced, as directed by some; nor any explora- 
tions with the finger; the vaginal mucus which 
collects about the wound, and the sutures, does 
no harm whatever. Should the patient be an- 
noyed with tympanitic distension of the abdomen, 
■which not occurs, a little camphor- 
water and aromatic spirits of ammonia may he 
given, or a little turpentine in mucilage of gum 
acacia, from time to time. 
Diet. The patient should he allowed a liberal 
hut unirritating diet. Milk, soft-boiled eggs, 
cream toast, chicken, or beef broth, mutton chop, 
with coffee and tea, offer a sufficient list from 
which to select her food. 
Removal of the Sutures. On the eighth or ninth 
day after the operation, the stitches should be 
removed, and for this purpose the patient may be 
placed on the side, her limbs well drawn up, and 
hips over the edge of the bed, before a good light; 
or she may rest on her knees and elbow. The 
removal of the sutures not being painful, the ad- 
ministration of an anaesthetic is unnecessary, un- 
less the patient be timid, and shrink from the ex- 
Fig, 58. 
Shows the suture seized with the forceps and being clipped by the scissors. 
From Simpson’s work on Diseases of Women. 31 
posure; in which event it should be given. The 
number of assistants requisite for the object in 
view will be determined by the taking or not 
taking an anaesthetic. In the former, there will 
be needed one to take charge of the ether or 
chloroform, and two to support the limbs and 
manage the speculum. In the other case, a sin- 
gle assistant will be sufficient. The catheter be- 
ing removed, the patient is placed in position, 
and the speculum inserted and given to the as- 
sistant. The parts being satisfactorily exposed, 
the surgeon clears away the mucus from the 
sutures with a piece of moistened sponge; then 
taking hold of a shot with the long forceps, lifts 
it from the parts until the wire is distinctly seen, 
and with the scissors clips it on the proximal 
side, (Fig. 58,) straightening the end at the same 
time by pressing it outward with the blade of the 
instrument. This done, plant the blade of the 
scissors against the loop on the distal side, and 
drawing on the shot with the forceps, the suture 
will come away by revolving about the blade of 
the scissors as a point d'appui, (Fig. 59.) 
several weeks to become distended. Should the 
union not have taken place, and a considerable 
portion of the fistula remain unclosed, the cathe- 
ter may be removed at once, the bowels opened, 
and the patient allowed to rise and go about as 
usual. When it is discovered that union has 
taken place save at a single point, so small, for 
instance, as to be readily closed by a single 
stitch, introduce at once that stitch, scarify 
well the edges, and approximate as before; con- 
tinuing the management of the case in all re- 
spects as in the primary operation for six or eight 
days longer; the probabilities are it will succeed. 
In one of my cases, (Case 3,) it was so done, 
and with complete success. No apprehension 
need be entertained in regard to keeping the 
bowels so long confined. 
Causes of Failure. These will be found refer- 
able to some one of the causes enumerated below. 
Ist, imperfect freshening of the margins of the 
fistula; 2d, mal-adjustment; 3d, insufficient tis- 
sue from loss of substance, thereby rendering the 
permanency of the sutures uncertain; 4th, diar- 
rhoea accompanied with tenesmus; sth, soft state 
of the tissues, permitting the sutures to cut 
through readily; 6th, enfeebled state of the 
health; 7th, thin condition of the sides of the 
opening; Bth, proximity to the cervix uteri. 
Fig. 59. 
In regard to the first and second, the fault he- 
wing with the operator, can only be remedied by 
care and experience. The third is not always in- 
capable of being remedied; much may be done 
by deep stitches, incisions to relieve tension, 
and rather than abandon the case as hope- 
less, a plastic operation as practised by Jo- 
bert, taking a flap from the inner surface of 
the labium. Should these fail, then it would 
be better, rather than allow the woman to 
remain in so miserable a condition, to freshen the 
outlet of the vagina, and close up the canal, 
making a common cavity of it and the bladder. 
The fourth complication (diarrhoea and tenes- 
mus) will be best met by enematas of laudanum, 
or suppositories of opium. The sixth (feeble 
health) by tonics, nutritious diet, and pure air. 
Seventh, (thin edges of the fistula;) these may be 
greatly improved by scarifications, and the appli- 
cation of the nitrate of silver every three or four 
days to the circumference of the opening. Eighth, 
(proximity to the cervix uteri); when the fistula 
is situated in or extends to the cul de sac between 
the vagina and the anterior part of the cervix, 
any operation for its closure, including only the 
vesico-vaginal septum, will be likely to prove 
abortive. To obviate this difficulty when the or- 
dinary method falls, the anterior semi-circum- 
Exhibits one of the stitches after its removal, with the shot 
attached. The loop should be represented move open. 
The detail given in what may seem a very sim- 
ple matter will be appreciated when the reader who 
has not, may have occasion to perform the opera- 
tion. If neatly executed, it will save the patient 
some sharp pain, and not endanger the laceration 
of the cicatrix. The stitches being all removed, 
after the manner just explained, the result will 
be revealed; if favorable, the patient is to be re- 
placed in bed and the catheter again introduced. 
After two or three days the bowels should be 
opened by administering a teaspoonful of castor 
oil, or a seidlitz powder every four or five hours 
until a free evacuation is procured. The object 
in thus exhibiting the cathartic is to thoroughly 
liquefy, or soften the foecal accumulations, and 
prevent tension or straining during defeca- 
tion. This result may be promoted by the em- 
ployment of an enema of tepid water just before 
the evacuation. For five or six days after the re- 
moval of the stitches, the patient must continue 
in bed, and wear the catheter, in order to take off 
all tension from the cicatrix, and allow it to at- 
tain considerable consolidation. After this, the 
instrument may be removed and she may be al- 
lowed to walk about, remembering to pass the 
urine frequently, and not allow the bladder for 32 
ference of the cervix should be freshened, and 
the veslco-vaginal, similarly treated, stitched to 
it, thus turning the os into the bladder. In one 
of my cases, (Case 2,) such a plan was suc- 
successfully adopted, and the women continue to 
menstruate regularly through the bladder with- 
out any inconvenience whatever. 
was tried, two or three weeks subsequently, with 
a similar result. The operation adopted was, I 
presume, that of Dr. Sims, with the addition of 
the Bozeman button, as she described the em- 
ployment of silver wires, and a lead plate. Since 
the accident, she informs me she has not men- 
struated ; but alleges, that when the period comes 
round, a very copious flow of urine takes place, 
and continues for two or three days. I was in- 
vited to see her, July Ist, 1859, by Dr. R. K. 
Smith, Chief Resident Physician; and in com- 
pany with himself, and Dr. Elwood Wilson, 
made an examination. An extensive transverse 
rent was discovered, extending from one side ot 
the vagina to ihe other, and situated at the has 
fond of the b’ad ler. Through this protruded a 
considerable mass of the mucous membrane of the 
bladder. At the request of Dr. Smith, and her own 
earnest entreaty, I consented to attempt her relief 
by an operation. 
