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y 
 
 
ON THE TREATMENT
OF
VESICOVAGINAL  FISTULA,
BY
J. MARIOIV SIHS, Mi. D. of Stew-York,
        »ir ■'■'■

        (LATE OF MONTGOMKRY. ALA.)
— «♦. —
B1LANCHARD & LEA

      1853. 
vvp




I? 53
) 
PKEFACE.
   This brief monograph is a reprint from the "American Journal of Medical Sci.
 ences," for January, 1852.  When published, it was altogether probable that it would
 be my last contribution to Surgery.  But it has pleased God to raise me up after
 nearly four years of the bitterest affliction, and restore me again to  health,  and—I
 hope—to usefulness.  Having suffered so long from climatic influences, I have,  at
 length, much against my will, been forced to abandon my Southern home, and seek
 another, amongst strangers, in a higher latitude.  I have, therefore, selected New
 York, as my future residence, and opened an Infirmary for the treatment of the acci-
 dents of parturition, such as injuries of the bladder, rectum, perineum, etc. Expect-
 ing the profession to second my efforts, I have  made ample arrangements for the ac-
 commodation of patients from a distance, where they may enjoy all the comforts of a
 home.  Aware of the fact, that the general practitioner has neither the time nor in-
 clination to be troubled with such cases as I want, I feel that I am rendering a service
 to the profession in making the above announcement.
  These accidents cannot be treated with any reasonable degree of success, unless the
 patient is under the immediate and constant supervision of the surgeon.   To this  is
mainly due my success, having already perfectly cured, (by my operation), several
 cases of lacerated perineum, and upwards of twenty of vesico-vaginal fistula, a minute
detail of which I hope soon to lay before my medical brethren, together with the im-
provements and modifications of apparatus which a larger experience and better op-
portunities have suggested.

