T H K 
OPEBATIOIT 
OF 
Vesicovaginal Fistula 
A COMPARISON OF THE 
METHODS OF OPERATION 
OF 
N. BOZEMAN, M. 8., New York, and Prof. GUST AVI SIMON, 
Heidelberg. 
ILLUSTRATED WITH TWELVE WOOD CUTS. 
Translated from the Original as Published in the Wiener Woohenschrift. 
BY 
1, I 
With SotfcSUifi! Gtf'WttviV w6lWAfci«bM kifl*¥ife; slater. 
FROM THE JANUAR ; NO. RICHMOtIf ICAL JOURNAL. 
LOUISVILLE, KY.: 
RICHMOND AND LOUISVILLE MEDICAL JOURNAL BOOK AND JOB STEAM PRINT, 
104 Green Street, 2d door west of Post-office. 
1877. OBITUARY. 
[From American Journal of Obstetrics.] 
Professor Gustav Simon was born at Darmstadt on the 30th of May, 1824. 
He was educated at Heidelberg and Giessen, taking his medical degree at 
Giessen. He then accepted the position of military surgeon at Darmstadt. 
While here, he visited Vienna, Paris, and London for scientific observation. 
In 1861 he was called to Rostock, where he became professor of clinical sur- 
gery and director of the hospital. In 1867 he was chosen professor of clinical 
surgery in the University of Heidelberg, which he retained till the day of his 
death. He was repeatedly invited to other universities, but .preferred to re- 
main at Heidelberg. In 1866 he was director of the Military Hospital at 
Moabit near Berlin. In the late Franco-Prussian war he was surgeon general 
of the Reserve Barracks of the Grand Duchy of Baden. 
In 1851 he published his first treatise on “Gunshot Wounds,” containing 
the results of experimental researches, with original views on the.subject. 
In 1854 he published a “Description of the Operation for Vesico vagi- 
nal Fistula.” In 1862 he published more extended observations on the same 
subject. And the last paper he wrote was on vesico-vaginal fistula, published 
only a few weeks before his death. 
In 1868 appeared his “Communications from the Surgical Clinic of Rostock.” 
They contain a long series of original observations, with some “ New Methods 
of Operating in Cases of Incurable Fistulae,” also “Double Puncture and Sub- 
sequent Incision in Cases of Abdominal Echinococcus and Hydro-nephrosis,” 
" The Pendulum Method for the Reduction of Dislocated Humerus,” “Kol- 
poraphia Posterior for the Cure of Prolapsus Uteri,” “ Operation for Rup- 
tured Perineum,” “Contributions to Plastic Operations of the Face, Vagina, 
and Rectum,” “ Hare-lip and Cleft-palate,” “On Covering Amputation and 
Resection Wounds with Diseased and Perforated Skin Flaps,” “ Treatment of 
Malignant Disease of the Vagina, Bladder, and Rectum by the Curette, and 
the Methods of Exposing them sufficiently to View by Using the Sims’ Specu 
lum for the Vagina and Rectum.” 
Among his last contributions to surgical science is his “ Method of Render- 
ing the Female Urinary Bladder accessible, and on Probing the Ureter in 
Women,” a paper which, in the short space of six months, has appeared in 
four different languages. His “ Manual Palpation of the Rectum, etc.,” is 
now known and adopted by the Profession all over the world. He finished 
the second part of his great work, on “ The Surgery of the Kidneys," but a 
few days before his death. The third and last part will be laid before the 
Profession in an unfinished state. 
Until the last day of his life, he was busily occupied with the arduous 
duties of his profession. 
The foregoing resume of Prof. Simon’s labors was furnished by his friend 
and pupil Dr. A. C. Bernays, of St. Louis, Mo., now in Heidelberg. 
When in Europe, last summer, I made a visit from Paris to Germany espe- 
cially to see Koeberle at Strassburg, and Simon at Heidelberg. At Baden, I 
telegraphed to Simon, to know if he was at home, and received as answer; 
“Yes. Very ill, but most happy to see you.” Arriving late, I went to see 
him at 9P. M. He was in bed, and received me most cordially. I remained 
but a short time, but In ten minutes he arranged a day’s ivork, to begin at 9 
the next morning. On my arrival, next morning, I found several young doc- 
tors and many patients in the ante-chamber. Simon gave me a real clinical 
lecture for more than three hours, illustrating his method of operating for 
vesico-vaginal fistula, lacerated perineum, for exploring the female bladder, 
probing the ureters, and for exploring the abdominal cavity, by passing the 
hand into the rectum. OBITUARY—GUSTAV SIMON. 
It was a hard day’s work for a man in good health. But he did not seem 
to think of himself for a moment. He was wholly absorbed by the pursuit 
of science for the relief of humanity. His genius, learning, industry, and 
skill are known and recognized by the Profession everywhere; and we call 
him great. But his qualities as a man could only be realized by personal 
contact. His earnestness and enthusiasm, his sincerity and honesty, his 
generosity and kindness of heart, impressed all with the conviction that he 
was one of the best of men. 
I spoke to him of his health. He supposed he had emphysema, with some 
congestion of the lungs. He was not aware of his real condition, though it 
was well understood by his friends. 
The propriety of withholding from such a man the gravity of his disease 
seems to me questionable. 
He died on the twenty-seventh of August last, of an acute attack of oedema 
of the lungs, caused by an immense aneurism of the pars descendens of the 
thoracic aorta, which had greatly compressed the lower half of the left lung 
and pulmonary veins. The circumstances of his death are curious and inter- 
esting. One of his favorite assistants, Dr. Bernays, called, on the morning of 
the 27th, to read to him the translation of his paper on vesico-vaginal fistula, 
which he wished to see published in America. He expressed himself as well 
pleased, and Bernays was about to leave, when Simon, who was in bed, called 
him back, and said : “ Don’t forget to send my needle-holder and some needles 
to Mr. Marion Sims, and tell him I shall go to the Congress of Gynaecologists 
in America if my health improves.” 
This was but twelve hours before his death. 
At 4 P. M. Dr. Braun, his first assistant, called to report the condition of 
patients whose after-treatment he was conducting in the hospital for Simon. 
Simon gave him instructions about having some important cases ready for 
operation at 11 the next morning. Dr. Braun left at 6 P. M., and he had 
passed but a few steps from the villa, when Simon was taken suddenly with 
dyspnoea. He raised up in bed, ordered some one to open the window and 
call Dr. Braun, who hurriedly returned, expecting to find his friend and 
teacher dead. Simon requested him to call a carriage and go for his tracheot- 
omy instruments as soon as possible. Braun obeyed, and returned in twenty 
minutes with Dr. Haek. Simon now said: “Operate quickly; perform high 
tracheotomy.” He refused to take an anaesthetic. Dr. Braun operated as 
quickly as possible. The veins of the neck were greatly distended, and there 
was consequently some trouble. Simon still hurried him on. There was a 
good deal of venous haemorrhage, which had to be controlled before the canula 
could be introduced. 
Prof. Simon then said he felt easier, and breathed freer. His pulse kept up 
till 10 o’clock, when there was a sudden collapse, and he died about midnight. 
And thus passed away one of the great lights of medicine. 
The name of Simon was as well known and as highly honored among us as 
in his own fatherland. Science knows no boundaries. It is cosmopolitan, 
and its votaries all over the world are linked together in a common brother- 
hood. The success of one is the glory of all. The loss of one is a loss to all. 
Had Simon been an American, we could not have felt his death more keenly, 
nor mourned him more sincerely. 
For a quarter of a century he has been prominently before the Profession, 
and always as the standard-bearer of an onward movement. His name is the 
synonym of progress, and his fame will endure for ages. J. M. S. Figure 1. 
Original Defect. Figure 2. 
F, remaining little fistula; N N', cicatrix. (There are 
too many suture marks engraved.) Figure 3. 
F, vesico uretero-vaginal fistula.; S V, kolpokleisis. Figure 4. 
F, transverse fistula at the place of juncture between the 
urethra and the vesico-vaginal septum; Fr, second very- 
small fistula caused by the gradual dilatation of the vagina. 
The contraction of the vagina and the deep groove at the 
place of location of the fistula could not be represented in 
the engraving. Figure 5. 
Before the operation. F, fistula; SV, atresia of the 
vagina; S, remnant of the vaginal canal. The deep groove 
of the urethro-vaginal and the vesico-vaginal septum at the 
location of (he fistula is not engraved. Figure 6', 
F N, cicatrix of fistula; F, remaining little fistula, laterally 
of the suture; S V, atresia of the vagina; H S W, posterior 
wall of the vagina. Figure 7. 
Fistula at the anterior lip of the os uteri. The fistula is 
drawn somewhat too small in its transverse diameter. Figure 8. 
Shows the fistula left after Bozeman’s operation of the 
fistula represented in figure 2. F, fistula; N, cicatrix. (Too 
many suture marks here.) Figure 9. 
Shows fistula (figure 8) after cure. N, cicatrix; VS, ves- 
tibular section; SM, split of the os uteri, Jobert’s section. 
(There are also too many suture marks here.) Figure 10. 
F, fistula in the lateral vault of the vagina. The fistula 
is by mistake represented in the right vault of the vagina. 
It lay in the left. The band-shaped contraction anterior to 
the fistula could not be represented in the drawing. Figure 11. 
F A, pared fistula, or appearance of the same after ex- 
cision. Figure 12. 
N, cicatrix; F, fistula. THE 
OF 
Vesicovaginal 'Fistula; 
A COMPARISON OF THE 
METHODS OP OPERATION 
OF 
N BOZEMAN, M. 8., New York, and Prof. GUSTAV SIMON, 
Eeidelherg. 
ILLUSTRATED WITH TWELVE WOOD CUTS. 
Translated from the Original as Published in the Wiener Wochenschrift, 
BY 
A. G. BERN AYS, M. R, St Louis, Mo. 
With Notes and Additions by the Author and Translator. 
FROM THE JANUARY NO. RICHMOND AND LOUISVILLE MEDICAL JOURNAL. 
RICHMOND AND LOUISVILLE MEDICAL JOURNAL BOOK AND JOB STEAM PRINT, 
104 Green Street, 2d door west of Post-office. 
LOUISVILLE. KY.: VESICO-VAGINAL FISTULA. 
It was a certain sense of duty, by no means of pleasure, that 
prompted me to translate the following scientific article. As an 
apology, I can mention that the subject here considered is one 
of especial interest to American surgeons. To a young Ameri- 
can, whose medical education has been exclusively attained in 
Germany, where American surgery has always been praised 
before me by my teachers, this work certainly afforded no 
pleasure. But as Dr. N. Bozeman, of New York, has deemed 
it correct to publish an article about certain things treated of 
in this paper in a manner not exactly in harmony with the 
facts, I think it is no more than fair to put Prof. Simon’s state- 
ments before the profession in America. I assisted at every 
one of the operations, in Heidelberg, mentioned in this article, 
and examined their results. I think therefore that the transla- 
tion, if not liberal in every particular, at least gives the sense 
and exact meaning of the author. 
INTRODUCTORY WORDS BY THE TRANSLATOR. 
In the Fall of 1874, Dr. Bozeman, of New York, came to 
Heidelberg in order to become acquainted with my method of 
operating for vesico-vaginal fistula, and to show us his own. I 
was glad of the opportunity to see Dr. B.’s method, and, if 
possible, to be benefited by it; and therefore I instituted a series 
of operations, in which each of us operated on several cases, 
using our own methods, forming, as it were, a tournament. All 
operations were performed in the clinique in the presence of the 
students and assistants, several of them also under the eyes of 
our celebrated colleagues, Spencer Wells and Kdeberlb. The 
after-treatment, which Dr. B. considered necessary in his cases, 
was conducted by himself with the help of my assistants, who 
followed his directions in a most scrupulous manner. The re- 
moval of the sutures and all subsequent examinations of the 
cases were performed in the clinique. 4 
VESICO—VAGINAL FISTULA. 
Our methods differ very materially. While I operate in the 
“ Steiss Riickenlage,” coccygo-dorsal position (an exaggerated 
lithotomy position), B. places his patient in the knee-elbow posi- 
tion; while' I strive to dislocate all involved parts to the sur- 
face, B. operates with the parts in situ; while B. pares his edges 
to the far greater part with the scissors, I almost exclusively use 
the knife ; while B. applies a very complicated button-and-wire 
suture, I use the simple-knot suture with silk thread; and while 
B. uses the catheter en permanence during the after-treatment, 
and frequently gives large doses of opium, I do not take the 
slightest measures of precaution ; allow the urine to be passed 
unaided, and the patient wishing, I allow her to leave the bed 
on the second and third day. In cases which require prepara- 
tory treatment in order to render the fistula accessible to in- 
struments, I take all the necessary steps immediately before the 
operation, while B. in such cases prefers gradual preparation. 
DESCRIPTION OP THE CASES. 
The cases operated on by myself were the following: 
Case I. (See figures 1 and 2of the plate).—A Russian, twenty- 
two years of age, of small stature, shows a very large defect. The 
whole bottom of the bladder up to the os uteri and the upper 
part of the urethra were wanting; of the latter only 2f centi- 
metres (1 inch) were left. (See figure 1.) 