Failure ought not in any way to discourage either 
patient or the surgeon. The rule is to operate 
until the case is cured, as such a consummation 
is certain, unless there be some unusual state of 
things present. One caution is necessary here: 
The operation should not be repeated until at 
least six weeks have elapsed. 
Sequels. There sometimes follows a successful 
closure of the fistula a certain degree of inconti- 
nence of urine, which is due generally to one of 
two causes. First, loss of power in the sphincter 
vesicm, permitting the urine to escape when the 
bladder is distended, or during coughing, sneez- 
ing, or even laughing. This condition may fol- 
low when fistula -has been at the neck of the 
bladder. The second cause is shortening of the 
lower wall of the urethra, with a patulous condi- 
tion of the meatus—as in cases where the open- 
ing is low down, with such a loss of substance 
that when the stitches are inserted, and the parts 
drawn together, the traction produces the effect 
already stated on the urinary canal. 
On the 23d of August it was performed in 
the presence of Drs. Smith, Wilson, Levis, 
McClellan, Darby, Nichols, and the inter- 
nes of the house, the bowels having the day pre- 
vious been well emptied. The steps of the opera- 
tion consisted in placing the patient under the in- 
fluence of ether, turning her over, supported on 
the arms and knees, and exposing the fistula by 
inserting rectangular or lever speculm along the 
walls of the vagina, which enabled the assistants 
to draw the parts well asunder. The edge of the 
fistula was next seized with a pair of long rat- 
toothed forceps, and well pared by means of a 
long-handled straight bistoury. As soon as the 
bleeding ceased, nine stitches of silver thread were 
inserted, the needles being guided by the needle- 
holder of Mr. Gemrig, (see Fig. 46, page 273.) 
The wires being brought out of the vagina, the 
opening was drawn together by passing the two 
ends of each through an adjustor, which was slid 
down to the wound, while the threads Avere firmly 
maintained between the fingers. Not being alto- 
gether satisfied rvith the principle of the Bozeman 
button, as it prevented the operator seeing the 
approximation, I had a fenestrated one construct- 
ed out of lead (Fig. 60.) Through the perfora- 
To remedy these defects, tonics, cantharides, 
and strychnia have been prescribed; yet, after 
all, time is the great restorer, as the parts tend 
gradually to assume their original condition. 
Should the incontinence be so great as to produce 
much discomfort, an elastic ring pessary may be 
passed within the orifice of the vagina. In one 
case, (No. 14,) I had to resort to this, with the 
most complete success. 
Keport of Cases of Vesico-Vaginal Fistula Suc- 
cessfully Treated, and which have furnished 
the basis of the previous papers. 
Case 1. F. H. was admitted into the Philadel- 
phia Hospital, Blockley, suffering from a vesico- 
vaginal fistula. The folloAving account of the ac- 
cident Avas obtained from the patient: In Jan- 
uary, 1858, she gave birth to a child. Her labor 
was exceedingly difficult and prolonged, to aid 
which ergot was freely administered by her med- 
ical attendant. After delivery, for several days 
she was unable to pass urine; Avhich, continuing 
to accumulate, and not being relieved by instru- 
mental interference, she suddenly felt a large 
gush of vrater escaping from the vagina, since 
which time the urine continued to fIoAV by this 
route. In May, 1858, her physician performed 
an operation for her relief. This failing, a second 
Fig. 60. 
tions in its centre-bar the wires Avere next passed, 
the button run down over the line of adjustment, and there maintained by passing the ends of each 
suture through a perforated shot, which, being 
slipped down in contact with the button, was 
there secured by compressing it between the 
blades of a strong pair of forceps. The wires 
were next collected together, brought out of the 
vacina, and wrapped with adhesive plaster to 
prevent excoriation 5 and finally, the patient 
placed in bed, on her side, a catheter (Sims’) 
was introduced into the bladder, and the urine 
recieved on cloths placed beneath the end of the 
instrument. Half a grain of opium was directed 
to be given tAvice daily, and the diet to consist 
chiefly of arrow-root and cream. The catheter 
was to be closely watched that it should not become 
obstructed, to obviate which, it Avas to be removed 
once or tAvice a day, and cleansed. No consti- 
tutional disturbance occurred, nor was there any 
local soreness experienced. On Wednesday after- 
noon, September Ist, being ten days after the 
operation, I proceeded to remove the button and 
sutures, when the union Avas found to be com- 
plete. As a precautionary measure the catheter 
was directed to be Avorn eight days longer. On 
the twelfth day her bowels were opened, and 
again locked up for five or six days. Ten days 
after the removal of the ligatures she was al- 
lowed to rise from her bed and walk about. 
Hospital, under my charge, where, after some 
preliminary treatment to improve her general 
condition, she was operated on by my usual me- 
thod, seven silver sutures being required to close 
it properly. On the eighth day the stitches were 
taken out, and the Avound found to be only about 
one-half closed. On carefully examining the 
parts, and reflecting over the former failure, I 
thought I discovered the true source of difficulty, 
which subsequent events confirmed. The prox- 
imity of the fistula to the cervix uteri, the latter 
organ being somewhat retroverted, prevented an 
accurate adjustment; indeed the os was turned 
into the fistulous opening, and pressed toward 
the bladder. Profiting by this observation, at the 
second operation, undertaken nine Aveeks subse- 
quently, I determined to turn the os into the 
opening permanently. With this end in view, 
the inferior semi-circumference of the fistula was 
well pared. Next the posterior half of the cervix 
uteri, after which eight silver sutures were intro- 
duced, and secured by the shot, the ends of the 
wire being cut off close to the latter. The os 
uteri was by this method turned into the bladder. 
Nothing worthy of note transpired during the 
subsequent progress of the case. On the eighth 
day following the operation the parts Avere exam- 
ined with a view to remove the ligatures, which 
were found in such excellent position, Avithout 
any surrounding irritation, that, at the sug- 
gestion of Dr. E. Wilson, who rendered me 
valuable service in both operations, I was in- 
duced to allow them to remain for two days 
longer. On the tenth day they Avere clipped out, 
and to our great satisfaction the fistula closed. 
Since that time this woman has menstruated re- 
gularly through the bladder; enjoyed comfortable 
health; been able to support herself as servant to 
a private family, and certainly rid of a most dis- 
tressing and disgusting malady. Two years after 
I operated on this same patient for strangulated 
umbilical hernia, from Avhich she recovered with- 
out any unusual symptoms. It is not often we 
meet Avith an example of so many grave acci- 
dents, operations, and good recoveries, in one 
person, as are presented in the narrative of this 
poor, friendless Irish-woman. 
Case 2. A. M., an Irishwoman, about thirty 
years of age, during a severe labor with a first 
child, ruptured her uterus, the child escaping 
into the abdomen. The foetal head had not 
passed below the superior strait of the pelvis, the 
diameters of which were contracted. The case 
being under the care of the medical officers of 
the Nurses’ Home, Dr. E. Wilson was immedi- 
ately summoned to her aid by the attending phy- 
sician, Dr. Scholfxeld. The propriety of the 
abdominal section admitted of no question. The 
operation was accordingly performed by Dr. Wm. 