  79 Madison Avenue, New York.                          J. MARION SIMS.
          Nov. 1, 1853. 
 
ON  THE  TREATMENT
                             OF

YESICO-YAGINAL   FISTULA.
  Vesico-Vaginal Fistula—an abnormal communication between the blad-
der and vagina, allowing an involuntary discharge of urine—is produced gene-
rally by tedious labour.  The impacted foetal head, jamming the anterior vaginal
parietes against the symphysis pubis, obstructs the circulation of the parts,
which results in a slough of greater or less extent, according to the degree and
duration of the impaction.  Almost the only hope  of preventing so serious  a
disaster under such circumstances is the timely resort to instrumental delivery.
By this means I  have seen the slough confined to  the vaginal mucous mem-
brane, where, otherwise, it would unquestionably have extended entirely through
the vagino-vesical septum.  It occurs principally in first labours where the pelvis
is small, the soft parts unyielding, and the foetal cranium large;  but I have
seen it in those  advanced in life, who had given  birth previously to many
children.   Authors are disposed  to  attribute the accident, in many cases, to
the awkward use of obstetrical instruments;  but, from a careful analysis of
these cases, and from my own experience, I am well satisfied that for one case
thus produced, their judicious application has prevented it fifty times.
   Other causes produce it  occasionally, such as a prolonged retention of a pes-
sary in the vagina, a calculus or other foreign body in  the bladder, abscesses,
venereal ulcerations, &c.   I  have seen one case where  the whole  base of the
bladder was destroyed by a corroding ulcer, which, originating  in the cervix
uteri, extended forward to the urethra.  Whatever may be the cause of this
distressing affection, it is a matter of serious importance to both surgeon and
patient that it be rendered susceptible of cure.
   Its diagnosis is sufficiently easy.  Incontinence of urine, following a tedious
labour after a lapse of from one to fifteen days, will always prove its existence.
But to determine  the exact size, shape, and relative position of the artificial
opening requires  some nicety of examination.  The consequences of the in-
voluntary discharge of urine are indeed painful.  The  vagina may become in-
flamed, ulcerated, encrusted with urinary calculi, and even contracted;  while
the vulva, nates, and thighs are more or  less  excoriated, being often covered
     2 
6
Sims, Treatment of Vesico- Vaginal Fistula.
 with pustules having a great resemblance to those produced by tartar emetic.
 These pustules sometimes degenerate into sloughs, causing loss of substance,
 and requiring a  long time to heal.   The clothes and bedding of the unfor-
 tunate patient are constantly saturated  with the discharge,  thus exhaling a
 disagreeable effluvium, alike disgusting to herself and repulsive to others.
   The accident, per se, is never fatal; but it may well be imagined that a lady
 of keen sensibilities so afflicted, and excluded from all social enjoyment, would
 prefer death.  A case of  this kind came under my observation a few years
 since, where the  lady absolutely pined away and  died, in  consequence of her
 extreme mortification on ascertaining that she was hopelessly incurable.
   The relative position of the fistula has served generally as the basis of a
 classification.   Thus we have :—
   1st. The urethro-vaginal, where the fistula is confined to the urethra.
   2d. Those fistulae situated at the neck of the bladder,  or root of the urethra,
 destroying the trigonus vesicalis.
  3d. Those of the body and bas-fond of the bladder, of which, Velpeau says,
 " there is no fact, up to the present time, which proves indisputably that  they
 have ever been cured."
  4th. The utero-vesical, where the opening communicates with the body or
 cervix of the uterus.
  I have never met with one of the last-named class; but of the others I have
 seen a great variety, embracing almost every possible shape and size.
  The position of the patient for the operation, the speculum, the  means of
 vivifying the edges of the fistulous  opening, the suture  apparatus, and  the
 catheter  which I  shall describe, are, I believe, original with  myself, having
 been suggested by the peculiarities of individual cases.  The final perfection
 of these mechanical contrivances has been the slow work of experiment.
  At the first, I had three cases, upon which I  operated  about  forty times, but
 failed in  every instance to effect a perfect cure, though succeeding so far as to
 encourage me to persevere.  Now, I think I may say that almost every case of
 this hitherto intractable affection is rendered perfectly curable.
  Before detailing my operation, it  may be interesting  historically to take  a
 brief survey of the surgery of this disease up to the present time.
  For the last half century, though surgeons  have laboured assiduously to
 cure it, they have  almost always  been unsuccessful.   Cases  have,  now and
 then, been remedied, but they were so few that no general  principles of treat-
 ment could be established, and, consequently, no  certainty of  success, in any
 single instance, could be predicated.
  The suture was, of course, the first surgical appliance that suggested itself to
the mind of  operators.  It was used in all  its various  modifications without
 success.  The great difficulty of  applying the suture, and its signal failure
caused surgeons to invent a number of instrumental apparatuses, all of which
are  clumsy and complicated.
  As a curiosity, let me here introduce a description of  the apparatus of  Lal-
lemand, the distinguished professor, of Montpellier:— 
Sims, Treatment of Vesico- Vaginal Fistula.
i
  "It is composed—1st,  of  a  large canula about four inches long; 2d, of a
double hook, which is moved in the principal instrument by means of a stem,
in such manner as to push it out, or to make it enter its sheath ; 3d, of a circular
plato which terminates  the  other extremity of the canula, and which  would
hinder, if necessary, this latter from penetrating too deep into the urethra ; and,
4th, of a cork-screw spring, intended to draw forward the small hooks as soon
as they are inserted in the posterior lip of the fistula.  The canula, being passed
into the bladder, allows of our pushing the two small hooks into the vagina
through the vesico-vaginal septum, which latter is supported by the left fore-
finger.  By making a turn of the screw, they are kept in this position; a pledget
of lint, or tine linen, designed for protecting the tissues, is then placed between
the front part of the urethra and the external plate of the canula; finally,  we
relax the spring which acts  then, at the same time, by making traction on the
posterior lip with its hooks, and by pressing backwards the lower wall of the
urethra by means of the circular plate, or the  lint, which serves as its point
d'appui. By a  mechanism which would be too long for description, we may
regulate the stop of the spring in such manner that there will only result from
it a moderate degree of pressure, though sufficient for bringing the two borders
of the fistula in  contact."—(Velpeau, vol. hi. p. 852.)
  The apparatuses of Lewziski, of Dupuytren, of Laugier, of Fabbri,and others,
are equally complicated, quite as unfit to fulfil the proper indications of treat-
ment,  and, by experience, have proved as  wholly worthless.
  Others have attempted to improve different stages of  the operation.  Thus
Colombat praises his spiroidal needle for passing a whip suture in longitudinal
fistulas, and  M.  Sanson has proposed to enlarge the urethra by a double litho-
tome for the purpose of carrying the finger through the urethra into the blad-
der, merely to depress the fistula toward  the vulval opening; while Wutzer
proposes, and performs in a great number of cases, the high operation of para-
centesis vesicae, confining his  patient for  several days  on her abdomen,  by
means of cushions, straps, and buckles.
  These are referred to as historical  facts, and  not for any good that could
possibly result from them.
  While all these formidable  contrivances, and the suture, have failed  so sig-
nally, cauterization has but little more to boast of in  the way of success. Very
small fistulous openings have occasionally been reported as cured by the appli-
cation  of the nitrate of silver, a catheter being retained in the bladder; but,
in fistulas of any size, it has proved entirely abortive.
  To show how utterly hopeless have been all our efforts heretofore, we may
allude to the suggestion  of some of the French surgeons to apply the Taliaco-
tian method of anaplasty to this operation, which has actually been repeatedly
performed  by Roux, Jobert,  and others;  and, also, to  the  operation  of  M.
Vidal, for an "obturation of the vulva," whereby the bladder  and vagina  be-
come a grand compound receptacle of  the  urine  and menstrual secretion.  It
is an idle waste of  time  to dwell longer on means so perfectly ineffectual, not
to say mischievous.
  But  have  no  useful, practical suggestions been made, as yet,  by any one on
the treatment of vesico-vaginal fistula ?   Yes: two  names  stand  out  in bold
relief amongst  those who have devoted some time and attention to this sub-
ject.   I allude  to our own  countryman, Mettauer, who uses leaden sutures; 
8               Sims, Treatment of Vesico- Vaginal Fistula.

