Ef^y^lf-S-TT-vV s YESICO-VAGINAL FISTULA SPONTANEOUS RELIEF. "THE AMERICAN OPERATION.' David Clapp, Printer......Office of the Boston Medical and Surgical Journal, 334 Washington Street. THE BOSTON MEDICAL AND SURGICAL JOURNAL. Vol. LXIV. Thursday, July 11, 1861. No. 23. VESICO-VAGINAL FISTULA.—SPONTANEOUS RELIEF. ;> JjTL** •*': "THE AMERICAN OPERATION." .,\^ " ^'~ [Read before the Obstetrical Society of Boston, by B. E. Cotting, M.D., Cor. Secretary of the Society.] Vesicovaginal fistula has been justly called a lamentable acci- dent. Its consequences are truly deplorable; the remedy difficult, and, until recently, very uncertain. Spontaneous recovery, a re- sult hardly to be hoped for, is a mere possibility. As an instance of such unexpected good fortune, the following case seems worthy of record. In January, 1844, the patient, aged 33 years, was delivered of a first child, after a labor of five days without intermission. On the third day her medical attendant left her, because she would not allow the forceps to be used. After he left, she got no at- tendance until the last moment of her labor, when she had the as- sistance of a midwife. During the five days she was not conscious of having passed any urine. Before the removal of the placenta, the water was drawn, and the catheter was used at proper inter- vals afterwards. On the third day after delivery, however, she found that she had no control over the bladder. After this, all the urine came away involuntarily and without cessation. Having been called at this stage of the case, I found a sloughy opening from the vagina into the bladder, nearly an inch above the neck of the latter, large enough to admit the tips of two fin- gers. The catheter passed readily from the bladder into the vagi- na. The nature of the case, thus clearly made out, was explained to the patient; and she was informed that, after her recovery from confinement, means for permanent relief might be tried with rea- sonable chances of success. From time to time thorough explora- tions were made; and the case on the whole was considered a pro- mising one for a surgical operation. This was in 1844, and I was led to take this view of the mat- ter, because I had been either an observer or an assistant at most of the operations for this accident performed previously, 4 Vesico-Vaginal Fistula. or about that time, by Dr. George Hayward, Sen., of Boston. But the patient resolutely refused to submit to any operation, in spite of earnest and repeated persuasion, and at length declined all further interference; having, from the first, allowed examina- tions very reluctantly. All unusual interest in the case therefore subsided; and for a long time after, nothing was heard of the pa- tient, except that she was in a wretched condition. Seventeen years having passed, I accidentally, a few days ago,met with this patient, and obtained from her some particulars of her history subsequent to her misfortune. She had never been pregnant since, though she says that she knows of no reason why she should not have had other children. For three years or thereabouts, after the accident, she was unable to retain the least accumulation of urine, the dribbling having been constant and unceasing. In a word, she suffered all the discom- forts and loathsomeness ordinarily attendant upon such accidents. She afterwards began to experience some slight power of reten- tion, and this continued to increase, very gradually, until she had almost or quite acquired complete control over her urine. For the last three or lour years, and since her catamenia have ceased, she has been able to retain and pass her water, as she says, " as well as anybody." She goes to church and other public places without apprehension, though after several hours she sometimes feels uneasy and fears consequences. She has not, however, suf- fered from too long retention up to this time. She affirms that she is completely restored, and perfectly well. On partial digital examination, which she very reluctantly per- mitted, there were noticeable deep corrugations and contraction about the place of the former opening; and the upper part of the septum appeared to overlap the under. No communication with the bladder could be discovered by the finger; but whether it was completely obliterated, or, if any, how large the opening might be, could not be ascertained with absolute certainty, as she repelled the introduction of the catheter—seizing the instrument and pre- venting further exploration. At any rate, the injury has been completely repaired, and the patient relieved of her miserable state and restored to a comfortable existence. In looking up and reviewing a case like the foregoing, which terminated so fortunately, one is naturally led to reflect on the great difficulties formerly attendant on efforts to remedy such ac- cidents, and to call to mind some of the circumstances of the ear- lier operations performed by Dr. Hay ward, particularly those ori- ginal and scientific devices of his, which have rendered subsequent operations so much more successful; and which, having been ac- cepted by such men as Prof. Verneuil and M. Robert, of Hotel Dieu, have given to the method abroad the name of " The Ameri- can Operation." An account of some of these improvements is worth repeating— Vesico- Vaginal Fistula. 5 for their own intrinsic value, and more especially now as they^o not seem to be fully appreciated or properly acknowledged by some, whose success, whatever it may be, should be attributed to the more or less complete adoption of these improvements; and moreover as, in certain localities, they appear to be in danger of being overlaid by accumulating heaps of pretended discoveries and inflated assumptions. Bearing in mind that when the first case presented itself to Dr. Hayward, in 1839, there had not been a successful operation in this country, and very few anywhere; that little or no assistance in the details of such an operation could be obtained from any source; that troublesome and alarming symptoms had arisen from sutures carried through the walls of the bladder, as previously thought necessary; that danger and even death had occurred from hsemorrhage—bearing in mind these and other formidable obsta- cles on the one hand, and the confessedly slight chance of success on the other, we shall have a better conception of the great ser- vice Dr. Hayward rendered, in planning and executing, on strictly scientific principles, a new, safe and successful method of operating for the relief of this accident. And first, by passing a large, smooth and inflexible staff through the urethra beyond the fissure towards the fundus of the bladder, and using this