Byrd Page, the child removed through the pari- 
eties of the abdomen, and the life of the mother 
preserved. Sometime afterward it was discovered 
the rent in the uterine walls had extended through 
the cervix and involved the vagino-vesical septum, 
giving rise to a fistula. After the restoration of 
the woman’s general health, she was placed in 
St. Joseph’s Hospital, and at considerable in- 
tervals three unsuccessful attempts were made 
to close up the orifice, which was situated near 
the cervix uteri, and running in an oblique direc- 
tion, about three-quarters of an inch in extent. 
Two of these operations were skilfully performed 
by the Bozeman method, employing as a reten- 
tive mechanism a lead plate or button. The pa- 
tient was afterward placed in the Philadelphia 
Case 3. Catherine , a young woman aged 
19 years, was seized with labor-pains, September, 
1858, at the Philadelphia Hospital. In conse- 
quence of the great size of the foetal head, it 
became completely impacted in the pelvic cavity. 
After ineffectual efforts to deliver with the for- 
ceps, the operation of craniotomy was resorted to 
by Dr, R. K. Smith, Chief Resident Physician, 
and the child readily removed. In consequence, however, of the prolonged pressure sustained by 
the anterior wall of the vagina, a slough in a few 
days separated, opening a communication be- 
tAveen that cavity and the bladder, through which 
the urine flowed. An examination, some weeks 
after, showed not only the existence of this 
fistula, but the canal of the urethra closed by 
inflammatory deposit. A trocar was at once 
carried through the obstructing material into the 
bladder, followed by a catheter, which Avas re- 
tained for eight days, only being removed for the 
purpose of cleansing. In this manner the ure- 
thra Avas restored. 
bled with for some time previous to the operation, 
harassed her so much, notAvithstanding the free 
administration of opium, as sometimes to drive 
the catheter out of the bladder. 
On December the 27th, ten days after the ope- 
tion, the sutures were removed, and the wound 
found to have united, save at one single point, 
which was subsequently and permanently closed 
by a single stitch. The catheter was kept in the 
bladder a few days longer, in order not to en- 
danger the cicatrix. This patient was watched 
with great care by Drs. Darby, Richardson, and 
Taylor. 
On the 16th of December following, the parts 
having become sufficiently callous, an operation 
was performed for her cure; her bowels being 
well opened the day previous, after Avhich It 
grains of opium were administered. 
Case 4. Mary II , aged 25 years; unmar- 
ried, temperate, and a Philadelphian by birth, 
was received into the Philadelphia Hospital in 
September, 1858, pregnant. This was her second 
pregnancy. In her first labor, she states she Avas 
brought to bed on Monday morning, and delivered 
the folloAving Thursday morning of a still-born 
child; the delivery being brought about, as she 
says, by the physician in attendance using 
11 forcing powders.” 
She Avas placed under the influence of a mix- 
ture of ether and chloroform, turned upon her 
abdomen, over a stool Avell protected, the limbs 
being supported by two assistants, and the parts 
exposed by a Sims’ speculum. The fistula, which 
was transverse through the trigone vesicce, and 
exceeding an inch in its greatest diameter, could 
now be Avell seen. The edges were seized with 
the long rat-toothed forceps, and with a long, 
straight, sharp-pointed bistoury, pared in their 
whole extent. Seven needles, slightly curved at 
their points, each armed with a silver thread, 
were carried successfully, by means of the needle 
holder figured in cut No. 46, through the edges 
of the wound, down to, but not into the vesical 
mucous membrane. These sutures being brought 
out of the vagina, Avere passed through the adjus- 
tor, in succession, and draAvn upon as the latter 
was passed down, thus approximating the edges 
very completely. Perforated shot were next run 
down over the wires, and clamped by means of 
the compressor. The sutures Avere noAv tAvisted 
together, and passed through a small tube of 
rubber to protect the parts, and the catheter car- 
ried into the bladder, to which was attached a 
flexible piece of gum elastic tubing, designed to 
convey the urine into a bottle, properly placed 
between the limbs of the patient for its reception. 
The patient being placed in bed, an anodyne was 
administered; the Avhole time consumed, includ- 
ing etherization, did not exceed one hour. 
Everything progressed favorably until the third 
day, when, notwithstanding opium had been 
given to keep the bowels in a quiescent state, 
diarrhoea, attended AArith considerable straining, 
came on, but which was at length controlled by 
enemata of laudanum. To make the case more 
embarrassing, a cough, which she had been trou- 
On the 29th October, 1858, at ,A. M., labor 
commenced. At 6 o’clock, P. M., it was suffi- 
ciently advanced to establish the existence of a 
breech presentation in the first position. At 2, 
P. M., the foetus was expelled as far as the um- 
bilicus; the limbs being much discolored from 
long-continued pressure in the pelvic cavity. The 
delivery of the head was delayed by the chin 
leaving the breast, requiring finally the agency 
of the blunt hook to bring it down; the labor 
being completed at 5 o’clock, making from its 
commencement thirty-seven hours and a half. 
Alarming hemorrhage followed, which was ar- 
rested by the removal of the placenta, frictions 
OArer the hypogastrium, and ice. The child AATeigh- 
ed 9J pounds, and measured 22 inches in length. 
For twenty days the woman passed her urine 
naturally, and without pain or difficulty. On the 
tAventy-first day it commenced to Aoav through 
the vagina; a slough having separated, and 
formed the fistula. Its situation was at the tri- 
gonum vesicce, and about six lines in its greatest 
diameter. 
On the 14th of February, 1859, the parts hav- 
ing attained the requisite healthy conditions, the 
operation for cure was executed. An aperient 
was given the day previous. The Avoman was 
placed under an anaesthetic of ether and chloro- 
form, (three parts of the former to one of the 
latter, by weight,) turned over the padded stool 
on her abdomen, the hips being well elevated, 
and the fistula being exposed by introducing into 
the vagina the duck-bill speculum. The edges were next extensively denuded, and after the 
bleeding ceased, five silver sutures were inserted, 
and their ends brought out of the vagina, and 
the edges closed by the adjuster. Over each was 
passed a shot, and the stitch made secure by the 
compressor clamping it on the wires. The su- 
tures were gathered together, and passed through 
a piece of elastic tubing; the woman placed in 
bed, and the catheter at once inserted into the 
bladder, over the end of which was slipped the 
light gum-elastic tube, to oonvey the urine into a 
bottle properly placed in the bed. The bowels 
were controlled by opium, one-half grain, three 
times a day, for two days; after which, the one- 
third of a grain three times a day. The diet 
consisted of nutritious broths, with some fari- 
naceous articles. Nothing unusual occurred; 
and on the eighth day the stitches were removed, 
and the cicatrization found to be complete. The 
bowels were gently open on the ninth day, and 
the catheter continued five days longer. On the 
sixteenth day she was allowed to sit up, and on 
the twentieth day permitted to exercise in the 
ward. 
in the bladder, and carefully watched that it 
should not become obstructed with mucous or 
blood. This girl proved to be a very self-willed 
and troublesome patient. 