and to the indefatigable  Jobert, who is the author of the operation of auto-
plastic par glissement.  The first, by his plan, has cured several cases; while
the latter has achieved a greater degree of success than any other surgeon.
   Thus, all that we know on the subject worth knowing  is  due  to America
and  France; while German and  British surgery have done comparatively
nothing for the amelioration of this loathsome and troublesome disease.
   Many of our  systematic works pass it over in silence, or dismiss it with a
few remarks discouraging all attempts at treatment.   Samuel Cooper, in his
great Surgical Dictionary, does not introduce the  subject even by name;
while Liston  devotes  less than a page to it.  Alluding to the application of
the heated wire, he says:  " By this  means a small opening may occasionally
be made to heal up.  But when the communication is to a large  extent, but
little hope remains to the patient."  Fergusson, Gibson, and others  say nothing
about  it; while Millar dismisses it  as summarily as did  Liston.  But how
could it be otherwise,  when its mechanical treatment is so imperfect that no
general principles could be laid down ?
   It is not my  intention  to allude to all that has been attempted by different
surgeons;  but it is equally a duty and  a pleasure here to chronicle what has
been done by our own countrymen who lay any claims to originality or credit.
   The first successful case in this country is, I believe, by Br. Hayward, of
Boston.   The following is  his description of the operation:—

   " The  patient was placed on the edge of a table, in the same position as in
the operation for lithotomy.  The parts being well dilated, I introduced a large
bougie into the  urethra, and carried it back as far as the fistula.   In this way
I was able to bring the fistula downwards, so that the opening was  brought
fairly into view.  The bougie being then taken by an assistant, I made a rapid
incision with a scalpel around the fistula, about a line from its edges, and then
removed the  whole circumference of the orifice. As  soon as the  bleeding,
which was slight, had ceased, I dissected up the membrane of the vagina from
the bladder, all  around the opening, to  the extent of about three lines.  This
was done partly with  the view of increasing the chance of union, by presenting
a larger  surface, and  partly to  prevent the necessity of carrying  the needles
through  the bladder.   I  then introduced a needle, about the  third of an inch
from  the edge of the wound, through the membrane of the  vagina, and the
cellular membrane beneath, and brought it out at the opposite side, at about an
equal distance.   Before the needle was drawn through, a second  and a third
were introduced in the same way; and these being found sufficient to close the
orifice, they were carried through, and the threads tight^ tied. Each thread
was left about three inches  in length."—{Am. Journ. Med. Sciences,  Aug. 1839.)

   Besides this case, Dr. Hayward has recently reported eight others, operated
upon since August, 1840, two of which were entirely successful.   He says:

  ." The  operation was done in every instance by ligature.  The result has, on
the whole, been satisfactory.   Anything that  is calculated  to remove this
infirmity, or to  lessen in the slightest degree the sufferings of the individuals
who are afflicted with it,  should be made known.
   " I had never seen the operation done until I did it myself, nor could I find any
description of the  mode which  others had adopted, that was  sufficiently clear
and explicit to be of much service.   I had, therefore,  to take  such a course as
I thought safe, and at the same time likely to effect the object, viz -. the closure
of the fissure.  I do not know that  others may not have operated precisely in
the same way; but if  they  have, I am not aware of it.
   "I performed the operation twenty times, but it was done on nine patients 
Sims, Treatment of Vesico- Vaginal Fistula.
9
only, one being operated on six times, another five, two twice, and five once."—
(Boston Med. and Surg. Journal, vol. xliv., No. 11. April 16, 1851.)