staff" as a lever, the pubes being the fulcrum, he showed that the bladder could be brought forward until the fistu- lous opening came quite within reach and sight. This movement originated with Dr. Hayward. It can be effected without diffi- culty; and, even before the use of ether as an anaesthetic, caused no very considerable amount of inconvenience or pain. Now, of course, whenever ether is resorted to, the last and only objection is entirely obviated. The parts having thus been rendered accessible, Dr. Hayward's next and chief improvement consisted in superficially but tho- roughly paring the edges of the fistula without cutting deeply into the walls of the bladder, and more particularly in disscctiug or splitting up the vaginal membrane around the opening for the dis- tance of a few lines, in order to have broader surfaces to be placed in contact; thereby increasing the chances of adhesion, while the danger of haemorrhage, the result of deeper incisions, was g> catly diminished. In fact, the bjeeding was in this way reduced to the merest trifle, and the loss of substance, always to be avoided, rendered so inconsiderable that it need not be taken into account. A third and very great improvement, introduced by Dr. Hay- ward, was the passing of small sutures; and these through only a portion of the thickness of the pared parts—not through the walls of the bladder. Thus, inflammation of this organ, as expe- rienced by previous operators, was completely averted. In his first cases, Dr. Hayward removed the stitches a few days after the operations; but having in one instance, at least, which I 6 Vesico- Vaginal Fistula. happened distinctly to witness, re-opened an already united wound by pressing too suddenly on the staff in his endeavor to get at the most distant suture, he allowed in some of his subsequent opera- tions the threads to remain until spontaneously cast off". Left in this way, the threads caused no trouble whatever, usually coming away in from seven to ten days. In one instance one remained twenty-eight days without inconvenience or injurious effect—so that this course may be adopted whenever it may be difficult to reach or to remove the stitch. As so much has been said, from time to time, since the publica- tion* of Dr. Hayward's method and success—now on the varied contrivances for securing and retaining the sutures, again on their number and size, and still more on their material, till '• lo ! a new era dawns " 1 and we have " the great surgical achievement," " the imperishable discovery " of the silver suture (though unfortunately for our country's vaunted glory in the matter, this " result of a a Providential train of circumstances " occurred fifteen years after silver sutures had been in use in England, been advocated there on precisely the same grounds, and even been employed in a suc- cessful operation for vesico-vaginal fistula, as reported in vol. xxx. of the London Lancet); and as there is no little danger in all this clamor about clamps, buttons, shot, and other equally unimportant mechanical contrivances, that the true scientific principles, which should guide in these operations, may be overlooked or disregard- ed—it may be well to remark in a word, and it needs but a word, that, wherever union by the first intention is looked for, the edges of the wound must be kept in close contact; and that, if this be skilfully done, it is of far less consequence by what peculiar con- trivance it is effected. If sutures are used, more depends upon their proper adjustment, and their having the exact amount of tightening requisite, than upon the material. A metallic suture, of whatsoever or whomsoever's make, if imperfectly secured or too tightly tied, will prove as ineffectual or will cut its way out as certainly as that made of silk or flax. A delicate thread, even of cotton, properly adjusted, will retain its place, cause as little irri- tation, and leave as small a scar, as we have often had occasion to notice in operations about the face, as the purest silver, the soft- est iron, or the most polished steel. Let each operator, then, use whichever suture, knot, or fastener he himself chooses or can, in a given case, best manage, just as he would select any particular form of scissors or knife for paring the opening; but let him not forget the principles on which he must depend for success. The former, though perhaps not the best, may answer if adroitly used, but a neglect of the latter will result in inevitable failure. And having, by such a course, been successful, let him not, in his report of the case, as is too often done, wholly ignore the first demon- * American Journal of the Medical Sciences, Philadelphia, July, 1839, vol. xxiv., p. 283. Boston Medi- cal and Surgical Journal, April 16th, 1851, vol. xliv., p. 209. Vesico- Vaginal Fistula. 7 strator of these principles—an act of simple justice; while magna- nimity would suggest an honorable mention. The position of the patient during the operation is of some con- sequence, though it may occasionally be varied to suit the conve- nience, or even the whim, of the operator. Dr. Hayward adopted that of lithotomy, which has many advantages. The fistulous opening, naturally thrown forward by this position, can thus with- out difficulty be brought by the staff nearly or quite to the os ex- ternum, and the subsequent steps of the operation thereby greatly facilitated. In this way too, an assistant, on either side, can with one hand keep the leg in proper position, and with the other sepa- rate the labia with a suitable spatula, without being in the way of the operator, who stands in front of the patient. Besides, the patient is in the most comfortable posture for a prolonged opera- tion, and can thus take ether when and as long as desirable. The catheter for after use, contrived by Dr. Hayward, is, to say the least, quite as good as any of its imitations; while its advan- tages are the plate which enables it to be secured by a bandage, and the screw which allows the additional portion to be turned in any desired direction, or to be removed at pleasure. Much more might be added, but enough has been said for the present purpose, which is, simply, a short exposition of the prin- cipal improvements, based on which, the operation for vesicovagi- nal fistula is hereafter to become one of the successful operations of surgery. Having had the opportunity to be present and to assist in the earlier cases, I can bear testimony to the difficulties encountered, and to the original as well as successful means adopt- ed to surmount them—a grateful testimony to the merited eminence of* a faithful instructor and steadfast friend. Roxbury, July, 1861.