On the ninth day after the operation the stitches 
were taken out, and the fistula, as we believed, 
closed. She was kept in bed with the catheter in 
the bladder for five days longer, after which she 
was allowed to sit up, the instrument being used 
four times daily, and worn at night for three days 
more, when it was laid aside, and the patient 
allowed to walk about. She was retained in 
the house for two weeks longer, and then dis- 
charged well. 
About four months later this young woman re- 
turned, seeking admission, alleging that the fis- 
tula had re-opened. She had evidently, from her 
own statements, been leading a very irregular life. 
On carefully inspecting the parts, a small open- 
ing, admitting the end of a probe, was detected in 
the middle of the cicatrix. There could be no 
doubt this fistula had opened during her ab- 
sence, as the bladder was perfectly retentive, and 
the urine passed voluntarily in a full stream for 
the two weeks previous to her leaving the hospi- 
tal. Four operations were performed unsuccess- 
fully to close this small hole, at intervals of eight 
weeks, and requiring but three stitches when 
freshened. I was satisfied there was something 
wrong, as there was nothing in the case which 
could explain this indisposition to heal. I sus- 
pected the woman was more anxious to have a 
home than to get rid of her disease, and doubt- 
less, at night, in the absence of the nurse, with- 
drew the catheter, introducing it herself before 
her morning visit. Accordingly, on discovering 
my failure in the fourth operation, without wait- 
ing for some time to elapse, the parts were again 
denuded, and two sutures inserted; relays of 
nurses were kept night and day by her bed, and 
on the eighth day the parts were examined, and 
the sutures taken out. The opening was closed. 
The bowels had been confined for 17 days, and 
after wearing the catheter four days longer, she 
was allowed to dispense with its use. 
This case was reported in detail, by Dr. Darby, 
in whose care the patient was, Med. and Surg. 
Reporter, vol. 1, page 435. 
Case 5. K. D., a Scotch girl, unmarried, 20 
years of age, was admitted into the Philadelphia 
Hospital in April, 1859, pregnant. Her labor, 
which occurred in September, was difficult and 
prolonged, the head presenting, although the 
position is not known. She was finally delivered 
by the forceps, of a dead child, at the full term. 
One week after, the urine was observed trickling 
from the vagina, and, on examination, some three 
weeks subsequent, a fistula was discovered, about 
seven lines long, and situated at the vesicle tri- 
angle. Two months after her parturition she 
was transferred to the Woman’s Surgical Ward, 
and prepared for an operation, by washing out 
the vagina every day with a solution of tannic 
acid, to give some tone to the parts; regulating 
the diet, and improving her condition by tonics. 
After the lapse of another month, she was con- 
sidered well enough to justify an operation. This 
was performed in the presence of the house resi- 
dents, in the manner already detailed in the pre- 
vious cases. Seven silver threads were intro- 
duced (the patient being under the influence of 
ether and chloroform), and these stitches secured 
with the usual clamp of shot. Instead of bring- 
ing the wires out of the vagina after the adjust- 
ment, they were cut off close to the pellets of 
shot. Opium was administered in doses sufficient 
to keep the bowels closed, and the catheter kept 
My surmises in regard to the cause of failure 
were corroborated by her own confession. One 
year after, this po'or unfortunate girl applied 
again for admission, not on account of the fistula, 
which remained well, but evidently dying from 
tuberculosis, induced by a life of dissipation. 
Case 6. Ann II , a native of Ireland, aged 
33 years, and a resident of Delaware County, 
Pennsylvania, was admitted into the Philadelphia 
Hospital on the 24th of January, 1860, with a 
vesico-vaginal fistula, situated three-quarters of an inch below the upper extremity of the vagina, 
four lines in length, and running oblique to the 
longitudinal axis of the canal. About ten months 
before her admission into the institution she had 
been delivered by instrumental means of a child, 
after a difficult labor of thirty-six hours duration. 
I believe this was her second child. A few days 
succeeding this she discovered her urine dribbling 
away, without being able to exercise any control 
over its escape. As the avoid an’s health was by 
no means good, the first attention Avas directed 
to its improvement, which, under the employ- 
ment of mineral tonics, and a good diet, AAras, in 
a few weeks, in a good measure restored. The 
last of the succeeding month (February) the op- 
eration Avas performed, while under the influence 
of ether and chloroform as an anaesthetic. Four 
sil\7er sutures were introduced, and secured by 
means of a Avire tAvister. The wires were next 
cut off very near to the wound, and the ends 
turned doAvn in such a manner as not to irritate 
the posterior wall of the vagina. The catheter 
was worn uninterruptedly, and the bovrels locked 
up with opium. The case progressed without 
any unfavorable symptoms Avhatever, and on the 
eighth day the stitches Avere removed, and the 
union found to be complete. The patient was 
retained in the hospital nineteen days longer as a 
precautionary measure, during four of which she 
was obliged to wear the catheter. 
catheter was introduced into the bladder, and the 
patient placed in bed, with directions to adminis- 
ter the usual pills of opium. Difficulty was expe- 
rienced in keeping the catheter clear, it becoming 
obstructed with clots of blood for three or four 
days. She suffered also, throughout the whole 
treatment, with flatulent colic and some diarrhoea ; 
the last Avas controlled by enemata of starch- 
water and laudanum, morning and evening. Her 
appetite failed, and her stomach became irrita- 
ble, for the relief of Avhich alkalies were pre- 
scribed with benefit. At the expiration of nine 
days, the sutures wese examined, without being 
at all sanguine as to a favorable result. Several 
had ulcerated out, and no disposition was exhibit- 
ed at any point to heal. They were all removed, 
and the patient, in a few days, ordered out to 
take exercise in the open air. 
Yegetable tonics, with an occasional mercurial, 
followed by the tincture of the chloride of iron, 
wrought a wonderful change in her condition, 
so that in six Aveeks after, avc deemed her health 
sufficiently good to undertake a second operation. 
The edges of the fistula had changed. Instead of 
being spongy and soft, they had become firm. 
There Avas no more than the ordinary bleeding 
after the application of the knife in vivifying the 
margins. Six metallic threads Avere introduced, 
secured each by the shot-clamp, and the usual 
treatment pursued. Not a single untoward symp- 
tom occurred, and after eight days the stitches 
were removed, and the union found complete. 
Dr. Recio, one of the resident-physicians of the 
hospital, Avas unremitting in his care of this pa- 
tient. 
Case 7. Matilda L., aged 24 years, was sent 
from Wilmington, Delatvare, by Dr. Pepper Nor- 
ris, She entered the hospital August, 1860. 