   Dr.  Pancoast, of Philadelphia, has operated  successfully in two  cases, by
the following method :—
 _  " The peculiarity of the operation consists, virtually, in attaching the two
sides of the anormal opening firmly together, on the principle of the tongue and
groove, so  as to get four raw surfaces in contact, and thus increase the proba-
bilities of union by the first intention.  For this purpose it is necessary that
the margins of the fistula should have considerable  thickness, and when not
found  in this state, they are to be thickened by repeated applications of  lunar
caustic; or, better still,  of the actual cautery.
   " Having exposed the fistulous orifice as thoroughly as possible with a  Char-
riere's speculum, from which the sliding blade has been removed, an assistant
at the same time drawing  the vestibulum well up towards  the front of the
pubis, my  first object in the operation is to split the most posterior margin of
the fistula  to the depth of half an inch.  I next pare off the edges of the other
lip of the fistula, so as to bring it into a wedge shape ; first reverting it as much
as possible with a small blunt hook, and trimming off  the mucous  membrane
on the side next the  bladder with the curved scissors or scalpel, and then de-
taching, in like manner, the vaginal mucous membrane,  to the  breadth of three-
quarters of an inch, along the whole extent of the lip.  This was a very difficult
but most important part of the process.  Having checked the bleeding by the
use of astringent  applications, my next object is to  insert  the  raw wedge or
tongue, into which one of the  lips of the fistula has been converted, into the
groove which has been cut in the other, and hold  them in close connection.
This I accomplish by the means of a peculiar suture that might  be called the
plastic, and  in the same way that I have described its application in reference
to some plastic operations in my Operative Surgery; and in the American Jour-
nal of the  Medical Sciences for October, 1842.
   " When the sutures are knotted firmly, the tongue or wedge will be found im-
movably imbedded in the groove.  The sutures I leave  for two weeks or more,
or until they become loose.  A gum catheter should  be kept in the bladder to
prevent the accumulation of urine.   To keep the inflammation  from running
to a destructive height, a bladder of cold water should be applied for thirty-six
hours to the vulva.
   "On the second or third day, I direct the frequent injection of a solution of
zinci  sulph. into  the vagina, in  order to increase the  tone of the  parts.  On
the fourth or fifth day,  I  apply to the line of union a solution of lunar caustic
with a camel's hair pencil. This application should be made twice in the twenty-
four hours, the solution being gradually increased in  strength.  Union by first
intention may be expected to take place under this treatment  to a considerable
extent; at such points as it should fail to occur, union by second intention is
to be promoted by the use of lunar caustic in substance, so as to raise a  bed of
granulations on the raw  surfaces of  the lips, while they are held in contact by
the plastic suture.
   " In one case, there was a complete destruction of a cross section of the whole
 urethral structure, near  the neck of the bladder;  in the other, there was an
elongated  orifice in the bas-fond of the bladder, which would  more than admit
 the end of the finger."—(Med. Examiner, May,  1847.)
   Dr. Mcttauer's operation, the  peculiarity of which  consists  in  the   use of
leaden sutures, is described  in the Am. Journ. Med. Sciences for July,  1847,
 to which I beg leave to refer the reader for particulars.
   Having thus briefly alluded to what has been done,  up to the present time,
 for the treatment of this affection, I shall now proceed to detail my own ope-

 ration.
   I conceive that I may claim originality:  1st. For the discovery of a method
 by which  the vagjna can be thoroughly explored, and the operation  easily per-