The defect reaches into the lateral parts, and upwards into 
the lateral vaults of the vagina. The bladder had prolapsed as 
far as the introitus vaginae. An operation had been performed 
in Berlin without result. 
I had left it optional with Mr. Spencer Wells, who was staying 
in Heidelberg for several days, and with Dr. Bozeman, whether 
I should operate on this large defect or on a fistula of but I J or 
\\ centimetres in diameter, which also was at my disposition. 
Both gentlemen desired to see the operation on the large defect. 
The defect could only be covered by drawing the uterus for- 
ward and letting it partly supply the fistular loss. By some 
traction with a Musseux’s forceps I could so draw forward the 
anterior lip of the uterus as to bring it in contact with the 
urethra. I pared the edges (behind the anterior lip of the os), VESICO VAGINAL FISTULA. 
5 
which was done without difficulty save in the posterior angles, 
and-united them with eleven sutures. The line of union was of a 
semi-lunar shape, with its strong convexity towards the front 
(see figure 2 of the plates). During the first day only was cathe- 
terization necessary; after the second day the patient urinated 
voluntarily. On account of the considerable wounding of the 
bladder and traction on the united parts, spasms of the bladder 
ensued, which diminished only on the fourth day; there was 
also reiterated vomiting during the first two days. Sutures 
were taken out from the fifth to the eighth days. The defect 
proved cured, excepting a small fistula from the size of a lentil 
to that of a pea at the point of union between the anterior lip of 
the uterus and the urethra (see figure 2). This small fistula was 
afterwards operated on by Dr. Bozeman. 
Case ll* (figure 3of the plates).—l had six years ago com- 
pleted an almost total obliteration of the vagina in a woman 
fifty-six years of age, which had originated subsequent to severe 
labor, by closing a transverse opening of one centimetre in length 
situated in the atresia. A cure with total continence was 
effected. At first operation a pyelitis calculosa suppurativa 
existed, which had constantly increased up to the present time. 
The urine was constantly mixed with pus, frequently showed 
alkaline reaction, and calculi had formed, of which at various 
times small fragments passed the urethra. Finally, six months 
before the reception of the patient into the hospital, a stone had 
sloughed through that part of the bladder and urethra situated 
before the atresia of the vagina, causing a fistula the size of a 
cherry-stone. The patient was emaciated on account of fever, 
loss of appetite, and pains in the bladder, sleeplessness, etc. 
Her wish for an operation was urgent, in order to be rid of the 
torture caused by the involuntary flow of urine. I was thus in- 
duced to operate. I made a longitudinal excision of the fistula, 
which extended forward to centimetre from the orifice of 
the urethra, and backwards vertically through the cicatrix of 
the atresia of the vagina, and united the edges by means of six 
sutures, of which three were superficial and three deep. Fever 
increased after the operation, chills appeared, and the patient 
* Dr. Kdeberle, of Strasburg, assisted in this operation. 6 
VESICO-VAGINAL FISTULA. 
died after six days. The united parts had become separated. 
The post-mortem proved the left kidney to be changed to a pouch 
filled with pus, as also the greater part of the right kidney 
destroyed by suppurative pyelitis. A calculus was found in the 
left ureter. 
Case 111 (figure 4 of plates).—Fistula in the upper third of 
the urethra about two centimetres from its orifice. The fistula 
represents a transverse slit of two centimetres in length and 
one-fourth of a centimetre in breadth. The vagina is so narrow 
at the seat of the fistula that scarely the points of two fingers 
can be passed. The opening lies in a deep groove of the urethro- 
vesico-vaginal septum, which was retracted towards the arcus 
pubis, and very firmly attached to it. The edges of the fistula 
were much attenuated (see figure 4). The cicatricial atresia of 
the vagina extended upwards (longitudinally) more than one- 
half of a centimetre.* 
Previous to operating, I intended to split the annular atresia 
of the vagina, and then, as I always had done, proceed to the 
operation at once. 8., however, thought the result would be 
unsafe unless a gradual dilatation of the vagina had preceded, 
and offered to bring this about in two weeks. He cut through 
the cicatricial bands with the knife and introduced soft and 
hard rubber tents. The patient suffered the most1 excruciating 
pains in the vagina, the abdomen, and the region of the kidneys, 
and very high fever with chills set in, so that we thought her 
health seriously endangered. After six days of such treatment, 
the tamponade was abandoned. On recovery of the patient, the 
vaginal atresia remained nearly as considerable as before the 
tamponade. At the same time we ascertained, that at the prox- 
imity of the anterior lip of the mouth of the womb a new (very 
small) fistula existed.! A second trial of the gradual dilatation 
I considered improper, and according to my experience not 
* This patient had previously undergone the operation of kolpokleisis by a 
German colleague. I reopened the obliteration in order to close up the fistula 
itself, which seemed not over-difficult to do. 
f This little fistula was very likely not caused by ulceration in consequence 
of tbe tamponade, much rather had the tampon severed a small cicatrix pre- 
existing at this point. There was indeed no sign of ulceration visible. VESICO-VAGINAL FISTULA. 
7 
necessary. Before the operation I split the cicatrices, which 
caused the atresia, with a probe-pointed knife. They were cut 
in various places, and more especially those bands which 
bound both angles of the fistula to the bone. Thereupon I 
pared the inturned edges of the fistula very broadly, and 
united them by means of five sutures. On the fifth and sev- 
enth days the sutures were removed. The fistula was closed, 
witli the exception of a very small slit in the middle of the 
cicatrix. I predicted that this little fistula, most likely, would 
spontaneously heal, because it was enclosed between very 
deep margins. On the tenth day the patient was taken sick 
with a catarrh of the bladder, accompanied by strong fever and 
pains in the kidneys, lasting a fortnight. Four weeks after- 
wards, when these symptoms had disappeared, an exploration 
proved that the small opening was closed, and thereby the 
whole fistula totally cured. The following summer I operated 
on the small fistula near the mouth of the uterus, which had 
appeared during the gradual dilatation, and achieved a cure by 
two sutures. 
Case IV (figures 5 and 6 of the plates).—The patient, aged 
twenty-six, suffered from a transverse fistula in the upper third 
of the urethra, at the juncture of the urethra to the vesico- 
vaginal septum, complicated with very considerable atresia of 
the vagina. The fistula was located in a deep retraction of the 
urethro and vesico-vaginal septum—i. e., 2J centimetres further 
from the urethral orifice than in the former case. The vagina 
was contracted and laterally attached to the bone at the location 
of the fistula; one-fourth of a centimetre in its rear is a tough 
cicatricial mass, which reaches up to the os uteri, and almost 
completely shuts up the vagina. A probe can merely pass 
through a narrow canal on the right up to the region of the 
womb. The extent of the fistula in a transverse direction 
amounts to about two centimetres; its length is only about half a 
centimetre; its edges are adherent to the arcus pubis, and there- 
by difficult to expose (demonstrate). The angles of the fistula 
were deeply hidden in callous tissue (see figure 5). In this pa- 
tient also I allowed Dr. B. to make an attempt to enlarge the 
vagina. After a bloody division nearly up to the os uteri the 8 
VESICO VAGINAL FISTULA. 
tamponade was daily carried on, but the result was also nega- 
tive. The pain became unbearable, and fever set in on the sec- 
ond day, which, by degrees, reached such a height, that towards 
the fifth day the tampons were abandoned. When the fever 
had abated, the atresial masses proved nearly as extensive as 
before. I therefore resolved to operate without previously re- 
sorting to gradual dilatation of the vagina. By means of 
several deep incisions to the rear and laterally, the cicatrices 
were divided in the region of the fistula, so that the instru- 
ments of dilatation could be applied and the attenuated margins 
of the fistula brought into sight. I now pared the edges and 
the deep groove between the urethro and vesico-vaginal septum 
in broad extent. The paring extended mainly into the mucous 
membrane of the vagina; only close to the fistula the whole 
thickness of the septum was pared away. The union was 
brought about by means of six sutures, their application espe- 
cially in the left corner being extremely difficult. Immediately 
after the patient had been again placed in bed there was invol- 
untary emission ot urine, nor did this involuntary loss of urine 
cease thereafter. From the fifth to the seventh day the sutures 
were taken away, and we saw the urine ooze out at the left 
angle. An opening could not be detected, because we did not 
dare to draw asunder the fold in which the fistula was located. 
Only towards the end of the fourth week we found a very small 
opening at the left end of the otherwise entirely-healed fistula. 
It was seen to lay outside of the reach of the last suture mark. 
It had evidently never been closed up. In this way the invol- 
untary loss of urine immediately after the patient’s return to 
bed was readily accounted for. Unfortunately I had neglected 
to test the bladder as to its continence, while the patient was 
yet on the operating-table, by injecting water. Had I done so, 
the small opening would have been found and subsequently shut 
up (figure 6). In the course of the summer of 1875, I operated 
twice more on that small remaining fistula before it could be 
brought to a closure. It lay very deep in a mass of callous 
tissue, which was firmly attached to the bone. In the first 
operation I had pared the edges of the groove, and thereby 
made the fresh edges of the fistula very broad, and had applied VESICO-VAGINAL FISTULA. 
9 
two very deep sutures, and confidently hoped that even the 
remotest part close to the bone was included in the loops of 
the sutures, although the bone was a great hindrance to their 
application. This time also I omitted to make the “continence 
test” by injecting water after the operation, having no idea 
that the cure would fail. But as soon as the patient had been 
brought to bed, I was again most unpleasantly surprised by the 
involuntary flow of urine, which had taken place after the con- 
cours operation. The fistula had again not been closed by the 
suture. At the next operation I separated the whole cicatrized 
mass in which the fistula lay, from the bone down to the depth 
of three-fourths to one centimetre, and had all the parts drawn 
over to the right side by means of sharp hooks. I could now 
operate exactly, and succeeded in closing up the fistula. Evi- 
dently I might have attained this end at the first operation had 
I not neglected to try the “continence test.” Had I then 
reopened the fistula, paring and sewing up the left angle, it would 
have been much easier, and might perhaps have been done 
without cutting the callous masses from the bone. 
Case I (figure 7).—In a patient aged thirty years a fistula 
was situated in the anterior vault of the vagina; it measured 
and 2 centimetres in diameter, and freely allowed the index 
finger to pass. Its posterior edge was formed by the anterior lip 
of the os uteri. It was located in the middle of the vagina, 
and was comparatively easy of access, because the vagina could 
readily be dilated (see figure 7). After the fistula had been 
exposed, in knee elbow position, Bozeman* pared the anterior 
margin with the knife, the posterior with the scissors, increas- 
ing its size considerably, and making very broad wounds. These 
were united by five sutures transversely to the direction of the 
vagina, the anterior lip being united with the vesico-vaginal 
septum. On the eighth day the sutures were removed. One 
loop of wire was so retracted into the tissues that, after the 
Dr. Bozeman executed the following operations: 
* Bozeman thinks the retention of a wire-loop totally harmless. Neverthe- 
less, I had to crush a calculus of the bladder, the nucleus of which was formed 
by a loop of wire. The loop had been left after an operation for vesico-vagi- 
nal fistula one year before, and had migrated into the bladder. 10 
VESICO-VAGINAL FISTULA. 
pierced shot which contains the ends of the wire fastened 
within itself was cut off, it could not be extracted. The fistula 
is entirely cured ; one piece of wire is yet retained. 
Case II (figures 2, 8, and 9). Bozeman operated on the 
small fistula which had remained after my first operation (see 
figure 2). It was situated in the line of union between the 
anterior lip of the uterus and the urethro-vaginal septum, which 
latter was only 2| centimetres in length. The anterior edge 
of the fistula was pared with a knife, and the posterior margin 
and the angles with the scissors. Three sutures closed up the 
fistula, two of which were to the right and one to the left side 
of the urethra. At this operation Mr. Koeberlb, of Strasburg, 
was present; it lasted thirty-five minutes from the time the 
patient was chloroformed and strapped (buckled literally) on 
the chair. The edges had been pared off obliquely; at the os 
uteri the pared surface was very broad, about 1 and 1| centi- 
metre; and even the lateral parts of the anterior edge of the 
fistula were made one centimetre. At the urethra itself (the mid- 
dle part) the paring was one-fourth of a centimetre in width. 
The fistula was considerably enlarged; of the urethra there 
remained but 1J centimetre. The paring had been done in per- 
fectly normal tissue, and a cure was therefore to be expected. 
During the first days the patient lost no urine. On the fourth 
and fifth days spasms of the bladder set in; the urine, which 
had heretofore been rather clear, now became turbid and mixed 
with mucus. On the seventh day, when Bozeman removed his 
suture apparatus, urine flowed from the right angle of the fistula; 
and at the exploration two days later the fistula proved reopened 
in its whole extent, and was so much increased in size that the 
finger could easily pass through (figure 8). 
The future fate of this patient was the following: The very 
considerable increase in the size of the defect, and the fact that 
the urethra is but 1-| centimetre in length, made the prognosis 
for a second operation much worse than it had been for the 
former, and even after a successful operation as to closing 
the fistula, incontinence was with certainty to be expected. 