An examination proved the existence of a vesico- 
vaginal fistula at the has fond, transverse in di- 
rection, and about six lines in length. It fol- 
loAved her first labor, which Avas sufficiently 
difficult to demand delivery of the child (dead- 
born) by the forceps. The presentation was a 
cephalic one, and she heard nothing said about 
anything being wrong. A few days after, she 
could not state lioav many, the urine began to 
Case 8. K. C., born in Ireland, recently from 
the vicinity of Bordentown, N. J., aged 28 years, 
entered the hospital in the spring of IB6o*, with 
a vesico-vaginal fistula situated a short distance 
above the neck of the bladder, oblique in position, 
and about five lines in extent. The entrance to 
the Amgina was much constricted, rendering the 
exposure of the fistula difficult. The accident 
occurred about eighteen months before, in a first 
labor, in Avhich a dead female child was deliv- 
ered by instruments. She is not certain that 
the head presented. Difficulty Avas experienced 
in adjusting the instruments, and she felt as 
though the vagina had been torn at the time. As 
the fistula was seated above the stricture, it 
became necessary to institute the preliminary 
treatment of dilatation, Avhich Avas effected 
by gum-elastic bougies, after two weeks. This 
i flow from the vagina. The woman was pale, 
ctamemic, and had but little appetite. She was 
bplaced on a regimen of tonics and nutritious food, 
Tin order to improve her health. Some progress 
atwas made, but by no means equal to our expecta- 
htions, and after Availing five weeks, I concluded 
to make an attempt for her cure. On paring the 
edges the bleeding became very profuse, and 
continued, notAvithstanding the application of ice 
and a stream of cold Avater from the nozzle of a 
syringe. To arrest this, seven stitches were in- 
serted, and the edges draAvn firmly together. 
Even these did not entirely control the haemor- 
rhage, some considerable oozing continuing. The 
* The record of this case being lost, I am unable to refer with 
certainty to the date of her admission, my own notes only con- 
taining the details of the operation. 37 
accomplished, the operation was performed in 
the presence of the medical residents, the patient 
being under the influence of the usual anaesthetic 
of ether and chloroform. After the edges were 
sufficiently denuded, six metallic (silver) threads 
were introduced, the parts brought in contact by 
passing each suture in detail through the adjus- 
tor, and securing the apposition by the shot- 
clamp. The rigid character of the vaginal walls, 
in consequence of the amount of cicatricial tissue, 
rendered all manipulations difficult. 
Penrose, Drs. La Roche and Boardman. Nine 
silver threads were inserted and secured by the 
shot-clamp. The usual course in regard to 
opium, catheter, and diet was observed. No- 
thing unusual occurred, worthy of' note, during 
the treatment. On the ninth day the stitches 
were removed, and the wound found united. 
The catheter was continued five days longer, the 
bowels being gently moved on the twelfth day 
after the operation. This patient I saw over two 
years after, when she stated she remained per- 
fectly well, and was about four months advanced 
in her second pregnancy. 
From this until the ninth day following, no- 
thing of importance occurred. The threads were 
on this day removed, and the fistula found about 
two-thirds closed. She was allowed two months’ 
respite, occasionallly having a large-sized bougie 
introduced to counteract the persistent tendency 
to contraction of the vaginal canal, after which a 
second operation was executed, in which four 
stitches were inserted. A good deal of bleed- 
ing from the bladder followed for two days 
succeeding this, rendering it difficult to keep 
the catheter unobstructed. On the third day it 
ceased, and the case progressed very favorably 
during the remaining period of her treatment. 
The stitches were cut out on the ninth day, the 
union having taken place throughout. This wo- 
man, after getting about, complained of some in- 
continence, and I was disposed to believe some 
minute orifice must still exist, although undis- 
covered. Since, however, the nurse informs me, 
this disappeared, and she left well. 
Case 10. L. L., aged 35 years, from Pennsyl- 
vania, was admitted to the Philadelphia Hospital 
in the month of April, 1864, suffering from a 
transverse vesico-vaginal fistula, three-quarters 
of an inch in extent, and situated in the has 
fond, with the complete destruction of the ure- 
thra. She was married at the age of 17 years, 
and 15 months after fell in labor with her first 
child at full term. She knows the child pre- 
sented by the vertex. After being in labor forty- 
eight hours the forceps was applied, and after 
one hour the child was extracted dead, a male, 
and more than ordinarily large. Her urine, she 
states, was not drawn off, and she was never con- 
scious, after delivery, of passing her water the 
natural way. This fistula was therefore over 
seventeen years’ standing. The vagina had un- 
doubtedly sustained much injury, as it was 
greatly narrowed in its whole extent. Her health 
was poor, and in no condition for an operation. 
She was placed on a tonic course of treatment, 
with some improvement, and on the 9th of June, 
1864, I concluded to make an attempt for her 
relief. The edges were pared, and fifteen wire 
threads inserted, securing each with the shot, 
which closed the vesico-vaginal rent satisfactorily. 
A catheter was placed in the bladder, and worn 
for nine days, when the stitches were removed; 
no attempt even at union seemed to have occur- 
red. Increased attention was now given to her 
general health, and on the 28th of the following 
October, a second attempt was made, twelve 
stitches being inserted, and with an unsuc- 
cessful result, union having taken place only to 
the extent of one-third of an inch. On the 3d of 
March, 1865, a third operation was executed, 
nine sutures being used, and the result again 
unfavorable, On the 2d of June a fourth opera- 
tion was performed, in which, nine threads were 
employed, and this time with complete success. 
During the period she had been suffering from 
this fistula she had five miscarriages, all occur- 
ring at the fourth month. It is contemplated to 
- Case 9. Mrs. GL, an Irish woman, aged 40 
years, who married late in life, fell in labor with 
a first child January, 1863. She states her pains 
commenced on a Friday, and gradually increased 
in severity until the following Sunday, when she 
became so exhausted as to render the application 
of the forceps necessary to complete delivery. 
The child, a male, head presentation, was born 
dead. The bladder had not been catheterized. 
At no time after that had she a sensation like 
urine passing by the urethra. Her getting upwas 
slow, and it was many weeks before she was 
able to walk, in consequence of a feeble state of 
the limbs, with diminished sensibility. In No- 
vember, 1863, she was kindly referred to me by 
Prof. F. G. Smith, of the University of Pennsyl- 
vania, to whose care, she had been sent from the 
country. On examination, a fistulous opening 
was found between the vagina and bladder, situ- 
ated at the has fond, three-fourths of an inch in 
extent, and transverse in direction. 
On the 10th of November, I operated in my 
usual manner, assisted by Profs. F, G, Smith, 38 
attempt next the formation of a urethra for this 
patient. 
lowed some to escape, and advised the use of 
tonics, with the extract of nux vomica, and not to 
allow the urine to accumulate. The difficulty 
was not relieved, and, on a second careful exami- 
nation, an opening, of almost capillary dimen- 
sions, was discovered at one angle of the cicatrix. 
The part was denuded, and two stitches inserted, 
which completed the cure, as she has since been 
perfectly well. 