 formed. 
10              Sims, Treatment of Vesico- Vaginal Fistula.
    2d.  For the introduction of a new suture apparatus, which lies imbedded
 in the  tissues  for an indefinite period without danger of cutting its way out,
 as do silk ligatures.
    And 3d.  For the invention of a self-retaining catheter, which can be worn
 with the greatest comfort by the patient  during the whole process of treat-
 ment.
    Of the position of the patient for the operation.—With  the exception of
 Velpeau and Chelius, all  other operators, even  Jobert, recommend  that the
 patient be placed on the back as in the operation for stone.
   Yelpeau*  says, " A round-shaped mattress is placed under the belly, in such
 manner as to enable her to keep her thighs flexed, while lying upon her abdomen.
 An assistant keeps the vagina dilated by means of a large gutter of metal, horn,
 or thin wood."
   Cheliusf directs " the patient to be placed on her belly upon  a table covered
 with a mattress, so that she may kneel near its edge, with her  head and chest
 bent forwards, and supported with small bolsters.  The operator  sits between
 the patient's thighs, upon a seat of proper height, so that his arms should not
 soon tire."
   In 1845,  previously to the translation of either Velpeau or Chelius, I hit
 upon the proper plan of exploring the vagina in these cases; but to the latter
 is due the first published account of even a hint towards that method.
   In order to obtain a correct view of the vaginal canal, I place the patient upon
 a table  about 2£ by 4 feet, on her knees, with the nates elevated, and  the head
 and shoulders depressed.  The knees must be separated some 6 or 8 inches, the
 thighs at about right angles with the table, and  the clothing  all  thoroughly
 loosened,  so that there shall be no compression of the abdominal parietes.  An
 assistant on each side lays a hand in the fold between the glutei muscles and
 the thigh, the ends of the fingers extending quite to the labia majora;  then, by
 simultaneously pulling the nates upwards and outwards, the os externum opens,
 the pelvic and  abdominal viscera all gravitate towards the epigastric region,
 the atmosphere enters the vagina, and there, pressing with a weight of 14 lbs.
 upon the square inch, soon stretches this canal out to its utmost limits, affording
 an easy view of the os tincae, fistula, &c.   To facilitate  the exhibition of the
 parts, the assistant on the right side of the patient introduces into the vagina
 the lever speculum represented  in Fig. 1,  and then, by  lifting the perineum,
 stretching the sphincter, and raising up the recto-vaginal septum,  it is as easy
 to view  the whole  vaginal canal as it  is  to examine  the fauces by turning a
 mouth widely open, up to a strong light. (See Fig. 4.) This method of exhibit-
ing the  parts is not only useful in these cases, but in all affections of the os and
cervix uteri requiring ocular  inspection.   The most painful organic diseases,
such as  corroding  ulcer, carcinoma, &c, may be thus exposed without inflict-
ing the  least  pain, while any local treatment may be instituted without danger
of injuring the healthy structures.  By this method, also, a proper estimate,
anatomically, can be had of the shape and capacity of the vagina; for where

            * Operative Surgery, Am. edition, vol. iii. page 851.
            t Chelius' Surgery, by South, Am. edition, vol. ii.  page 191. 
Sims, Treatment of Vesico- Vaginal Fistida.              11
there is no organic change, no contraction, and no rigidity of it from sloughs,
ulcers, and cicatrices, and where the uterus is movable, this canal immediately
swells out to an enormous extent, thus showing its great expansibility.
   Fig. 1 represents  the speculum.  When introduced and held properly, it
causes no pain whatever.   It is well enough to have two or three of different
sizes, so as  to be  prepared for any case.   The one ordinarily used by me is
about 2 J  inches from a, where it supports the sphincter, to its terminal ex-
tremity at b.   Its concavity c, c serves to reflect a strong  light down on the
vagino-vesical  septum,  the seat of fistula.  Its breadth from d to e is  about
|ths of an inch, widening a little as it approaches the end, making it somewhat
in the shape of a duck's bill.   The handle is made strong and unyielding,
because a considerable  degree of leverage has to be exercised by it.  The curve
at ff  being cushioned to prevent its hurting the forefinger, fits  accurately
over it.   The whole instrument is made of German silver, the concavity being
highly polished for reflecting the light.
  A small, slightly convex spatula, Fig. 2 (of German silver), may occasion-
ally be needed to press  the urethra downwards against  the symphysis pubis, 
12              Sims, Treatment of Vesico-Vaginal Fistula.

when there is a very minute fistula in the neighbourhood of the trigonus vesi-
calis; particularly if the urethral folds are very redundant.  This will seldom
be used, but  is sometimes indispensable, not only in exploration, but  in hold-
ing the healthy parts out of the way in passing sutures.
  These simple instruments, with this position and a good light, are all that
are  necessary for obtaining an accurate view of the parts.   If the vagina and
outlet are ordinarily capacious, a good strong northern  light, of  a  clear day,
from  a large solitary window, is  all-sufficient.   But if this canal has  been
narrowed by  cicatrices after extensive sloughs, or from other causes, then sun-
light is absolutely necessary for every stage of the operation from first to last.
For this purpose, a small table  is placed near a  window admitting the sun-
light.   An assistant, sitting by, adjusts  on the  table a glass, Fig. 3, some
eight or ten inches in diameter, so as to throw the rays of light into the vagina,
which, passing to the  right of the operator, and  striking the concave surface
of the bright  speculum, are reflected down on the anterior vaginal paries, mak-
ing everything perfectly  distinct.