The chances would now have become especially unfavorable if, 
on paring, B’s. plan of taking away large quantities of tissue VESICOVAGINAL FISTULA. 
11 
was adopted. Nevertheless, B. insisted that he could not only 
cure the fistula, but also establish continence. I therefore re- 
quested him to perform the operation once more. But Dr. 8., 
who just then was compelled to depart, promised that he would 
return in the summer and operate on this fistula. I therefore 
kept the patient in the clinique (Academic Hospital) the whole 
of the summer and fall up to October, 1875. B. had been invited 
through one of his acquaintances living here, and I invited him 
twice myself in October for the very purpose of carrying out 
this same operation. Unluckily, circumstances did not permit 
him to come here. I had, therefore, to perform the operation 
myself. I reopened the cicatrix of the first large defect very 
extensively into the lateral parts of the vagina, so as to make 
the uterus more movable; I also pared the edges very closely 
in their totality, drew the uterus downwards and forwards, and 
fixed it to the anterior pared edge with six sutures. The 
urethra itself was united to the anterior lip by means of one 
suture through its centre, while the other very deep sutures 
united vagina and uterus, and held the latter down towards the 
introitus-vaginse. When the sutures were removed, five or six 
days afterwards, but one-half of the fistula proved cured. No 
doubt very considerable traction was the cause of this very 
poor success. 
In the following operation I again separated the united parts 
of the fistula, cutting deep into the lateral parts of the vagina, 
as I had done in the previous one. The anterior edge of the 
fistula was pared sparingly in a very superficial oblique direction, 
so that the urethro-vaginal septum lost but two minims of its 
substance. Union was completed by means of eight sutures, of 
which two very thin ones united the urethra to the os uteri. 
At this time I was not satisfied to counteract the tension by 
means of deep-drawing sutures applied at the sides of the 
urethra, but I also separated the urethra from the arcus pubis 
by means of the vestibular section, and split the commissures of 
the os uteri, after Jobert, to the extent of 1J centimetre, in 
order to give mobility to the anterior lip. Perfect union was 
achieved throughout the extent of the fistula; but continence 
existed only while the patient lay on her back. When walking 12 
VESICOVAGINAL FISTULA. 
or standing longer than one-fourth or one-half an hour, she lost 
urine. The urethra was at most centimetre in length (see 
figure 9). 
Case 111 (figures 10, 11, and 12).—In consequence of heavy- 
labor a woman, thirty-eight years of age, had acquired a fistula 
in the left vault of the vagina, which was no larger than to 
admit the nail-phalanx of the index finger. It represented a 
transverse slit T£ centimetre in length, and half a centimetre in 
width (figure 10). Anterior to the fistula the vagina was rather 
narrowed by a thin cicatricial band. The edges seemed to be 
attached to the bone. I attempted to expose (bring in sight) 
the fistula by means of a gutter-shaped speculum while the 
patient was in the coccygo-dorsal position, when I found that 
this could only be achieved in a very unsatisfactory manner. 
The fistula seemed to me very hard of access, and I thought 
the peritoneum might easily be injured by the paring or sew- 
ing. I remarked at the time that under the influence of chlo- 
roform in very high coccygo-dorsal position, and by dividing 
the impeding cicatricial bands, access to the fistula must be 
strived at; that, however, under certain circumstances—i. e., 
supposing the fistula could not be properly exposed, no attempt 
at closing it should be made. But, as I have done in one 
case,* an obliteration of that part of the vault of the vagina in- 
cluding the os uteri in which the fistula was situated was indi- 
cated. In this manner, at all events, an injury of the perito- 
neum would be prevented. However, I abstained from further 
attempts at exposing the fistula, but left the patient to Dr. B. 
for operation, in order to see how he would achieve access to 
the fistula in the knee-elbow position. Dr. B. preparatorily, by 
means of incisions and subsequent tampons, dilated the cicatri- 
cial bands causing the stenosis. The lesions caused by the 
incisions were very small, and the band was readily stretched on 
inserting the tampon. After ten days the operation was per- 
formed, and I saw that the fistula could be well exposed in the 
knee-elbow position with Dr. B.’s speculum. But, nevertheless, 
access for the instruments was yet very difficult. The paring 
* See minor communications of the Surgical Clinique of the Rostock Hos- 
pital, second division. VESICO VAGINAL FISTULA. 
13 
lasted more than two hours, and the fistula had to be extraordi- 
narily enlarged, in order to be able to pare left angle (figure 11). 
The adaptation of the suture was attended with great difficulties, 
and it took two hours and one-half to apply five sutures. The 
whole operation, therefore, lasted four and one-half hours. 
During the after-treatment large doses of opium were admin- 
istered, and a catheter en permanence was used. On the eighth 
day Dr. B. himself took out the sutures. The original fistula 
was closed, but right in front of the anterior lip of the womb 
an opening remained, through which (three weeks after the 
operation), when the patient left the hospital, the nail-phalanX 
of the index finger could be passed, and which therefore was as 
large as the original fistula. The state of the patient was in 
so far improved that the remaining fistula was far easier of 
access, and consequently more amenable to a cure (figure 12). 
On account of the exhausting and the equally weakening after- 
treatment, the patient felt so much worn out then that she 
would not make up her mind to another operation. Up to the 
present time she has not reappeared in Heidelberg. 
CRITICAL EXAMINATION OF THE RESULTS OF THE OPERATIONS 
DESCRIBED. 
If we wish to get at a correct opinion as to which of the two 
methods of operation was the most successful, we begin by elim- 
inating my second case. The patient was suffering from pye- 
litis suppurativa calculosa at the time of the operation, and died 
on account of it. The post-mortem showed that the substance 
of both kidneys was almost entirely destroyed, and one of the 
ureters contained a stone. The patient would have died under 
these circumstances, which, before the operation, could not be 
diagnosed as to their full extent under any mode of operation, 
and the fistula would also have reopened, as Dr. B. readily con- 
ceded. 
Thus three cases are left for comparison on each side. My 
results were the following : In the first case a small fistula, from 
the size of a lentil to a pea, about the twenty-fifth part of the 
line of union had remained open. Three or four weeks after the 
operation of the second patient (Case III.), a little fistula, which 14 
VESICOVAGINAL FISTULA. 
had remained after the operation, spontaneously closed up, and 
thereby a cure was effected. In the third patient (Case IV.) 
the fistula healed, with the exception of a small spot in the left 
angle, which lay outside of the suture. 
Bozeman achieved a perfect cure in his first case. In his 
second the fistula reopened throughout its entire length, and the 
patient became incurable. In his third patient four-fifths of the 
line of union healed. 
My results, therefore, are absolutely, as well as relatively, 
better than Dr. B.’s, as we will see directly. For even if we 
do not ascribe the small fistula which remained in my fourth 
case to my negligence (as it ought to be), but ascribe it to the 
method itself, this would only have amounted to the twelfth or 
fifteenth part of the line of union. Under this acceptation 
there would, in my cases, be openings of one-twenty-fifth and 
one-twelfth to one-fifteenth of the line of union standing against 
a total failure and an opening of one-fifth of the line of union. 
In order to attain a correct idea about the relative worth of 
the two methods, considering the small number of cases, their 
equalities also must be considered—i. e., we must see what kind 
of difficulties were opposed to the exact execution of each sin- 
gle operation, and after tbe completion of the operation, what 
difficulties were opposed to the healing process. 
The execution of the operation can be impeded by such con- 
siderable difficulties in the exposure of the fistula that but an 
incomplete paring and union of the edges is possible. The 
large defect in ray first case presented greater difficulties only 
in its remotest angles, which prolonged the operation, but did 
not prevent an exact execution of the same. In the third case 
cicatricial bands impeded the operation; these being divided, 
the impediment vanished. In my fourth case, also, paring and 
suture were very difficult, owing to the deep location of the 
fistula in a fold which was closely attached to the bone, which 
circumstance caused a small part in the left angle, not included 
in the suture, to remain open. But as the subsequent occlusion 
of the little fistula proved, I might have arrived at complete 
access. 
In Dr. B.’s cases the two first fistulse were very easy of YESICO-VAGINAL FISTULA. 
15 
access, whereas the last was very difficult to get at. It lay in 
the left vaginal vault and so high up that I, on hasty examina- 
tion, thought it possible that, from insufficient accessibility (and 
the proximity of the peritoneum), we would be compelled to 
perform obliteration of the vault of the vagina. But Boze- 
man, by gradual dilatation of the vagina and a very tedious 
operation of four and a half hours’ duration, succeeded in ex- 
actly paring and sewing the fistula. Therefore, accessibility 
was so far established in the six cases that the main conditions 
of healing a fistula, paring and suture, could be executed to the 
fullest satisfaction of the operators. 
Impediments for the healing of the pared edges are the fol- 
lowing : 
1. Considerable Size of the Defect.—In my first case the de- 
fect extended over the whole of the vesico-vaginal septum as 
far as the lateral vaults, and even into the urethro-vaginal sep- 
tum. Of the latter, only 2| centimetres remained. The uterus 
could, indeed, be drawn down so far that the anterior lip of the 
os uteri touched the remnant of the urethra, yet the tension 
was considerable and the line of union very extensive. My 
other fistulas were transverse slits of moderate size. , 
In Dr. B.’s cases the size of the fistulae could not present any 
difficulty. The largest was of the moderate dimensions of half a 
centimetre in length and two centimetres in width (see his first 
case). Of the other two, one was the size of a lintel or a pea; 
the other just admitted the nail-phalanx of the index finger. 
(Cases 11. and III.) 
2. Implication of the Urethra.—Fistulae which involve the 
urethra are more difficult to cure than fistulae which are situated 
higher up, even if the latter present no difficulties in making 
them accessible. The septum urethro-vaginal is by far thinner 
than the septum vesico-vaginal, and we must economize when 
paring in order to preserve continence; whereas this motive does 
not exist in fistulae situated higher than the urethra. The larger 
the loss of substance in the urethra is, the more difficult is the 
cure, because the thickness of the muscular coat, and conse- 
quently the thickness of the whole septum, decreases from the 
orificium-vesicale to the orificium-externum, and the danger of 16 
VESICO VAGINAL FISTULA. 
incontinence increases at the same ratio. If the urethro-vaginal 
septum is three centimetres in length, which nearly or altogether 
equals its normal length, the prognosis is comparatively favora- 
ble ; for this septum is but very little thinner than the vesico- 
vaginal septum, and broad strips of substance can be pared off 
for the purpose of making good edges without running the risk 
of incontinence. In case of a defect extending to 2|- centime- 
tres from the orificium-externum, the danger arises that on mod- 
erately extensive paring (about one-half to three-fourths of a 
centimetre) a cure will not take place, owing to the thinness of 
the edges, or that if it has taken place, continence is impaired. 
Thus it is that, generally speaking, fistulse in the urethro-vagi- 
nal septum, or such as extend into the same, are much more 
difficult to cure than those further back (higher) in the vagina. 
In all of my cases the urethra was implicated. In the first, 
2f of a centimetre were left; in the third and fourth the fistulm 
were located in deep transverse folds of the vagina, which were 
but 2 to 2J centimetres distant from the orifice of the urethra. 
In Dr. B.’s cases the urethra was defective but once (see his 
second case). It measured 2J centimetres in length. 
3. Cicatricial Contractions and Adhesions of the Vagina 
Immediately at or Close to the Fistula Edges.—ln two of my 
cases (figures 3 and 4) these impediments existed; for in the third 
case there was a band-shaped contraction one-half a centimetre 
in width at the seat of the fistula. In Case IY. the vagina was 
narrowed to a small canal from the upper margin of the fistula 
to the mouth of the womb. If such masses of callous tissue 
are divided in order to make the fistula accessible, or to make 
its edges movable by means of the knife or the scissors, it is 
possible that on account of the reunion of these incisions a 
traction is brought to bear on the fistula which is capable of 
reopening it as late as the sixth or seventh day. This is espe- 
cially to be apprehended if very great tension is to be overcome 
during the act of knotting the sutures, and I myself witnessed 
this reopening in a former case. Bozeman thought a cure very 
difficult in my two cases without preliminary treatment, and 
attempted to prepare the parts for my operations by means of 
gradual dilatation subsequent to dividing the contractions and VESICO-VAGINAL FISTULA. 
17 
cicatrices. When these attempts had proved fruitless, I under- 
took the operation, trusting my paring and sutures to be war- 
rants enough against these unpropitious circumstances, the 
more so as the edges could be united without traction. I 
divided the cicatricial contractions and adhesions as far as they 
impeded the operation, united the pared edges, and achieved a 
cure. 
Bozeman found only in his third case a narrow band-shaped 
contraction of the vagina, which he gradually overcome by 
dilatation, so that it offered no difficulty to the union of the 
edges. 