Case 11. Mrs. H., aged 28 years, residing in 
an adjoining State, fell in labor with a first child. 
Her parturition was slow, vertex presentation, 
and becoming exhausted, the forceps was applied 
for her relief, and the process completed by the 
removal of a dead female foetus at full terra. 
Four or five days following, her urine was dis- 
covered dribbling over the genitalia, and on in- 
quiry, by her physician, little doubt was enter- 
tained that a fistulous opening existed between 
the bladder and vagina. On the 24th of May, 
1865, eight weeks after recovery, I visited her, 
and on examination discovered the opening situ- 
ated near the cervix vesicae, oblique in direction, 
and about three-quarters of an inch in extent. 
She was placed under an anaesthetic of ether, and 
after freshening the margin of the opening, it 
was brought together by six sutures of silver 
wire, and clamped with shot, the usual detail of 
treatment being observed. In consequence of 
some pleuritic symptoms occurring about the 
eighth day, the stitches were not removed until 
the tenth day, when the wound was found thor- 
oughly united. 
Case 13. Mrs. •, aet. 30, a small delicate 
lady from a distant land, in a first labor, greatly 
protracted, discovered, after five days, her urine 
running from her without control. She was in- 
formed that a fistula existed, and was for some 
time treated by cauterization. Becoming in the 
meantime pregnant, all remedial measures were 
suspended. Her confinement took place in Phil- 
adelphia, under the care of Dr. Stroud, seven 
weeks after which, I was invited by the Doctor 
to visit her and examine the case. The fistula 
was quite small, and situated in the vesicle tri- 
angular space. On Sept. 12th, 1865, assisted by 
Drs. Stroud, Hunt, Rodman, and Townsend, I 
performed the usual operation, inserting, after 
the edges were properly denuded, four silver su- 
tures, and securing them with shot. The subse- 
quent treatment was conducted by Dr. Stroud. 
The only troublesome symptom arising in the 
progress of her case was occasionally a violent 
spasmodic contraction of the bladder, expelling 
the catheter, but which was overcome by enemata 
of a little thin starch-water with laudanum. On 
tho ninth day I removed the sutures, the opening 
being successfully closed. Yery recently I have 
heard from this patient, who continues to enjoy 
perfect health. 
Case 12. Mrs M., of Philadelphia, aged 30 
years, applied to be relieved of a vesico-vaginal 
fistula. A few months previous she had been 
delivered of a dead child (her first), after being 
in labor forty-eight hours. It was a breech pre- 
sentation, and after the extrusion of the body, 
the head was retained for several hours. At 
what time after, the opening occurred she could 
not determine, as she had no sensations decisive 
of the accident, but believes the urine dribbled 
ever after her labor. 
Case 14. Mrs. G., mt. 29, residing in a neigh- 
boring village, went into labor -with her first 
child. Her pains were severe and exhausting. 
The head of the child presented, and after thirty- 
six hours, the forceps were applied and the child 
extracted, dead. Her urine had not been re- 
moved during labor, and she thinks that, four 
days after, it commenced escaping from the va- 
gina. 
On the 24th of November, 1864, I operated, 
assisted by Drs. McLerny, Wilson, and Allen. 
The opening was situated about three-quarters of 
an inch above the cervix vesica;, transverse in di- 
rection, and about six lines in extent. It was 
freely freshened, and closed with eight silver 
sutures. Nothing unusual occurred during the 
subsequent course of the case, and on the ninth 
day the sutures were removed, the opening to all 
appearance closed. After getting up she was 
under the impression all was not quite right, as 
she was conscious of an unusual moisture at the 
outlet of the vagina, and her clothing had a 
urinous odor; still she was able to pass her water 
in a fair stream. On examination I failed to de- 
tect any opening, although the bladder was not 
injected, the cicatrix looking so perfect. I was 
disposed to believe the urethra or neck of the 
bladder had not entirely recovered tone, and al- 
When I first visited her, she informed me a year 
and a half had elapsed since the accident, and 
that three operations had been attempted without 
success. On examination a double fistula was 
discovered, each running transversely through 
the vesical triangle, and separated from each 
other by about three-eighths of an inch. This 
condition was easily explained by referring to 
the previous operation—the middle of the wound 
uniting, and the extremities remaining open. 
Assisted by Drs, Morton, Sutton, Agxevv, and 39 
Weightman, I operated a few days after, by par- 
ing the edges of each, and closing one with 
five, and the other with four sutures. Everything 
progressed well until the third day, when she 
was seized with pain in the abdomen, with free 
Heeding from the vagina, which at first I was 
disposed to believe was a copious menstruation. 
Her bowels also became disturbed, and her ap- 
petite failed. Opium and warm fomentations re- 
lieved her pain and diarrhoea, but the bleeding 
continued for seven days. On the ninth day, the 
threads were removed, one fistula being found 
closed, and the other open. After this the wo- 
man became pale and dyspeptic, and in no con- 
dition to justify an operation. Under a properly 
regulated diet and tonics, she improved rapidly 
in general health, and in the meantime became 
again pregnant. 
Two months after her confinement, on the 4th 
of November, 1865, assisted by Drs. Patterson, 
Hall, and Townsend, I operated, closing the 
opening with nine metallic threads. Not an 
unpleasant symptom occurred, and the sutures 
were removed on the ninth day following, the 
wound proving to be closed soundly in its entire 
extent. An interesting fact connected with this 
case was the disposition, if she allowed her blad- 
der to become too much distended, to some in- 
continence. To correct this an elastic-ring pes- 
sary was introduced, which, by its pressure on 
the neck of the organ, effectually relieved the dif- 
ficulty. 
Mortox, Hem'son, and the hospital residents, I 
executed the operation described in the previous 
cases. As the neck of the uterus formed one 
side of the fistula above, the os looking into the 
bladder, it was necessary to freshen it, and secure 
it to the opposite side. The opening was closed 
longitudinally with thirteen sutures. Not an 
unfavorable symptom followed the operation, and 
on the ninth day these stitches were taken out, 
and except at a single point, where the vaginal 
wall blends with the cervix uteri, a solid union 
secured. To close this a second operation was 
performed, eight weeks after, requiring three 
Stitches, and resulting in complete closure. 
Anomalous Symptoms.—Death.—Pyeexnio Peri- 
tonitis. 
Reported by Dr. William Pepper, Resident Physician. 
Case 16. Cornelia Augusta Handy, mt. 24, color- 
ed, was admitted to Pennsylvania Hospital April 
14th, 1866, suffering with a vesico-vaginal fistula of 
very great size, resulting from prolonged second 
stage in her first labor, six months ago. She 
has been for years in delicate health, though 
evincing no positive sign of organic disease'. Hr. 
Agnew operated upon her, Thursday, Apx-il 19th, 
1866, the edges being pared and brought to- 
gether, antero-posteriorly, by thirteen silver sU- 
tures, clamped with shot. The two upper stitches 
including the involved anterior lip of the os uteri. 