          Fig. 3.                               Fig. 4.
  Fig. 4 shows the speculum introduced, elevating and supporting the sphinc-
ter; also the relative position of the organs, when the patient is examined as
directed; the vaginal canal being distended to its greatest capacity.
   Of  scarifying  the  edges of the fistulous  opening.—-This  was  the   most
tedious and difficult part of the operation with me, as it has always been with
others.   For three or four years, I  had great trouble in getting such instru- 
Sims, Treatment of Vesico- Vaginal Fistula.              13
ments made as I thought indicated; but those I now use for this purpose are
so  simple, that they  can be had
anywhere.  A delicate tenaculum,
Fig. f>, <i, and a sharp-pointed knife,
Fig. 5, b, are alone necessary.
   The  tenaculum,  Fig.  5, a,  is
very  small;  the curve  being  at
right angles  with the shaft, and
not more  than one-third of an inch
long.  If longer,  it is not easily
managed, nor so generally applica-
ble to any and every part of the
fistula.  The  shaft, some  five  or
six inches long, is set into a firm
handle.   Of this  size  and shape,
it can be used to  elevate the  edge
of the opening with equal facility,
whether  laterally or  otherwise;
while, if  curved  at more  than a
right angle, it can be useful  only
in  hooking up  and drawing for-
ward the  anterior  and  posterior
margins.
   Fig. 5 represents the tenaculum
a, hooking up  and elevating the
edge  of a  fistula,  while the point
of the knife b is applied, ready  to
separate   the part  so raised up.
This process  is  continued till the
edge of the opening is  well vivified
all round (as seen by the dotted
line), sometimes removing a strip
an inch or more long  before  it  is
cut or torn off.   The denudation
is to be from a quarter to the third
of  an inch wide.  I  have often
made the mistake  of not removing
enough of the callous  edge; but I
now take  good  care to remove  it
freely, extending  the  scarification
up on the vaginal  surface.   I  do not remove any of  the lining membrane of
the bladder, unless it is very much  altered in character, and projects through
the fistula into the vagina in such a way as  to obstruct the easy performance
     3
 