4. Proximity of the Ureter or Opening of it into the Fistula. 
—This circumstance seems to me no obstacle to a cure; but I 
here quote it because Dr. B. is of different opinion, and in his 
third case ascribes the remaining opening to this cause, suppos- 
ing it to have originated from the ureter being caught in the 
suture (see below my remarks to Dr. 8., article in the “ New 
York Medical Record,” July 25th). But even admitting this 
to be an impediment in Dr. B.’s case above described, it can not 
possibly have been the cause of the remaining fistula; for, as 
figure 12 shows, it is situated immediately in front of the mouth 
of the womb, and at least one centimetre distant from the ureter. 
The orifices of ureters in the bladder correspond to two points in 
the vagina about one centimetre each side of the os uteri and 
about one-fourth of a centimetre in front of it; therefore the 
ureter could more likely have been caught in the end of the 
suture which healed up than in that which remained open. How- 
ever, as I have shown in my paper of 1868,* proximity of the 
ureter seems to offer no bad auspices for the cure of a fistula; for 
I have operated on quite a series of fistulse which were located at 
or reached the point where the ureters are found; but I have 
neither observed a symptom which, with certainty, indicated 
occlusion of the ureter, nor have I very frequently seen open- 
ings appear at the points named. In these cases the ureter had 
either not been caught in the suture, or if caught, had not been 
* Communications from the Rostock Surgical Clinique, Second Part. Leip- 
zig, Hirshfeld. 18 
VESICOVAGINAL FISTULA. 
closed; or thirdly, the thread had cut through the uretero-vesical 
wall so quickly as not to cause any protracted retention of 
urine. It is most likely that the ureter is either not caught at 
all, or only one of its walls, by the suture in these (mostly small) 
fistulse, because it lies immediately under the mucous lining of 
the bladder, which, in small fistulse, is rarely taken into the loop 
of thread. Where the ureter evidently opened into the edge of 
the fistula, I have taken the precaution to remove its vesical 
orifice to a spot distant from the edge, so that it could not be 
caught in the suture. If the ureter had not retracted from the 
edge of the fistula, I would have shortened it with the scissors 
and removed its cover, formed by the mucous lining of the 
bladder, or only cut out a part of the uretero-vesical parietes, 
so that the orifice could not be closed up by the suture.* 
* For the operation of the very rare uretero vaginal fistulse a similar method 
of treatment might be applicable. Formerly, I had always spoken in favor 
of (see my article in Scanzoni’s Beitragen, vol. vi., 1860) an indirect cure for 
the treatment of the incontinentia urinse, after I had repeatedly tried a direct 
one without success. These attempts had failed because I had cut the orifice 
of the ureter into the closed bladder too small, so that I was not successful in 
establishing a permanent opening of the ureter into the bladder. By means 
of the above-mentioned methods of operative treatment for vesico-uretero- 
vaginal fistulas, and now since the bladder has been made accessible by means 
of the bloodless dilatation of the urethra, a direct treatment of uretero-vagi- 
nal fistulas seems to me to offer a better show than heretofore. In my gynae- 
cological course I have been teaching for several years, that at the place of 
the fistula the wall of the bladder is to be cut through, thereupon a probe to 
be inserted into the ureter from this opening into the bladder, and using it as 
a director, the uretero-vesical parietes are to be split upon it to the extent of 
from Ito L} centimetres upwards towards the kidney. The after-treatment 
would consist in daily inserting a thick probe into the slit until cicatrization 
had taken place. Afterwards, the vesical fistula which now lies distant fiom 
the new orifice of the ureter is to be pared and united in the direction of its 
longest diameter (which in both of my cases happened to be the transverse). 
It might not be bad to pare the parts of the vault of the vagina adjoining 
the edges of the fistula and use these as material for occlusion. This proposi- 
tion seems to me to offer a safer way to attain the purpose than a late pro- 
posal made by Dr. Loudau (Archiv. fiir Gynascologie, ix., 3). I will speak 
about these subjects more extensively in another place before long. 
Addition to the American Edition hy the Author.—Uretero-uterine fistulse, 
for which heretofore neither an operation has been performed nor a proposal 
for its performance (see Scanzoni’s Beitragen, vi., Wurzburg, 1860) offered to 
the profession, may probably be cured by splitting the portio-vaginalis up to VESICO VAGINAL FISTULA. 
19 
5 and 6. Finally, I have achieved my results under two cir- 
cumstances, which are, in the eyes of Dr. B. and many others, 
especially American colleagues, considered great obstacles to a 
cure (but I confess not in mine), and therefore must considera- 
bly increase the value of my results in their estimation; for I 
achieved my cures not with metallic but with silk threads, and 
applied no catheter en permanence, but allowed the patients to 
urinate at their free will. I have employed sutures of Chinese 
(a very tightly-twisted material), and of this for most of the 
sutures, not the finest kind, but such of No. 1, which is 
thicker than a double thread of No. 0, that I formerly fre- 
quently used, but have now abandoned on account of its weak- 
ness, and I now only employ it in case of very thin edges for 
the purpose of auxiliary superficial sutures.* The sutures were 
fastened simply by knotting. Concerning the after-treatment, 
I never take the slightest precautionary measures to keep the 
urine away from the wound; nor against tearing while the blad- 
der is filling or discharging. The patients were allowed to 
urinate when they pleased, and Dr. Bozeman saw them walk 
into the operating hall and climb on the table, four or five days 
after the operation, in order to have the threads taken out. 
Dr. Bozeman used the wire suture, which he fastened on a 
pierced plate with pierced shot (his so-called suture apparatus) 
in his cases. He claimed for it not only the advantages of 
metallic sutures, but also a better fastening of the sutures, 
which, in my method, consists in simple knotting of silk threads 
(which is equal to Sims’ twisting-of-wire suture). 
Dr. Bozeman applied an elastic to the 
bladder, which he rinsed out several times a day, and gave 
large doses of opium. He puts such value on this after-treat- 
ment that he intimates (in his article in the “New York Medi- 
cal Eecord ”), that the result in his second case was so unfa- 
vorable because he had not been able to carry out the after- 
treatment exactly to his wishes. Actually he visited the pa- 
and even above the insertion of the vaginal vault, as Jobert has first done for 
vesico-uterine fistula. In this way the orifice of the fistula in the canalis 
cervicalis may be exposed and cured either by bloody suture or cauterization. 
* Explanatory note of the Translator. 20 
VESICO-VAGINAL FISTULA. 
tients from three to four times a day himself, and my assistants, 
on his wish, paid attention to them at night. As stated above 
in the history of Case 11. of Dr. 8,, I afterwards closed up that 
fistula under circumstances much less favorable, and without 
any after-treatment whatever. * * * * * 
To the exact execution of the operation, in all six cases, only 
B.’s third offered serious difficulties as far as access is concerned, 
and these were eventually overcome. 
The above can be condensed in the following words : 
Further, we have seen that the operation being completed, in 
my cases, with the exception of Case I, where a little fistula 
remained, union of the edges took place, notwithstanding many 
real difficulties, or such as were considered so by Bozeman. On 
the other hand, B. had only one case (number 2) in which, by 
implication of the urethra in the defect, the cure was difficult. 
In this case reopening of the edges ensued, which rendered the 
case incurable. 
Therefore it remains to inquire; 
(1). Whether access to the fistula in B.’s third case could 
have been reached by my method also, or whether his method 
of exposing fistulas has an advantage over my coccygo-dorsal 
position. 
(2). Whether my paring and suture, to which the favorable 
results can only be ascribed, are better than the same acts in 
B.’s method, and whether the very unfortunate result in B.’s 
second case was merely accidental or must be ascribed to the 
method. 
Concerning the first question, I indeed thought that in B.’s 
first operation the exposure of the fistula in the knee elbow 
position and through his speculum succeeded better than in the 
coccygo-dorsal position and by my instruments. After B.’s ex- 
posure the fistula could easily be seen during the whole of the 
operation, and if not the operating itself, yet the effect of every 
cut and of each suture could be followed (controlled).* In this 
first case the paring of the fistula was completed with one single 
onset of the scissors and the knife, very substantial edges in 
* During the execution of both acts the hands of the operator darken the 
field of operation. VESICOVAGINAL FISTULA. 
21 
healthy tissue were formed, and the whole operation completed 
in one-half hour, notwithstanding the very complicated suture. 
The result of the operation was a complete cure. Remarkable 
in the performance of this operation, to me, was the extremely 
broad excision (paring) of the edges, amounting to one centi- 
metre in width. At the same time I found it injudicious that 
the larger part of the fistula was pared with the scissors, yet in 
the face of the result this scruple had to vanish. The whole 
operation impressed me favorably, though the fistula was, com- 
paratively speaking, easy to cure. I confessed to myself, that 
if in difficult cases operations could be performed with the same 
certainty, celerity and equally good results, B.’s method de- 
served to be preferred to my own, especially in fistulse situated 
high up in the vagina, which can not be dislocated towards the 
introitus-vaginse. I thought the method might be advantageous, 
because these cases sometimes offer greater difficulties to the 
operation with the knife in the coccygo-dorsal position, but the 
results of the two following operations convinced me of my 
error: 
In the second, executed in presence of our colleague Koeberl6,* 
the fistula was only situated 2| centimetres from the orifice of 
the urethra. After the patient was fastened in the knee-elbow 
position and chloroformed, the operation was carried out with 
great rapidity and dexterity (thirty-five minutes); all the spec- 
tators as well as myself admired Dr. B.’s skill (virtuosoship) (?). 
But here also I was struck by Dr. B.'s extensive excision of the 
edges, and that, as in the first operation, he used the scissors in 
preference to the knife. The anterior margin of the fistula was 
situated in the urethra, which only measured 2J centimetres in 
length, so that a very slight paring was indicated in order that 
continence of urine be retained; nevertheless, Dr. B. cut off 
about one centimetre of the edges, so that but centimetre of 
the urethra remained, and thereby risked incontinence in case of 
a failure. But the edges fitted closely upon one another; they 
* During this operation it is likely that I made the remark which Dr. B. 
quotes in his article in the New York Medical Record (see “remarks to this 
article” below), referring thereby to B.’s first case, for Dr. Koeberle was not in 
Heidelberg at a later period. 22 
VESICOVAGINAL FISTULA. 
were situated in perfectly healthy substance, and could be easily 
united in spite of the tension on them. If a cure with conti- 
nence had followed, nothing could have been said against this 
operation either. But the whole fistula rebpened and the 
patient became incurable. 
In the third case the fistula was very difficult of access, being 
situated in the left vaginal vault. After the exploration in 
the coccygo-dorsal position, in which I did not make use of any 
auxiliary instruments for this purpose, excepting Sims’ duck- 
bill speculum, not even using chloroform, its edges seemed to be 
attached to the bone; and as above remarked, I expressed the 
opinion that in this case, on account of the inaccessibility of the 
edges and of the proximity of the peritoneum, an oblique ob- 
literation of the left vaginal vault might be indicated. Dr. 
Bozeman cut a cicatricial band which narrowed the vagina ex- 
terior to fistula, gradually enlarged the same by tamponade, and 
ten days afterwards carried out the operation. The fistula was 
clearly brought to sight by means of the speculum, and I was 
able to convince myself that my first thought after superficial 
exploration, that the fistula was attached to the bone with the 
greater part of its edges, was wrong. On the contrary, only 
the extreme corner of it was adherent, and therefore much 
easier of access than I believed, I thought that in this case 
also the operation would be carried out as quickly as in the 
former cases; but the fistula was, in spite of easy exposure to the 
eye, so difficult of access to the instruments that it. took Dr. B. 
four and a half hours, a time now a-days unheard of, to complete 
the operation, though the defect was small. In order to pare the 
edges exactly, he had to so enlarge the fistula that its inner angle 
extended past the left of the anterior lip of the uterus (see fig- 
ure 12). At the end of the operation the edges were very 
broad and situated in exceedingly sound substance, and during 
the application of the suture apparatus no tension was felt. In 
this case I was likewise struck by the extensive paring in so 
immediate proximity to the peritoneum, and the broad excisions 
extending to parts 2J to 3 centimetres from the fistula. Therefore 
I feared a peritonitis, as I remarked to Dr. 8., without ever 
doubting that a union would properly take place. Yet in this VESICO-VAGINAL FISTULA. 
23 
case neglecting the proximity of the peritoneum was followed 
by no evil consequences. Peritonitis did not make its appear- 
ance; yet, on the other hand, the fistula did not heal in its 
totality, as I had predicted, but an opening remained before the 
os uteri, through which the nail-phalanx of the index finger 
could be introduced. 
After these operations I understood that my former supposi- 
tion, namely, that accessibility in the knee-elbow position and 
by means of Dr. B.'s speculum, could better be obtained than 
by the coccygo-dorsal position and my instruments, was an 
illusion. True it is that, in Dr. B.’s method throughout the op- 
eration, the fistula can well be seen, but the instruments are so 
difficult to handle that Dr. B. must in all cases, even where the 
fistulse are easy to expose (Case II), make use of the scissors, 
and always excise large portions of marginal substance while 
paring. These disadvantages, which will be treated of more 
thoroughly below, are not inherent to my method, and I there- 
fore hold the opinion, that in general it is preferable to Bozeman’s. 
In answering the question above proposed, whether in Dr. 