A full opiate was administered, and a self-retain- 
ing catheter introduced. The urine came readily 
through catheter, and the woman did well until 
the afternoon of Saturday, April 21, 1866, when 
she had a very slight chilly sensation, followed 
by scarcely any fever or sweat. The following 
morning I found her with a dry hot skin, rest- 
less, lying on her back with legs drawn up, com- 
plaining much of abdominal tenderness. The 
entire abdomen was sensitive to pressure, rather 
more markedly so in the hypogastric region than 
elsewhere. There had been very little hemor- 
rhage, and the catheter remained quite clear. She 
was at the time under mild opiate influence— 
having taken gr. i. twice daily. Bowels consti- 
pated. Opium and emollient applications to ab- 
domen were ordered, but during the day she had 
four or five thin serous stools, and vomited a 
number of times, the abdominal symptoms re- 
maining unabated. No recurrence of chill. 
Case 15. S. G., aged 25 years, a native of Ire- 
land, was admitted into the Pennsylvania Hos- 
pital, October the 10th, 1865, suffering from a 
vesico-vaginal fistula since the April previous. 
It occurred as a consequence of a tedious labor 
with her second child, forty-eight hours having 
elapsed before it was delivered. Her physician 
stated to her it was a cross-birth. No instru- 
ments were used, but the leg of the child was 
broken in two places. Of course the foetus was 
dead. The time she passed her urine first through 
the vagina, she could not determine, but thinks 
before the second day after her confinement. At 
the expiration of two weeks she got up, but found 
herself so weak on her limbs as to be unable to 
walk. Her first labor was not difficult. After 
her recovery, two operations were performed for 
the closure of the fistula, by her physicians, both 
unsuccessful. On examination, after her admis- 
sion, the fistula was found to extend longitudi- 
nally from the neck of the bladder to the os 
uteri, and inclining to the left of the cervix passed 
along its entire length. 
April 23d. Much the same. Diarrhoea and 
vomiting persisting. Complains of abdominal 
tenderness. Tongue furred in centre, merely 
dryish. Pulse rapid and small. Catheter runs 
freely, but little blood passing. No chill or chilly 
sensation. Opii, gr. J, calomel, gr. ss., q. t. h. 
Hop-poultice to abdomen. Light diet. 
On the 24th of October, assisted by Drs. Hunt, 40 
April 24. Expresses herself as feeling better 
Less abdominal tenderness; Belly not'distended 
No vomiting. Less diarrhoea. There is, how- 
ever, extreme huskiness of voice, and mental de 
jection. 
deeply stained of a yellowish hue. The blood in 
the cerebral veins was clotted, as it was in most 
of the vessels of the body. 
Thorax. Lungs anaemic, congested postero- 
inferiorly, but contained no pysemic deposits. 
Bronchial glands not enlarged. Heart contained 
no fluid blood, and a very small, quite firm coagu- 
lum in right ventricle, extending into pulmonary 
artery, but by no means filling its calibre. Healthy 
in structure, though these organs, as all the 
others, were stained yellow. 
April 25th, 26th, 27th, 28th. Remained in 
much the same condition, excepting that great 
jaundice came on, the conjunctive being deeply 
yellow, and the jaundice-tinge showing through 
the dark skin. The vomiting has not recurred; 
but, despite the free use of opium, she had several 
thin stools daily. The calomel and opium were 
suspended after sixty hours, as the abdominal 
tenderness disappeared almost entirely; the pulse 
became less frequent, and the skin less parched 
and dry; and Huxham’s tincture of bark, with 
nitro-muriatic acid and a small amount of stimu- 
lus, were ordered. There was nothing like a 
chill or intermission in the febrile movement. 
The voice remained very husky and feeble, and 
she evinced great hpbitude. 
Abdomen. On opening the abdominal walls, 
there was a gush of thick yellowish, ochre-colored 
fluid, identical in thickness, color, and smell, 
with the fluid so often seen in pyasmic pleurisies, 
and upon examining the cavity of abdomen, it con- 
tained at least Oij. of this fluid. All of the vis- 
cera were coated more or less with yellowish 
cheesy-looking lymph, although the spleen, greater 
omentum, and ilium were so to a most marked 
degree. Upon stripping off this lymph, the sub- 
jacent peritoneum seemed almost entirely healthy, 
not having even an excoriated appearance. In 
no place had any adhesion formed between two 
portions of this deposit. 
April 29th. Expressed herself as feeling more 
comfortable. Had some appetite. Pulse not more 
than 110. Jaundice somewhat decreased per- 
haps. Bowels more quiet. Tongue dryish and 
coated. Abdomen not sensitive, rather retracted. 
No cough. Heart sounds healthy. No delirium 
or brain symptoms. Voice extremely feeble, but 
is a little more animated. 
The liver was of normal size and consistence, 
but deeply stained with the same yellowish tinge 
as wore the other organs. 
April 30th. Stitches removed by Dr. Agnew. 
The anterior half of fistula found to have healed, 
this being the twelfth day. The vagina was 
coated with yellowish layers of lymph, mixed ap- 
parently with urinary salts. Condition very 
much the same. 
Gall-bladder pale and almost empty. 
Spleen slightly enlarged and rather soft. 
Pancreas healthy. Kidneys apparently healthy. 
There was an increase of these appearances over 
the bladder and rectum, and upon opening bladder, 
it was found merely much discolored by chronic 
congestion. It was somewhat thickened, but no 
evidence of any recent inflammation. 
May Ist. Much the same. Pulse small, but 
not so frequent. Skin not harsh. Tongue dry- 
ish. Jaundice marked. Considerable hebitude, 
but perfectly rational, and expresses herself af 
feeling more comfortable and stronger. Her ap- 
pearance, however, belies her, as she was evi- 
dently emaciating rapidly. Her voice Avas al- 
most extinct. She seemed to be more easy when 
lying on her side, and yet Avas almost unable 
to turn over. Made no complaint of pain. Had 
no diarrhoea or vomiting. Took nourishment 
quite Avell, and passed the day mjich as usual, but 
about 10, P. M., after having spoken to the night 
nurse five minutes previously, she was found 
dead, lying quietly in the same position—on right 
side. 
The uterus was of fair size, firm, and on sec- 
tion, presented a normal appearance. The mu- 
cous membrane of its cavity was dark and some- 
what thickened. No evidence of inflammation of 
uterine veins. Eallopian tubes healthy appa- 
rently ; calibres free. 
The fistula Avas found, as stated, reduced in 
size. Edges presenting a pale granulating sur- 
face encrusted with phosphates. The neck of 
uterus, avc have seen, Avas turned into the blad- 
der, and the highest stitches almost passed through 
tissue of the os, but no evidence existed of any 
uterine inflammation, or of the peritonitis having 
started from this point. 
Post Mortem, fifteen hours after death. Quite 
marked rigor mortis. Body emaciated. Spine 
not examined. 
Stomach and intestines presented nothing to 
account for gastro-intestinal symptoms, excepting 
some softening and thinning of the mucous mem- 
brane. 