14              Sims, Treatment of Vesico- Vaginal Fistula.
of the operation; which rarely happens, and only where there is a great loss
of substance.
   Where the fistula is very small, say not larger than a common-sized probe,
or even as small as a number seven or eight sewing  needle, the best plan to
scarify is, to hook up the part with the tenaculum, pull it  forward, and  by a
thrust of the knife transfix the entire  thickness of the vagino-vesical septum;
then by a circular sweep of the instrument, the whole  fistulous track may be
removed at once; which substitutes for the  small  and  callous opening, a
smoothly cut orifice of  rather a conical shape, large enough to admit the end
of the forefinger.
   Where the fistula is  so small, there  is  always an abundance of tissue, and
there need be no fear of removing the parts freely;  for it is easier to  close
properly an opening as large as the end of the finger, than a smaller one, pro-
vided there is no scarcity of texture.
             Where the  fistula,  on the  other  hand, is very large, there is
   Fig. 6.   occasionally some trouble in determining exactly what to cut; be-
           cause  by the bearing down, sobbing, straining, or even voluntary
           resistance of the patient,  the mucous membrane of the  bladder
           may be forced out in voluminous folds, so as to render the fistu-
           lous edges indistinct, and there is danger of scarifying, either too
           high up on the vaginal surface, or too far in on the vesical lining.
           To obviate  this difficulty,  a properly curved metallic bougie may
           be passed through the urethra up to the  fundus of the bladder;
           thus putting the parts on  the stretch and carrying back into its
          ' cavity, the apparently redundant lining.   The bougie curved down
           between the thighs may be held by a third assistant.  But I greatly
           prefer to introduce  a bit of soft sponge, of proper size, into the
           cavity of the  bladder, which forces back the  lining membrane,
           leaving the fistulous boundary distinct, when the scarification may
           be easily accomplished.   The introduction of the sponge into the
           cavity of the bladder,  or merely between the edges of the fistula
           as well as  its removal,  is always attended with  very great pain.
           Once introduced, I allow it to remain, till  the  sutures are passed
           and ready to be secured.
             During the scarification, there is,  of course, always hemorrhage;
           and, in some instances, it  is  so profuse as to compel us to desist
           for  a  short time, the patient being allowed to change her position
           and rest.   As soon as the bleeding ceases, the operation may be
           resumed.
             To  remove  the blood from the cut surface  during the scarifi-
           cation, a probang is necessary (Fig. 6), which  is  made by tying a
           nice bit of  sponge to the end of a  piece of whalebone some eight
           or ten inches long.   It is well  enough to have  two or. three of
           these, which will keep one assistant pretty busy to wash clear of
           blood at this stage of the process.   The probang can generally 
Sims, Treatment of Vesico-Vaginal Fistula.             15
be best applied by  the  operator, as his  position allows  him to see exactly
where it is most needed.
  I cannot lay too much stress on the great necessity of  perfecting well  this
part of  the operation; for, upon a proper and free denudation of the fistulous
orifice, success or failure will mainly depend.
  Sometimes one edge of the fistula is thinner than another.   Velpeau  and
others have noticed this fact;  but in not  a single instance  have I found (as
they did)  the thinner edge behind and the thicker before.  Where there was
any appreciable difference, the reverse was the fact in every case that I have as
yet examined.  This thinning of the anterior edge, where it was right at the
neck of the bladder, was always a serious obstacle to the proper  closure of the
fistula.  By giving way too soon, it almost invariably left an opening at the
point of its greatest thinning.  This, however, is  a  peculiarity belonging to
individual cases, and will be  dwelt on more particularly when we come to
describe them.
   Of the Suture  Apparatus.—Sutures all  serve the same general purpose,
viz. the bringing and holding together parts that we wish to  unite.   They
are variously named, according to circumstances—as the Interrupted, because
it is solitary;  the Continued,  because a plurality of them  are joined  together;
the Quilled, because of the peculiar  method of securing it;  and the Twisted,
for a similar reason.
  The  one that  I use for closing  vesico-vaginal  fistulae, I have termed the
clamp suture,  from  its  peculiar  method  of action.   Thus, if the profession
allow me  to introduce a new  suture by its most appropriate  name, we  shall
then have in general use, sutures named, first, aecording to  their relation, the
interrupted and continued.   Second,  according  to the method of securing
them, the quilled and twisted; and  third, according to its method of action,
the clamp suture.
  As all  sutures are but modifications,  one of another, so  is the clamp  a
modification of the quilled.
  The clamp suture  is composed of small annealed silver wire  fastened to
cross-bars, after the  manner of the quilled suture.  The wire  is drawn  down
to about the size of a horse-hair, and then annealed.  The cross-bars, or clamps,
are very small, not more than a line in diameter, and made of silver or  lead,
as most convenient.   If of silver, they may be tubular;  when of lead, solid.
They must be highly polished, and without the slightest asperity, particularly
at their extremities.   They act as clamps in this way.   The  parts embraced
between them, being  held  in close  apposition, swell upward, and overlap
them;  while they, by pressure, produce an ulceration in  the vaginal surface,
sufficient  to allow of their being perfectly embedded, and after  a  while  even
sometimes hidden from view.   This ulcerative process is  attended, of course,
with a purulent discharge, which, continuing for three or four days, diminishes,
and soon  ceases altogether; but not till the bed made  by the clamp becomes 
16              Sims, Treatment of Vesico- Vaginal Fistxda.
lined with  mucous  membrane.  After  this the apparatus would  lie innocu-
ously in the tissue  for an  indefinite period.   I have  allowed it  to remain
long enough for the extremities of the  clamps to be covered over completely
by firm granulations, which,  opposing considerable resistance to their removal,
had to be lacerated before this could be  accomplished.
  This suture is far preferable to anything before suggested  for the purpose.
Its introduction dates from June 1849, since which  time I have had compara-
tively little trouble in the treatment of  the great majority of cases of vesico-
vaginal fistula.  Properly applied, this suture never ulcerates out, having always
to be removed  by means of  scissors, hooks, and forceps.  It may be allowed
to remain intact for  six, eight, or  ten days, or even longer.   If removed too
soon, the delicate cicatrix may gradually yield to the traction  of the ascending
uterus, or to the force exerted by the bladder in expelling its contents, and
thus reproduce a small fistulous orifice to be closed by a subsequent and more
cautious  operation.   I have seen  the  new cicatrix give way from  another
cause, and perhaps it is the chief one.  The clamps, burrowing in the vaginal
surface, leave a deep sulcus  or fissure on each side of the new cicatrix, which,
when they  are  removed too  soon, fill up by granulation.  It is a law of all
granulating wounds to contract as  they heal, and this contraction on each side
of the new cicatrix is often sufficient to pull it gradually apart.   But if the
clamps are  allowed to remain till  their  sulci are covered with mucous mem-
brane, then there is no danger of this accident, for these chasms then gradually
disappear, less  by filling up  with granulations, than by an absorption  of their
elevated edges.
  Accidents of this sort have happened repeatedly in  my hands, from  a too
early removal of the suture apparatus.   Great judgment, which experience
alone can give, is necessary  to determine the length of time that  the sutures
ought to remain intact, for no positive rules can be laid down that will answer
invariably in every case.
  I have also seen serious mischief result  from leaving the clamps too long
embedded in the  parts.   Their burrowing and ulceration may extend entirely
through the vagino-vesical structure, thereby substituting new fistulous open-
ings for the original one.  This complication is by no means incurable, but
only prolongs the treatment, and postpones ultimate success.
  In two or three instances I have witnessed a still more serious  accident
from  an undue pressure of the clamps, viz. a strangulation of the enclosed
fistulous edges, which unfortunately resulted in  a  sloughing of the tumefied
parts, and a consequent enlarging of the opening.   In no instance, however,
has this accident rendered  the case hopeless,  or even caused me to feel any
concern either  for th& immediate safety  of the patient, or for ultimate success
in treatment.
  After the scarification is completed, the patient is allowed to rest for  a few 
Sims, Treatment of Vesico-Vaginal Fistula.             17
minutes, before the introduction of the sutures;  an ope-
ration which is somewhat tedious, but not difficult.   The
number of sutures will depend on the size of the fistula.
Less than two will not suffice for the smallest opening;
while the great majority of cases will require three; and,
occasionally, we meet  with one sufficiently large to de-
mand four.
   The needle which I  use is represented by Fig. 7.   It is
awl-shaped, and spear-pointed, with the eye near the point.
The shaft is about six inches long; the part near the handle
is made malleable, allowing it to be bent into any desirable
shape for the purpose of preventing the hand, as it grasps
the handle, from obstructing the view of the operator.
   To illustrate the  method of suture, let us suppose a
case, where the fistula is oval, transverse, occupying the
bas-fond of  the  bladder, about  half  way between the
urethra and os  tincae, in the mesial line, and large enough
to admit the end of the index finger.   This, in shape,
size, and position, is altogether the most favourable case
that can  occur, both for  a neat performance of the opera-
tion, and  for certainty of success.  Such a fistula will
require three sutures.
   Fig. 8 represents them introduced at proper intervals;
the two outside ones passing within a fourth of  an inch
of the angles of  the fistula.  The middle one is  first ap-
plied.  The  needle, armed with a silk thread, is  entered
about half an inch anterior to the scarified edge of the
fistula;  pushed deeply into the vesical septum,  without
transfixing it; brought out just at the edge of the  mucous
lining of the bladder;  carried across  the  opening;  made
to enter the opposite side at a point corres-
ponding with its  direction anteriorly, observing
the same precautions in its course;  while it is
brought out on the vaginal surface about half
an inch beyond the scarified part.
   The passage  of the  needle  through the an-
terior edge of the opening is easy enough; but
the loose and yielding nature of  the posterior,
renders some support  necessary before it can
be made to appear on the vaginal surface.   For
this purpose  a blunt hook (Fig. 9, d) is placed
flatwise, just beyond the spot  at which we in-
tend the needle  to come out, thus making a fixed
point for it, when it passes with great ease.
Fig. 7.
Fig.
 