B.’s third case the fistula, which was very difficult of access, 
could have been exposed and approached by my method, I was 
impressed during the operation that with such protracted efforts 
as were necessary for Dr. B. to perform paring and union, I 
could also have succeeded in the coccygo-dorsal position in 
paring and sewing the edges, and even paring with the knife, 
though I had heretofore doubted the possibility. By division 
of the impeding cicatricial band and dilatation of the vagina 
under the influence of chloroform, access would very probably 
have been reached; yet even then it would have remained 
doubtful with me if obliteration of the left vaginal vault, in 
order to avoid injuring the peritoneum, were not preferable. I 
would have only united the edges in case I could have perfectly 
controlled each cut of the knife and carried out continued nar- 
row paring, as indeed by such proceeding lesion to the peri- 
toneum is much less possible than under Dr. B.’s broad excision. 
True, the peritoneum was not hurt in this case, either because 
the lateral cul-de-sac of Douglas was broadly obliterated or 
because it did not reach the field of operation on account 24 
VESICO VAGINAL FISTULA. 
of individual peculiarity; but that danger exists, and that it 
is advisable to look out for it, can not well be denied. Dr. 
B. himself has seen in his fourth case, in Vienna, during his 
preliminary operation, that a prolapsus of the fallopian tube 
occurred through a fold of the peritoneum opened by himself, 
though there were callous cicatricial contractions of the vagina 
in its immediate proximity, which made it probable that similar 
ones existed in Douglas’ sac. 
In these fistulas situated in the lateral vault, and so very dif- 
ficult of access, happily of rare occurrence, it is left optional 
with the operator whether he will, as Dr. Bozeman did, close 
up the fistula or perform obliteration of the vault, including 
the os uteri. In the first case, the patient is exposed to the 
danger of losing her life; in the second case she remains sterile, 
but the operation is harmless.* Were it possible in these cases 
to obliterate the vaginal vault without including the os uteri, 
then the operation would avoid the unfavorable points of either 
of them. I have never performed this obliteration myself, but 
I do not believe that its execution would meet with very great 
difficulties. 
* The oblique or transverse obliteration of the vaginal vault can be per- 
formed without fear of lesion to the peritoneum. True, Douglas’ cul-de-sac 
extends over the posterior side of the vault, but it is separated from the latter 
by the thick mucous membrane of the vagina and a rather strong stratum of 
connective tissue. On superficial paring and employing sutures which do not 
pierce or perfectly embrace the whole wall of the vagina, the peritoneum can 
not be injured, provided the mucous membrane is not attenuated by a cica- 
trizing process and the peritoneum thereby attached to it. These latter are 
rather to be expected close to the fistula than lower down, where occlusion is 
to be performed. I have carried out the obliteration of both vaults together 
immediately in front of the os uteri in two cases, and in one case oblique ob- 
literation, but have never observed peritonitis, not even a peritoneal irrita- 
tion. How little a lesion of the peritoneum after superficial paring is to be 
feared, becomes obvious also by the results of another operation, viz., col- 
poraphia posterior, which I have invented for the cure of prolapsus uteri (see 
rny Mittheilungen aus der Chirurg. Klinik in Rostock ”). Here the upper 
part of the pared surfaces is situated right over Douglas’ cul-de-sac, only 
separated from the same by the mucous membrane and a layer of connective 
tissue. But neither myself nor any other operator has seen a lesion of the 
peritoneum, though the operation has been performed in more than one hun- 
dred cases. VESICOVAGINAL FISTULA. 
25 
We now approach the second question : Why were the results 
of my paring and suture absolutely and relatively far better 
than Dr. B.’s, and are they to be ascribed to chance only, or to 
the method itself? 
To me they seem to rest on the method. 
Dr. B.’s paring is done in the following way: He takes hold 
of the anterior edge of the fistula with a tenaculum, pierces the 
same with a knife, and cuts in a transversal direction towards 
both angles; thereupon he takes hold of the loosened edge 
with a tenaculum and exerts traction on it in such a manner 
as to give the fistula a more vertical (antero-posterior) direction. 
Now he excises the posterior edge of the fistula from the right 
angle to the left with uninterrupted cuts with the scissors. The 
marginal parts were cut away so broadly in his first two cases 
that no secondary paring needed to be resorted to. In the third 
case, in which the fistula was very unfavorably situated, Dr. B. 
cut away still larger pieces, in order to be able to get at the 
extreme angle of the original defect. The edges were almost 
exclusively pared by the scissors in this case (figure 11). Dr. 
B. practiced broad excision even in those cases in which the 
fistula extended into the urethra, or was situated close to the 
peritoneum. I, on the contrary, after dilatation of the vagina, 
attempt to dislocate the fistula nearer to the introitus vaginae 
(by means of sharp, single and double tenacula, and by means 
of loops carried through the lips of the os uteri); then I take 
hold of the edges of the fistula, which, in the coccygo-dorsal 
position, lies directly in front of me, by means of a fine tenacu- 
lum or forceps, and if sufficient substance is at my disposal I 
excise the edges with a few cuts of the knife in a slightly ob- 
tuse angle; but in all cases where tissue must be spared, I suc- 
cessively cut off thin layers of substance. 
Let us compare these methods of paring: To. begin with, I 
do not consider the scissors as good an instillment for the pur- 
pose as the knife. Indeed, in deep cavities the operation with 
the former is easier to perform than with the latter; but there 
can be no doubt that even the sharpest scissors bruise the edges 
to some extent, and therefore are not as good for a prima 
intentio as those cut with the knife. In plastic operations, scis- VESICOVAGINAL FISTULA. 
sors are only resorted to where the knife can not be brought 
into use. I have convinced myself of the advantages of the 
knife in my numerous plastic operations, especially in cases of 
broad hare-lip and staphyloraphia,* in which the scissors were 
formerly made use of; and, indeed, Ido not know of any Ger- 
man surgeon who, for the operation of hare-lip, staphyloraphia, 
vesico-vaginal fistula, or rupture of the perineum, uses the scis- 
sors by choice. 
In the operation of vesico-vaginal fistula, in which a com- 
plete prima intentio is far more necessary on account of the 
disagreeable consequences of even the smallest part remaining 
open than in any other plastic operation, the scissors certainly 
would seem to be less suitable than the knife. Dr. B.’s total 
failure in his second, and the incomplete result in his third case, 
might be extensively, indeed, perhaps, totally ascribed to his 
;paring with scissors. The edges were in both cases as substan- 
tial and as broad as the circumstances admitted, for they in- 
volved the whole thickness of the vesico-vaginal and urethro- 
vaginal septum ; they were located in healthy tissue most favor- 
able for prima intentio; the traction on uniting th 6 edges was 
easy to overcome, and after the operation no untoward circum- 
stances happened which might have interfered with a speedy 
cure. If these edges had been cut with a knife, according to 
ray experience, a cure would have been the result, even though 
* Twenty years ago I operated on hare-lip, as I was taught, with sharp 
scissors and the clamp; but I could only count on a good result where the lips 
were well formed, which is the case in the fourth, fifth, or sixth month after 
birth, and even then only when the defect was not too broad. My attempts 
at closing up hare-lips during the first month, i. e., while the lips are very 
thin, were generally useless, even in very simple cases. I therefore took to 
the knife, and now-a-days I operate at the earliest period, namely, from the 
first day after birth, even complicated double hare-lips, and I can say that but 
very rarely the defect reopens, notwithstanding I never take the slightest pre- 
cautionary measures for preventing traction, nor do I ever apply a strip of 
sticking-plaster. In children of six, five, and even four months of age, I 
have often operated complicated and broad hare-lips without keeping them 
under after-treatment, but simply sent them home and had them brought for 
the necessary after-acts. Even under this treatment the most satisfactory 
results were gained (compare Rostock Mittheil., ii., p. 13). My results in 
staphyloraphia also became more certain when I had exchanged the scissors 
for the knife, as just now stated, in cases of hare-lip. VESICOVAGINAL FISTULA. 
27 
the pared surfaces were not brought into exact apposition by 
the suture. 
Only in those very rare cases in which the fistula is of very 
difficult access for the knife, the scissors might be preferred, 
because, under such circumstances, paring can be carried out 
more exactly than by the latter. 
Addition to this Translation by the Author.—This view might 
be opposed by the fact that many hundreds of fistulas have 
been operated upon and cured, especially by American colleagues, 
by means of the scissors. This fact, however, only proves that 
the vesico-vaginal septum offers far better conditions for a prima 
intentio than thin lips of children or edges of a cleft palate. If, 
therefore, (I do not mean to contradict) in a large majority 
of cases of vesico-vaginal fistulae, paring with the scissors fur- 
nishes as good results as the same act performed with the knife, 
I am, nevertheless, of the opinion that the certainty of good 
results is increased by the latter method, which is especially to 
be borne in mind in such cases where the edges are thin and 
their substance must be economized. 
A second and perhaps a still greater disadvantage of Dr. B.’a 
paring is, that very large pieces of the edges must he cut off in 
order to be sure that the margins are situated in perfectly 
healthy tissues. In the knee-elbow position, and on exposure 
by Dr. B.’s speculum, the fistula is not moved forward, but even 
pushed back, and though naturally situated near the introitus 
vaginas, is removed pretty far from the vulva. The fistula 
thereby becomes more difficult of access for the instruments, 
the field of operation is darkened by the hands of the operator, 
and the paring can not be so easily controlled, as is necessary 
under certain circumstances, during that act. Bozeman, there- 
fore, inserts his knife three-quarters to one and a quarter centi- 
metre from the anterior edge of the fistula into the tissues, and 
cuts equally broad parts all around the fistula, in order to be 
sure to have the fresh margins in perfectly normal tissues. 
No objection can be made against this broad paring* as long as 
* I make a distinction between broad and narrow paring and between 
broad and narrow excision {or ablation). By the first, only the breadth of the 
fresh surface is meant; in the latter, the width of the piece cut out is taken 
into consideration. 28 
VESICO-VAGINAL FISTULA. 
there is abundant tissue which can be wasted without harm. 
In all small and middle-sized fistulas, and even in a number of 
larger defects where there is no strict contra-indication, broad 
paring is justified; and I have ever been a defender of it, 
though I did not pare as broadly as Bozeman, Such fancy paring 
is even commendable for inexperienced operators, because 
thereby the edges are sure to be located in normal tissues. On 
the other hand, if we have to do with a fistula in which saving 
of the substance is law, unnecessarily broad excision may be 
conducive to the most serious consequences. 
Under this category are to be counted all those fistulae which 
extend into the urethro-vaginal septum; further defects whose 
edges, after protracted or unsuccessfully practiced preliminary 
treatment, have not become sufficiently movable to be brought 
in apposition without considerable traction; and, finally, those 
cases which are situated in the lateral or posterior part of the 
vaginal vault. In those in which the urethra is implicated, in- 
continence may be caused by too extensive paring. In larger 
fistulae, where the edges are very immovable, the defect becomes 
larger, and thereby traction is increased ; and, thirdly, the peri- 
toneum may be injured in fistulae situated in the lateral vaults. 
In these cases gradual ablation of the edges is the mode of 
paring which answers best under the circumstances. Thin 
layers of the margin are successively cut away until the edges 
are situated in perfectly normal tissues. In this way every bit 
of fancy excision is avoided. 
This gradual ablation is far easier to perform with a knife 
than with the scissors, and is in my method rendered a great 
deal easier, as by antero-dislocation of the fistula and retraction 
of the posterior wall of the vulva and vagina the way to the 
fistula is much shortened. It can be done with the greatest 
ease in defects in which the urethra is implicated, and in which 
this kind of ablation is especially indicated. Vesico-urethro- 
vaginal fistulae can be excellently exposed in the coccygo-dorsal 
position, and usually can be dislocated as far as the introitus 
vaginae, frequently even still further forwards, so that the oper- 
ation is almost performed as if on the surface of the body. In 
Ur. B.’s exposition parts of the edge one minim in width, VESICO-VAGINAL FISTULA. 
29 
which it may sometimes be essential to remove, can not be 
taken from the anterior edge with the knife, and still less from 
the posterior edge, where he uses the scissors. At any rate, Dr. 
B. cut away so much from the edges that but centimetre 
of the urethra, which, before the operation, measured 2J, were 
left. So extensive an excision, which had the above-mentioned 
evil consequences, was, however, perfectly uncalled for, as the 
edge of the urethra in question, which had just been operated 
on, was only covered by a thin cicatrix, and could not possibly 
have undergone cicatricial change to any great extent. The 
subsequent cure of the same (only enlarged fistula) by means of 
paring, which took away but a minimal part of the urethra, 
furnishes, as I think, the unmistakable proof of Dr. B.’s fancy 
excision. In this case, as above related, I operated twice more. 
The urethra itself lost but one and a half to two minims in each 
operation, since I pared very superficially. In my third and 
fourth cases the fistulas were situated in deep grooves at the 
place of juncture between the urethro-vaginal and vesico-vagi- 
nal septum, and its anterior edge was only two centimetres 
from the orifice of the urethra. Here also I saved substance 
by superficially paring the borders of the groove and excising 
but minimal parts of the fistula margin throughout its thick- 
ness. Dr. 8., wrho was present at the operation, remarked that 
in these cases he would pare much more extensively. But had 
I done so, larger parts of the urethra would have been lost, 
and even in case of union incontinence was to be feared. 