Brain presented no abnormal condition, save 
that it, like all other parts of the body, was 
Urine could not, of course, be obtained. 41 
The fluid In abdomen contained granular cor- 
puscles, with single or double nuclei, some with 
none apparent, large nucleated cells, a little has- 
matin. After addition of acetic acid, a few cor- 
puscles showed trefoil nuclei. Most of the cor- 
puscles, however, had but one or two. Some 
coagulation of mucus. The whole being evidently 
cacoplastic lymphy fluid. 
The blood, bistre tinted, pale and thin, clotting 
imperfectly, though quite rapidly, forming large 
dark clot, full of white corpuscles. No attempt 
at formation of rouleaux. Red corpusles crena- 
ted. Quite numerous flakes of hasmatin. 
loose, with dyspnoea and a sensation of choking; 
also some tympany; pulse 100. Beef essence, 
and an enema of tinctures opii gtt. L. in a little 
starch water. 
Bth. Eruption made its appearance over the 
abdomen, resembling that of typhoid fever; belly 
tympanitic; tongue dry and brown; dyspnoea 
less; pulse becoming more frequent; twelve of 
the stitches removed by Dr. Agnew, with the 
assistance of Dr. Hunt, the union appeared 
complete, save a small point at the upper ex- 
tremity of the wound. The removal was dictated 
by the feeling, thht, possibly, they might have 
kindled up inflammation, which had extended to 
the serous lining of the pelvis and abdomen. 
Ten drops of oil of turpentine, in mucilage, di- 
rected every two hours; beef essence; milk punch. 
There was no enlargement of inguinal, pelvic, 
dr lumbar glands. 
(Reported by Dr. Andrews, Resident Physician.) 
Case 17. M. S., set. 38 years, a native of Ire- 
land, was admitted into the Pennsylvania Hospi- 
tal, February 13th, 1866, suffering with vesico- 
vaginal fistula. She was a woman of good habits, 
but living in a miserable house, in the vicinity of 
one of our suburban towns. The accident hap- 
pened with her fifth child; was delivered with 
instruments, after being in labor two days. Pre- 
sentation, head. In her former labors she had 
experienced no trouble. The fistula, on examina- 
tion, proved to be longitudinal, and quite two 
inches and a half in length. The tissues ap- 
peared healthy. After a few days of preparation, 
consisting in regulating the diet and opening the 
bowels, the operation for her cure was performed 
by Dr. Agnew, in presence of Drs. Hunt, Mor- 
ton, and the Resident physicians of the hospital. 
The patient being under the influence of ether, the 
edges were extensively pared, and fourteen silver 
stitehes inserted, which were secured by the shot- 
clamp ; the approximation being effected longitu- 
dinally. She was now placed in bed, a catheter 
placed in the bladder, and one grain of opium 
ordered morning and evening. For four days 
everything went on well; all the urine passing 
by the catheter, appetite good, pulse normal, and 
abdomen soft. On the sth she was taken with 
a severe chill, followed by headache, vomiting, 
and mental aberration. As she had suffered from 
chills before entering the hospital, it was hoped 
this might be nothing more than a return of the 
intermittent attack, and accordingly quinine was 
prescribed in antiperiodic doses, 
6th. Vomiting continued; bowels loose; deli- 
rium increased; eyes inflamed; tongue dry and 
crisped. Lime water and milk administered; also 
camphor water, with liq. morph, sulphatis. 
7th. Some abatement of vomiting; stomach 
retains a little liquid nourishment; bowels very 
9th. Patient exceedingly exhausted; pulse'very 
frequent; muttering delirium; diarrhoea; enema 
of laudanum; continue stimulants and nourish- 
ment. 
10th. Died. 
Post-mortem, six hours after death. Adhesions 
between the margins of the fistula had given way, 
and were coated with a dirty lymph; no inflam- 
mation of bladder or uterus. The viscera of the 
abdomen were much congested, though not in- 
flamed. Peyer’s patches healthy; no signs of ul- 
ceration; no peritonitis; no metastatic abscesses. 
The lungs somewhat congested, (hypostatic); 
the pulmonary pleura covered with soft lymph. 
During life, a blowing sound emitted with the 
first sound of the heart was noticed, but no lesion 
of the organ appeared on examination. The 
blood was remarkably fluid. In all probability, 
had this patient been operated on outside of the 
hospital, the termination would have been other- 
wise. A number of cases of pyaemia having 
occurred in the wards, the atmospheric conditions 
were beyond all doubt unsafe. The same may be 
asserted of Case 16. 
Case 18. Rose , an Irish-woman, aged 
about 33 years, was admitted into the Pennsyl- 
vania Hospital in June, 1866, for vesico-vaginal 
fistula. On examination, a stricture of the vagina 
was found about the middle of the canal, the 
opening not exceeding a quarter of an inch in 
extent. The tissue around was dense, almost 
cartilaginous in consistence, and the vagina 
greatly diminished above. It was, of course 
impossible to see just where the communication 
with the bladder existed, but of the fact no doubt 
existed, as the urine all passed throuoh the 
vagina. The accident occured in a first labor 
which had been tedious, lasting two days. Thinks 
no instruments were used. Did not understand 42 
anything was wrong. It was of eight years’ 
standing, and had once been operated on by a sur- 
geon without success. Her health was tolerably 
good, though she was exceedingly nervous. I con- 
cluded to vivify the edges of the vaginal stricture, 
and unite them with the metallic threads, thus 
converting the narrow upper part of the vagina 
and the bladder into a common cavity. This 
course was resolved upon, as the thickening and 
extensive rigidity of the vaginal walls would 
have made the process of dilatation very slow and 
unsatisfactory. This was accordingly done, and 
four sutures inserted, secured in the usual way. 
The bladder was kept drained with the self- 
retaining catheter, and everything passed satis- 
factorily until the fourth day, when she com- 
plained of great abdominal distension, with severe 
paroxysms of pain. All of this was due to accu- 
mulation of flatus, and nothing seemed to control 
it. Her appetite failed, and she was harassed 
with nausea. On the ninth day the stitches were 
taken out, but no union had occurred. She left 
the hospital with the understanding she should 
return, with a view of giving her some prelimi- 
nary general treatment before another operation 
should be undertaken. 
ERRATUM. 
Page 10, 2d column, first line after (Fig. 8), read as follows • 
to freshen the parts. The lining membrane of 
the bladder he does not disturb, unless it pro- 
trudes through the opening in excess. When the 
fistula was very small he hooked the tenaculum 
through both sides, and raising it up, cut out a 
circular portion with the bistoury. When the 
vesical mucous membrane concealed the margin 
of the fistula, interfering with its proper manage- 
ment, a soft sponge should be pressed through 
the opening into the bladder, and allowed to re- 
main until the stitches are ready for adjusting. 
To remove the blood from the parts during the 
operation, little mops (Fig. 9) should be on hand. 
These are readily made by securing small bits of 
sponge, to whalebone, or rods of wood.