Other disadvantages of B.’s method seem to be founded on 
the fact that, on account of the transverse tension given the 
vagina by his speculum, the edges must always be united in 
a transverse direction, thereby excluding all other kinds of 
plastic not based on stretching the edges. In transversal, round, 
and even long oval fistulas, transverse union may be practiced 
with advantage. Longitudinal fistulas, whose longest diameter 
exceeds their transverse diameter by only one centimetre, can 
not be transversely united without the excision of large parts 
of substance which might have been saved. The line of union 
is thereby much lengthened and the tension increased. This 
drawback increases directly with the longitudinal diameter. I 30 
VESICOVAGINAL FISTULA. 
always unite in the direction of the longest diameter of the 
fistula—viz., in transverse, longitudinal or oblique direction, 
and I think this to be the most rational. In triangular longi- 
tudinal fistulae, whose basis was turned to the urethra and apex 
towards the os uteri, and in cases of large, square defects, I have 
united in T-and-Y shape, and achieved cures which, had I ad- 
hered to transverse suture, would have been very questionable 
(see my Rostock Mittheilungen). Besides, in cases which were 
therefore deemed incurable, I have several times successfully 
used bridge flaps for covering the defects, and in two cases I 
made use of petiolated flaps taken from the surrounding parts, 
and healed them into the fistula. 
These latter operations might, on account of the deep location 
of the fistula in the knee-elbow position, be combined with the 
utmost difficulties—yes, indeed, almost impossible. Should one 
attempt to make a transplantation in B.’s position (with his 
speculum, etc.,) the knife would have to be used, and at all 
events B.’s suture be abandoned. 
Besides his paring, B.’s suture might also have contributed to 
his unfavorable results, though this acceptation seems to me 
unlikely, because so far as I could judge the fistulas seemed well 
closed up. Yet B.’s suture has, besides the difficulties of its 
adaptation, several disadvantages, which I will now mention in 
a few words. B. thinks that his button-suture is superior to 
the interrupted silk or wire-suture, so far as exact adaptation of 
the edges is concerned; but anybody having seen his suture 
will hardly be of his opinion. I admit that by it the edges can 
well be kept together, but exact control of the union is not 
as safe as in the interrupted suture, where no plate hides the 
threads during the moment of their fastening. Besides, B. 
uses very thick wires, and places them comparatively far apart 
(one centimetre), and by means of these he draws the edges up 
against the leaden button. lam of opinion that finer threads 
put closer together, as in my suture, produce better union. Bor 
relaxation of the tissues, as well as union of the edges, is thereby 
effected from many more points, so that the former is brought 
about more uniformly, and the latter as closely as possible. 
By means of sutures, which are here further from, there closer to VESICOVAGINAL FISTULA* 
31 
the edges, and according to necessity are superficial or deep in 
the tissues, each postulate of a good union is answered to the 
fullest extent.* 
Finally, if Boz. thinks that his thick wires are less liable 
to cut into the tissues, and for that reason give rise to fewer 
suture holes than more numerous fine threads tied immediately 
on the edges, this position also seems to me to be built on sand; 
for if fine threads cut through, the tissues generally reunite 
immediately behind the thread, and in case a little fistula re* 
mains, it heals by cicatrization and without the help of art. 
Thick threads, it is true, are less liable to cut the tissues than 
fine ones, but if they do so, the danger of permanent fistulse is 
evidently greater. I also can not admit that fastening the 
sutures, without knotting, simply by pressing them up against 
a pierced lead button, is less conducive to cutting, because the 
tissues are as firmly compressed as when included in a knot, or 
on twisting the metallic wires, after Sims. If we consider that 
not rarely spasmodic contractions of the bladder act upon the 
united edges which are immovably fixed to the unyielding button, 
the weight of which constantly exerts traction on the suture, 
it is much more likely that B.’s suture can be damaged by ten- 
sion, and thereby favor the cutting of the wires than the above 
compared simpler sutures. 
In Dr. B.’s cases I have indeed been able to follow the suture 
incisions into the reopened fistula, notwithstanding the wire had 
been carried through the borders far from the edge. Bandl 
also remarked that, in Dr. B.’s fourth case which he operated 
on in Vienna, it was high time to take out the sutures. For, 
although on the eighth day the cure was completed so that no 
more traction could take place on the edges, the suture had 
almost entirely cut through the tissues. 
After the above investigations, the second question must be 
answered in the following manner: My paring and suture are, 
from the different above-mentioned reasons, to he preferred to the 
same acts in Dr. Bozemans operation, and that the failure in 
his second case must he ascribed to the method itself and not to 
accident.. 
* See mj Mittheilungen aus der Chirurgischen Clinique in Rostock, etc. 32 
VESICOVAGINAL FISTULA. 
REMARKS ON DR. BOZEMAN’S FISTULA OPERATIONS IN VIENNA. 
To the above discussions of the fistulse operated on in Heidel- 
berg, I take the liberty to add a few remarks on Dr. B.’s fistula 
operations in Vienna, which Dr. Bandl has very clearly de- 
scribed.* In Vienna Dr. B. had better results than in Heidel- 
berg, for of four fistulse he completely cured three, and in one 
only a very fine opening remained. These fistulse prove to be 
merely such as any expert can cure, whether he operates in the 
knee-elbow, the side, or the coccygo-dorsal position. The cases 
were, in my opinion, comparatively favorable.f The fistulse 
were located in the median line of the vagina and in the fundus 
of the bladder, where they are easiest of access, and where a 
cure is most likely to take place. In all of them there was 
enough substance, even for broad paring, and after dilatation of 
the contracted vagina, which was found necessary in three cases, 
the edges could be united without much tension. The urethra 
was intact in all cases; two defects (figures 2 and 4) extended 
towards it, so that it was involved in the paring, but only small 
parts of it were taken off1. Even in the largest defect (Case II) 
the prognosis was not at all unfavorable. Erora its posterior 
edge to the uterus there were still two centimetres of the vesico- 
vaginal septum left, and the distance from the exterior orifice of 
the urethra to the anterior margin of the fistula was 3J centi- 
metres. Broad excision could therefore be resorted to, not only 
in the posterior but also in the anterior edge. Indeed, such 
good edges could be produced, and their adaptation could be so 
exactly carried out, that I was astonished at Dr. Bozeman’s 
remark: “He would be satisfied if only five sutures would 
hold.” For under similar circumstances I would with my par- 
ing and suture expect a perfect cure. 
* Dr. Bozeman’s method of operation for vesico-vaginal fistula, etc., Wiener 
Medizinische Wochenschrift, 1875, No. 49, 52.—Bandl. 
t Such they were, especially when compared to the fistulse operated on in 
Heidelberg, of which only one was favorable, viz., Dr. Bozeman’s first case. 
In Heidelberg we generally treat but very difficult cases. Most of our patients 
come from a great distance, and have either been operated on by others, some- 
times by skillful operators without success, or the operation was never under- 
taken, being thought too difficult to cure. VESICOVAGINAL FISTULA. 
33 
Dr. Bandl, the reporter, lays special stress on the fact that 
three of the fistulas were very inaccessible on account of con- 
traction of the vagina, and that he could not expose them with 
my modified Sims’ speculum. According to common usage, 
therefore, transverse or oblique obliteration of the vagina would 
have been indicated; but that Dr. 8., by means of his prepara- 
tory measures, had been able to accomplish a cure of the fistulas 
by uniting their edges, I do not pretend to be able to give 
a perfectly correct judgment, as I have not seen or examined 
the cases myself, but I believe that I may be allowed to claim 
that Dr. Bandl’s first examination with the speculum only, and 
without any other instrument for the exposure of the fistula, 
without chloroform narcosis, and without dividing the impeding 
contractions, is no proof of the inaccessibility of the fistulas in 
question. From the description of the existing relations, I would 
probably not have deemed any preliminary treatment necessary 
in the first and fourth cases, and in the second case I would 
have resorted to repeated tractions on the womb, and perhaps 
divided one or the other of the cicatricial bands. I should most 
likely have omitted the gradual preparation, because only one 
thick cicatricial band narrowed the vagina and rendered the 
posterior edge of the fistula immovable. 
For the purpose of exposing the fistula, I would probably 
have divided the impeding contractions and adhesions with the 
knife, thereupon expanded the vagina by means of my specula, 
and completed the operation either with or without dislocating 
the parts surrounding the fistula. Whether the result would 
have been favorable must naturally remain undecided, though 
it may be considered very probable; for in the third and fourth 
of the above-described cases I have overcome similar, perhaps 
larger difficulties, although Dr. B. thought a gradual prelimi- 
nary treatment necessary, and indeed had begun the same, but in 
vain. 
Up to the present time I had almost entirely practiced rapid 
preparation, and but rarely thought a gradual preparatory 
treatment necessary. I divide the contractions of the vagina 
which make the fistula immovable immediately before the oper- 
ation of the fistula with the knife, and generally cut them at 34 
VESICO-VAGINAL FISTULA. 
different places. In the lateral parts and the anterior wall 
of the vagina, I make deep incisions, if necessary; in the pos- 
terior wall, where the peritoneum might be injured, I make but 
shallow scarifications. Thereupon I distend the vagina by in- 
troducing a set of grooved and flat specula increasing in size, 
practicing scarifications at such places where I find dilatation 
prevented by cicatricial tissue. By exerting traction on the 
lips of the os uteri and on the posterior edge of the fistula, I 
attempt to make the parts movable, and draw them forwards 
and outwards, so long as this can be done without exerting great 
power. Tenacula are then used to bring the parts still more 
into view. Often it is perfectly astonishing to see how quickly 
fistulse which were scarcely visible can be made so easily acces- 
sible that they can be operated on without any difficulty. I be- 
lieve I have achieved as much by rapid preparation as has ever 
been done by gradual dilatation. As becomes evident from my 
third and fourth cases, it can be effectually practiced under cir- 
cumstances where gradual preparation must be abandoned. 
Rapid dilatation is frequently more difficult than gradual 
enlargement, and sometimes requires a good deal of experience, 
so that un practiced operators do not often succeed with it, but 
it has various advantages over the other method. It not only 
shortens the time of treatment by weeks and months, but is 
also much less dangerous. On gradual dilatation, where the 
incisions into the cicatrices are distended by force for several 
hours each day, the pus and urine; which rapidly undergo 
decomposition, are kept in the vagina in contact with the open 
sores. Colpitis, cystitis, and if the connective tissue surround- 
ing the pelvic organs be exposed, suppuration and sloughing of 
the same, parametritis, even pelveo-peritonitis, may arise and 
put the patient’s life in danger. On rapid preparation, im- 
mediately followed by the closing of the fistula, the vagina is 
not kept extended for any length of time by a tampon, matter 
flows off directly, and urine does not stagnate nor undergo 
decomposition in the vagina. In ray treatment I have, com- 
paratively, very frequently practiced rapid dilatation; but I 
remember no case followed by so heavy symptoms of reaction 
as Nos. 3 and 4 of the Heidelberg cases, in which Dr. 8., and a VESICO-VAGINAL FISTULA. 
35 
third case a few weeks later in which I, with Dr. Markwald, 
(Berlin) attempted gradual dilatation. For the more experi- 
enced, therefore, I consider rapid dilatation indicated whereas 
exceptionally gradual dilatation may be of use. Should the 
posterior edge of the fistula be very closely attached, tractions 
on it and the os uteri would precede rapid dilatation. Under 
all circumstances it is very advantageous to expose and examine 
the fistula several times previous to operating on it, in order to 
become acquainted with the most suitable instruments and 
manipulations to be used, and also to the impediments opposing 
its exposure. On all difficulties of exposure the less practiced 
had better resort to gradual dilatation, and to relinquish it only 
when in spite of the greatest circumspection the patient can 
not bear it. If after the cure the rapidly dilated vagina should 
contract, gradual dilatation may now be undertaken with less- 
ened danger. 
That Dr. 8., as the reporter repeatedly urges, strives to ob- 
viate transverse obliteration wherever possible, is decidedly a cor- 
rect principle, and gradual dilatation might with the unprac- 
ticed in the future greatly diminish the number of transverse 
obliterations.* Nevertheless, this operation, the priority of 
whose discovery Dr. B. formerly disputed, but which he now 
concedes to me, will never be forsaken in such cases where the 
edges of the fistula can not be united after a long-continued 
preparatory treatment was fruitless, or not sustained by the 
patient. If in such cases transplantation from the surrounding 
parts can not be carried out, nothing remains but transverse 
obliteration of the vagina. In the summer in which I expected 
Dr. B. in Heidelberg, transverse obliteration of the vagina had 
to be carried out in the patient whom I treated together with 
Dr. Markwald. The loss of substance extended in this case 
* Within the last years I treated two Eussians, in which transverse oblit- 
eration had been carried out by two German colleagues. The patients, not 
satisfied with their state, traveled to Heidelberg, when I discovered after 
bloodless dilatation of the urethra, and by palpation of the bladder, that 
both fistuhe were comparatively small. I therefore opened the artificial 
atresias, severed the narrowing cicatricial bands and cured the fistulse. The 
former operators seem neither to have tried gradual nor rapid dilatation of 
the vagina. 36 
YESICO-VAGINAL FISTULA. 
from one centimetre forwards of the os uteri to two centimetres 
from the orifice of the urethra. The vagina was so narrow that 
it admitted only one finger, and all the parts surrounding 
the fistula, with the exception of its anterior edge, were so 
firmly attached to their neighborhood as to make them perfectly 
immovable. The fact that its lateral edges were but two-thirds 
of a minim in width, callous, and attached to the bone, was 
especially unfavorable. Now, although convinced that even if, 
after dilatation of the vagina, the middle part of the posterior 
edge was rendered movable, and the lateral parts of the fistula 
were found to remain open, I still wished to try whether by 
gradual preparation circumstances could not be so much bettered 
as to allow of a transplantation. I severed the strictures and used 
nothing but soft tampons; but from the fifth day pelveo-peri- 
tonitis developed to such a degree that recovery remained 
doubtful for a long time. It took ten weeks for the patient to 
recover before transverse obliteration, now indicated, could be 
performed. Occlusion was gained. Continence is only complete 
in the horizontal position; when standing or walking nearly 
all the* urine flows off, because the remains of the urethra, only 
two centimetres long, had to be shortened in the operation. 
Nevertheless, her present state is a great gain for the patient. 
In such and similar cases, transverse obliteration must be per- 
formed, and if there be one-fourth or one-half-centimetre of the 
urethra left, complete continence will be the result. Then the 
operation will be what Dr. B. called it in 1868; “An import- 
ant operation,” because by it the patients become liberated from 
the most terrible symptom of their suffering, viz., incontinence.* 
In his article in the “ New York Medical Eecord,” Dr. 8., 
in order to show to what extent transverse obliteration should 
be shunned, has stated that pyelitis suppurativa is the conse- 
quence of this operation, and has cited my second case as new 
proof for his view. Ido not know on how many observations 
Dr. B. bases his view, but I can oppose the fact that I have 
seen at least ten patients in which transverse obliteration has 
been performed, who, ten years afterwards, enjoyed most bloom- 
* See my article, Historical Remarks, etc. (Deutsche Klinik, 1868). VESICO-VAGINAL FISTULA. 
37 
ing health. To be sure, I did also witness several cases that 
died from pyelitis suppurativa, either with or without forma- 
tion of calculi. But in this case transverse obliteration was 
not the reason, but contractions and deformation of the ureter, 
which were caused by cicatrization of lesions produced during 
delivery. Generally, symptoms of pyelitis had existed previous 
to kolpokleisis. 
In my second case, also, both ureters were much contracted 
near their insertion into the bladder. Indeed, I know of no 
reason why transverse obliteration of the vagina, after which 
the urine does not stagnate any more in the bladder than nor- 
mally, should produce pyelitis suppurativa. 
Dr. Bandl extols as an advantage of Dr. B.’s operation, that 
it is performed in situ of the parts involved. But Ido not know 
wherein this advantage consists; for it is perfectly equivalent 
for the cure whether the parts remain in situ during the opera- 
tion, or are only brought there after the operation, as in my 
method. Operating in situ and with Dr. B.’s mode of exposure, 
the operation can only be exactly performed with the scissors. 
If artificial antero dislocation of the parts involved can be 
practiced, the knife can be used and the operation done with 
such a degree of exactness as can not be reached by the other 
method; therefore, in all cases where my exposure can be em- 
ployed, I consider my method absolutely better than Dr. B.’s, 
and only in such cases where the fistula is situated high up and 
can not be dislocated, the question might arise whether in a 
given case the one or the other of the methods deserves prefer- 
ence. It is remarkable that many operators, yes, even followers 
of ray method, have entirely overlooked or not sufficiently 
valued the advantage of artificial descensus (antero-dislocation). 
Ullrich, in Vienna, for instance, has invented an apparatus 
to fasten the fistula during the operation, which, as every ap- 
paratus of the kind, must render dislocation forwards, i. e., to 
the surface, impossible. Such an apparatus could only be used 
to advantage in my method in case of an immovable fistula 
when dislocation is impossible. 
I must also recur to the question of catching the ureter in 
the suture. Bozeman makes this circumstance answerable for 38 
VESICO-VAGINAL FISTULA. 
the small fistula remaining after his second operation in Vienna. 
The history of the case, however, states that the visible orifice 
of the ureter was split to the extent of one centimetre in an 
outward direction, and it is therefore difficult to understand 
how the second last and not the last (most outward) suture 
which corresponded to the remaining fistular opening should 
have compressed the lumen of the ureter. 
To me the reason for the remaining small fistula seems also 
to be based on other moments. If Dr. B.’s supposition was cor- 
rect, that in Heildelberg and Vienna, as well as formerly in 
Paris,* the ureter had been caught in the suture, and that 
thereby the little remaining fistulee had been produced, we 
would have to conclude that his suture apparatus was especially 
unfavorable; for, as above stated, this occurrence has never 
been found an obstacle to a cure by me, nor by other operators. 
I was astonished that the reporter considered the result of 
Case II equal to a cure, though the worst spot had remained 
open; for, according to Dr. B.’s, as well as Dr. Bandl’s view, 
the remaining little opening was a vesico-urethro-vaginal fistula. 
Now, as Dr. 8., in the operation of the large defect, could not 
avoid the visible ureter, it must be anticipated that he will still 
be less able to do this at the operation of the small fistulae, at 
which the ureter will, of course, be much less visible, perhaps 
not seen at all. 
I have spoken at such length about Dr. B.’s method of oper- 
ation, because by far the greater number of fistulas can be cured 
by it, so that it can not be excluded from competing with the 
two methods in general use, viz., Sims-Emmet’s and my own.f 
But it will never become very popular, because, in a number of 
* See below, Critical Remarks on Dr. B.’s article in the New York Medical 
Record. 
| These three methods are especially distinguished by the different positions, 
the mode of exposing the fistula with its consequences in regard to the facil- 
ity and certainty of the operation. Preparatory treatment and after-treat- 
ment, however, are independent of the method. The material of the suture, 
whether metallic wire or fine silk thread, does not involve a material differ- 
ence. In a future article I will compare each single act of the three methods, 
but especially, however, Sims’ method and my own, and explain their differ- 
ences at some length. VESICO-VAGINAL FISTULA, 
39 
cases, the two latter methods do the same, and in some cases 
even more in a simpler way, and with less costly instrumental 
apparatus. Bozeman’s proceeding is complicated, and the 
position of the operator is a very forced one, and at the same 
time so wearisome that, in difficult cases, an immense amount 
of time and the most extreme perseverance is required on 
his part. For how long would a less skillful man operate, 
when Bozeman himself required four and a half hours in a dif- 
ficult case for the completion of an operation ? It is my opin- 
ion that Dr. B.’s method would gain considerably if he aban- 
doned his complicated button-suture and adopted the simple 
silk or wire-suture; besides, if he would give up the super- 
fluous, and sometimes even obnoxious, after-treatment with 
the catheter en permanence, in favor of my perfectly negative 
after-treatment.* Finally, I believe his results would be much 
improved, if in all such cases in which substance must be spar- 
ingly pared—l mean such fistulse as extend into the urethra— 
he would substitute my mode of operation for his own* 
From our Heidelberg operations, and more especially from 
the description of the Vienna cases, I have derived this benefit, 
that I now estimate gradual dilatation higher than I did here- 
tofore, and I believe that it deserves urgent recommendation to 
inexperienced colleagues. 
In regard to the exposure of the fistula, I will always try all 
positions in general use, and choose the one which furnishes the 
easiest access. 
Thus much about Bozeman’s operations performed in Heidel- 
berg and Vienna; as regards our “ concours,” it was not yet 
closed. The number of cases was yet very small, and I 
had as yet not operated on a fistula situated high up; Dr. 8., 
on the contrary, had operated on two cases of high fistula, and 
one deep, extending into the urethra. We had, therefore, 
agreed to continue the operations in the summer of 1875. I 
was then to operate on the fistulas situated high up, more diffi- 
* Marion Sims, who, a short time ago, was in Heidelberg, made us ac- 
quainted with his manner of position and of exposing the fistula, and ver- 
bally stated that, of late, he only exceptionally uses a permanent catheter in 
the after-treatment. 40 
VESICO-VAGINAL FISTULA. 
cult of access, but easier to cure. He (Boz.), on the contrary, 
was to operate on such as were situated further down, easier of 
access, but more difficult to cure. Especially was Dr. Boze- 
man to operate again on that fistula in which his result was so 
very unfortunate (Case 11, which he had said he was able 
to cure with continence). To my regret, he never came back 
to Heidelberg any more. 
In July, 1875, Dr. B. had published, without my knowledge, 
an article in the “ New York Medical Record,” and another in 
August in a Geneva political paper concerning our operations. 
For this reason I became acquainted with both of them only 
by chance, and very late after they were printed. Passing over 
the latter in silence, as written for an unscientific public, I must 
enter on the first, which was calculated fdr medical men, more 
closely, because in it are contained many inaccuracies and in- 
correct statements. 
REMARKS ON DR. BOZEMAN’S ARTICLE IN THE NEW YORK MEDI- 
CAL BEGGED, JULY 25, 1875. 
I here quote the most startling sentences. In regard to the 
extent of the fistula and result of the operation in my first 
case, Dr. Bozeman says : 
“ The first case presented a good-sized fistula, which occupied 
the base of the bladder. About seven-eighths of the fistula 
was closed.” 
In this case not only the whole of the base of the bladder, 
but also the lateral parts of the vaginal vaults and a part of the 
urethra were defective. After the operation there was not 
one-eighth of the defect open, but only a small fistula the size 
of a lentil or a pea, at the highest, one-twenty-fifth of the line 
of union (see figure 2). Afterwards, when describing his second 
case, Dr. Bozeman says of the remaining opening, “ the fistula 
was small.” 
In the description of my second case the following passage 
occurs: 
“The operation which he performed had for its object the 
reclosure of the vagina, which I witnessed. It was kolpoklei- 
sis for the second time.” VESICO-VAGINAL FISTULA. 
41 
In this case I had, six years ago, completed an atresia of the 
vagina occurring after heavy labor by closing up a small open- 
ing. A stone, which was very likely not formed in the bladder, 
but in the kidney, and which had descended into the bladder, 
had perforated that part of the urethra which lay immediately 
between the obliterated vagina and orifice of the urethra, not, 
however, the cicatrix itself; therefore I did not perform a 
second kolpokleisis, but I united the edges of the urethro-vagi- 
nal fistula in a longitudinal direction, that is, in a direction at 
right angles with the obliteration of the vagina. The line of 
union extended close to the orifice of the urethra (see figure 3). 
Concerning the result of my third case, Dr. Bozeman says: 
“ The operation succeeded only to a limited extent, the failure 
being due probably to the cystitis which still existed to a slight 
extent at the time of the operation.” 
In this patient only a small fistula had remained, which, 
on examination four weeks after, had spontaneously entirely 
closed, so that here a complete cure was subsequently achieved 
by the operation. The patient suffered from cystitis, pains in 
the lumbar region, and fever after the operation; nevertheless, 
a cure ensued. Bozeman had in this case (he does not mention 
it) unsuccessfully tried gradual dilatation. I therefore insti- 
tuted rapid extension immediately before the operation. 
My fourth case is thus described by Bozeman : 
“ The fourth case of Prof. S. was a young woman, aged about 
twenty. She had a small fistula at the root of the urethra with 
complete atresia of the vagina above, with no outlet for the 
menses. Prof. Simon proposed in this case to close the fistula 
as the first step of the treatment; but instead of closing the 
fistula as he intended, he closed the vagina below the fistula, 
thus making the operation one of kolpokleisis, with no pro- 
vision for the escape of the menses. The result was only a par- 
tial success, and further treatment will be required to complete 
the occlusion.” 
In this case the fistula, as represented in figure 5, is situated 
below an atresia of the vagina, which, however, was not com- 
plete. There was an opening on the right side which led up to 
the right side of the os uteri. Bozeman tried (and this fact he 42 
VESICO-VAGINAL FISTULA. 
admits also) to dilate the vagina from the opening described, 
but in this case also without success (see history of Case IV). 
I therefore operated on the fistula, dividing the contractions of 
the vagina immediately above it so as to have easy access. The 
result was the one in which but a small fistula remained at the 
extreme corner which had not been caught in the suture (see 
figure 6). It is hard to comprehend how Dr. B. here also came 
to the conclusion that kolpokleisis was performed. After hav- 
ing read Boz’s statement, I have at various times examined 
the patient in the presence of assistants and students, as well 
as traveling colleagues, and we have found the relation of the 
cured fistula to the incomplete atresia of the vagina, as given 
in figures 5 and 6. Through vaginal opening on the right side 
the os uteri can be reached; the partial atresia is situated above 
the healed fistula. 
In the description of my second case, Dr. B. states: 
“ The second case was the.one Prof. Simon first operated upon 
with partial success.* The fistula was small and involved the 
cervix uteri, perfectly simple and easy to get at, as shown by 
the fact that it took only thirty-five minutes to complete the 
operation. The case was just such a one that I would have 
guaranteed to cure in eight days, if I had had entire manage- 
ment of the after-treatment. But, as it turned out, the after- 
treatment was not properly carried out, and cystitis resulted, 
which caused the fistula to rebpen two days after the suture 
apparatus was removed.” 
Here the fistula had not only totally reopened, but bad be- 
come incurable so far as continence of the urine is concerned, 
and as I have above explained (see critical examination of the 
cases). lam convinced that by Dr. B.’s paring and suture the 
fistula could not even have been closed (see case). The fistula 
did not reopen two days after the suture apparatus was re- 
moved, but urine flowed from the fistula at the time it was 
* Dr. B. calls the result of my operation a partial success; a fistula of the 
size of a lentil or a pea had remained (see figure 2); but when Dr. Bandl puts 
the second of his Vienna cases among “ the cures,” though an opening the 
size of a probe-knob had remained (not much smaller than mine), and which 
he himself calls a vesico-uretero-vaginal fistula, he quietly accepts the situa- 
tion. VESICOVAGINAL FISTULA. 
43 
taken off. True, the fistula was only found completely open on 
examination two days afterwards. Dr. B. here accuses the after- 
treatment of the unfavorable result as not having been carried 
out according to his wish. But he conducted the after-treat- 
ment himself, as above stated. He visited his patient three or 
four times a day, and my very skilled assistants carried out all he 
wished for. I can not imagine how Dr. B. could have better 
provided for the after-treatment. The fullest proof that the 
after-treatment was not the reason of his bad success is given 
in the fact that I cured the fistula under far more difficult con- 
ditions without the use of the catheter, the rinsing of the blad- 
der, and without opium. Dr. Bozeman afterwards changed his 
opinion. In a letter which I received from him, dated Paris, 
October, 1875, he assigns as the reason for his failure ignorance 
as to the relative position of the urethra and fistula during the 
operation ; and, besides, that in my previous operation the edges 
had not been pared and united in the knee-elbow position, that 
is, not in situ of the parts! 
In the description of his third case, Dr. B. remarks: 
“ The operation proved tedious and protracted, though it was 
entirely satisfactory. Prof. S. expressed himself satisfied, and 
said he did not see how it could fail to succeed. Six or eight 
hours after the operation, I found an unusually small quantity 
of urine passing per catheter, which at once aroused my suspi- 
cions as to the right ureter being closed between two of my 
sutures. A few hours later the patient had great pain in the 
right kidney, and then felt a gush of urine into the vagina, with 
complete relief. When I saw her again, about eighteen hours 
after the operation, and learned the true story of the case, I 
told Prof. S. we would have a partial failure of the operation 
corresponding to the point at which the right ureter lay in the 
posterior edge of the fistula. The same accident having occur- 
red some years ago in a case in the Hotel-Dieu of Paris, upon 
which I operated, and in other cases, I felt confident of the final 
result—a partial failure. The removal of the suture apparatus 
on the eighth day in this case fully confirmed my explanation. 
A small fistula remained about the middle of the line of cica- 
trization, which was nearly two inches in length. This remain- 44 
VESICO-VAGINAL FISTULA. 
ing fistula is, properly speaking, a vesico-uretero-vaginal fistula. 
Now that the precise situation of the ureter is known, there 
can be no difficulty in the next operation, when a complete cure 
may be expected.” 
The remaining fistula was not as Boz. states, situated in the 
centre of the cicatrix, but at its inward (next to the middle 
line) end, just before the anterior lip of the os uteri, and is no 
vesico-uretero-vaginal, but a common vesico-vaginal fistula. It 
is, therefore, situated more favorably, and is not of as bad a na- 
ture as Boz. makes out. The symptoms which he (B.) describes 
as proof for the compression of the ureter by a suture, are by no 
means characteristic. The fact that but a very small quantity 
of urine had passed through the catheter the first six or eight 
hours, the pains in the lumbar region which appeared a few 
hours later in the right kidney, and their relief after a sudden 
gush of urine, may all be accounted for by an incomplete occlu- 
sion of the catheter, caused by a clot of blood. For this reason 
the urine flowed very scantily from the catheter, the greater 
part being retained in the bladder. When the bladder was highly 
distended the coagulum was forcibly thrown out, and the urine 
partially escaped along the side of the catheter.* The reason 
that the pain in the region of kidneys was unilateral, doubtless 
rests on casual circumstances, or accidental assertions of the 
patient, who was still considerably under the influence of chloro- 
form; for pains which arise after sudden occlusion of the ureter 
appear much sooner, as I have observed, after closing the ureter 
by cautery in cases of uretero-vaginal fistulas; about one or at 
the most two hours after the occlusion, and they are of extreme 
vehemence. They appear under the picture of severe colic of 
the kidneys. (See my paper in Scanzoni’s Beitragen, Vol. VI, 
1860.) Bozeman here considers the cure of vesico-uretero-vagi- 
nal fistula very easy, because he is acquainted with the location 
of the ureter, quite in contradiction with his second case in 
Vienna (see above). 
* Bozeman supposes that the gush of urine passed through the vagina, per- 
haps, because the sheet was -wet. But of course neither he nor the patient 
could possibly judge whether the urine had taken its way through the fistula 
or through the urethra, alongside of the catheter into the underlying sheets. VESICO-VAGINAL FISTULA. 
At the close of his article the following sentence is found: 
“At the second operation of Prof. Simon and myself, which 
we performed the same day, Dr. Koeberle, of Strassburg, the 
celebrated ovariotomist, was present. He came to Heidelberg 
and spent two days to see us operate. Prof. S. frankly admits 
the superiority of my operation in all cases when the fistula is 
situated high up. He is delighted with my speculum, and, in- 
deed, has ordered all my instruments to be copied, even my 
operating chair.” 
In regard to the remark which I passed on Dr. B.’s method 
after his first operation, I have above explained myself. It is 
evident that it was very prematurely published. If Dr. B. had 
asked my opinion a little later he would have heard that it was 
very soon changed. Concerning the acquisition of Dr. Boze- 
man’s instruments and apparatus, I have in a letter to Dr, 
Beigel, who asked my opinion, said that I had bought the same, 
partly to demonstrate them to my scholars, and partly to make 
experiments with the same.* Up to the present time I have 
not been .so converted to use Dr. B.’s method. In the summer 
and fall of 1875 I cured nine fistulse, all clinical cases (six of 
them, each by one operation), but have never once made use of 
Dr. Bozeman’s method, because I felt convinced that I would 
succeed more quickly and safely with my own. 
The above criticism of Dr. B.’s articles was necessary in 
order to state the facts correctly before the Profession. Yet I 
am far from reproaching Dr. B. for having willingly made 
incorrect statements, lam rather of the opinion that it 
was his ardent zeal for recognition (acknowledgment) (?) which 
prompted him to publish these over-hasty statements.! The 
* See Wiener Med. Wochehschrift, 1876, No. 5 (note by the translator). 
There is a fund in every German university for buying instruments, though 
they be never used, merely to complete the armamentarium collection of the 
cliniques. 
f la the Geneva article I find the author complains that Dr. B. is not 
appreciated according to his merit by his American colleagues. The sentence 
is the following- “We have heard it hinted that the welcome which Dr. B. 
has met from the profession in Europe is with contrast to the treatment which 
he has received at the hands of some of his professional brethren in America.” 46 
VESICOVAGINAL FISTULA. 
main errors were caused by the fact that Dr. B. did not take 
the trouble to examine the results of my operations later than 
the fifth or seventh day after the lifting of the sutures, when 
examination was very difficult, even to myself. Had he watched 
the results after cicatrization, and taken more pains to study the 
pathological relations of the fistulae which I had operated upon 
before him, he would have been better posted. Thus it hap- 
pened that he came to call the result in my third case, in which 
a complete cure was achieved after spontaneous occlusion of the 
little fistula, a cure of “ limited extent; ” and that in the fourth 
case, in which but a small fistula at one end remained, which 
had not been comprised in the suture, was called “only a 
partial success.” By his superficial examination he arrived at 
the marvelous conclusion, that in my second and fourth cases I 
had practiced transverse obliteration of the vagina, though in 
the second case the fistula was united at right angles to the 
preexisting obliteration of the vagina (figure 3); and though 
he had himself tried bloody dilatation and tamponade of the 
vagina (figures 5 and 6). Dr. Bozeman certainly is too expert 
an operator on fistulse not to know that the result after cica- 
trization, and later by contraction of cicatrix, often becomes 
materially better than it seems while the edges are not yet com- 
pletely cicatrized. Doubtlessly he also knows that pathological 
relations which may be connected with a fistula are frequently 
only fully cleared up after repeated and careful explorations. 
I have asked Dr. B. several times myself to examine the fis- 
tulas, once on his travels through Heidelberg, about six or eight 
weeks after the operations, and in two letters written to him to 
Paris in October of the same year. But the first time he had 
to depart too soon, and the second time he said he was kept 
back by family affairs from a journey to Heidelberg. But even 
if there was no chance for him to examine the fistulas person- 
ally, he might easily have avoided errors in his statements, or 
corrected them in a subsequent article, if he had only inquired 
about the final results by letter. From the reception which he 
found among us, and which he himself publicly acknowledged, 
he had to conclude that full statements would most willingly 
have been furnished him. YESICO—VAGINAL FISTULA. 
47 
Finally, I must add that this article appears thus late because 
I expected Boz. back here for a continuance of the concours 
until October, 1875. When he was not able to come I waited 
some time longer, in order to communicate the result of my 
operations performed in October and November on the patient, 
on whom he had unsuccessfully operated (see his second case). 
When at last I came to write the article, ray health was so im- 
paired that I could only work at it very slowly. PERIODICAL MEDICAL LITERATURE. 
Interesting to Physicians. 
Every physician who is just to his patients and to himself must read faith- 
fully and regularly the periodical medical literature of the day. It is only 
thus that he can learn quickly and correctly all of the improvements con- 
stantly taking place in every department of his Profession. To all who thus 
seek to make themselves most efficient in practice and most successful in com- 
petition, the undersigned offers the 
This work is issued monthly, and has now reached its twenty-third volume. 
It is clearly printed on rose-tinted paper, which is not only agreeable to the 
eye, but safe, as the superfluous rays of light are absorbed by it, and are not 
painfully and injuriously reflected,, The pages of the Journal have been 
increased in size, and there are now issued every year two volumes, making 
an aggregate of one thousand one hundred and fifty-two (1,152) pages. The 
cost of both volumes is but five dollars ($5 00) annually, with twenty-five 
cents added for the yearly postage. Medical works of this size cost usually 
double the price mentioned, and are issued on paper inferior to that on which 
the Journal is printed. This Journal has always embodied the best articles 
from the best physicians in this country. Its selections are made from origi- 
nal European journals, and from the best medical periodicals of this country. 
Its exchange list is large, and includes not only all American journals, but 
the best of those published abroad. The reader obtains thus, every month, a 
condensed report of all that is valuable in American and European medicine. 
In addition, there is furnished the professional proceedings of medical socie- 
ties; reports of interesting clinical cases; letters from European and American 
medical centres; reviews of all the new works; miscellaneous extracts; the 
medical news of the day; chemical and pharmaceutical literature; and edito- 
rial comments upon topics of current interest. The circulation of this Jour- 
nal is much larger than that of any medical journal in the South, and the 
work is read by the leading members of the Profession. Specimen numbers 
25 cents each. 
There is also offered to the medical public, by the undersigned, the 
American Medical Bi-Weekly. 
This Journal (as the American Medical Weekly) was founded July 4th. 
1874, and is now permanently established. It is mailed invariably 
every other Friday night (there has not been a single failure), and 
reaches its subscribers regularly. It is printed on paper similar to that 
used for the Monthly. Its exchange list is equally large. Its pages are 
made up in double columns, and the subscriber receives this enlarged 
worK for the small sum of three dollars ($3.00) annually, with an addition 
of ten cents for the year’s postage. The Bi-Weekly is issued in two volumes 
yearly; each volume having a complete index. Medical works of such 
size cost fully twice the price asked for this Journal. It contains origi- 
nal articles; extracts from foreign and domestic journals; reviews of new 
books, pamphlets, monographs, etc.; correspondence from European and 
American medical centres; the news of the day fresh and comprehensive; and 
editorial matter. Under no circumstances is the same material used for the 
two Journals; they are entirely different in the matter presented. • 
These are owned and edited solely by the undersigned, and are 
therefore managed with consistency and care. They are independent of all 
corporations, and are strictly organs of the Medical Profession of this country. 
Contributions for both Journals are respectfully requested. Those who 
have not the time or inclination to write formal articles can furnish matter of 
value in the form of letters. Every one observes something of interest, and 
all such facts should be given to the Profession. 
E. S. GAILLARD, M. D, 
163 Second Street, Louisville, Ky.