18              Sims, Treatment of Vesico-Vaginal Fistula.
  Fig. 9, b, shows the needle armed and passed as directed: the  spear-point
having emerged at its  proper place on the distal  side of the fistula, is sup-
ported by the blunt hook, a, over which it rests.
  As soon as this is accomplished, the blunt  hook is laid aside, and a  small
tenaculum (Fig. 10, a)  used to hook up the  ligature which lies close by the
side of the needle, 6.  There is sometimes a little delay in doing this, particu-

     Fig. 9.                                               Fig. 10.
larly if the parts are too contracted, or the light not good.  In this case, the
needle should be pushed an eighth or a fourth of an inch further on, and then
retracted as much, when a little loop of ligature will be left, into which the
tenaculum can  be passed.  (Fig. 10.)   After this, the needle is  to be with-
drawn entirely, leaving the ligature in sitti, with its distal end or loop seeurely
on the hook.   The hook is then drawn out, and with it, of course, the ligature, 
Sims, Treatment of Vesico- Vaginal Fistula.               19
Fia. 12.
the two ends of which are now hanging from the vulva.  The other ligatures
are passed in like manner, observing the precautions           Pio. u
already laid  down.*
   In pulling on  the distal end of the ligature, an-
other expedient is necessary  to  prevent the cutting
and pain, which  would  inevitably attend its passage
over the  posterior edge  of the fistula.   For  this, a
crescent-shaped  fork (Fig. 11)  mounted on a shaft
of convenient length, is passed up, which, pushing the
ligature above its furthest point of exit, serves the pur-
pose of a pulley;  when it (the ligature) can be easily
drawn backward or forward by traction on either end,
without inflicting the slightest injury on the part, or
pain on the  patient.
   Having now given directions  for passing the liga-
tures,  let us  suppose that we  have  introduced the
three, or  as  many as we want.   The difficult part of
the operation is over, and we  have only to  substitute
the annealed silver wires for
the silk  ligatures; which  is
the work of but  a  few  mi-
nutes.  Take  a piece of the
wire twelve or eighteen inches
long, making a  small  crook
at  one end  so as  to fasten it
securely  to  one of the  liga-
tures. Fig.  12 shows the wire
crooked  and hanging to the
end of  the thread; the other
end of the thread being pull-
ed on till it comes out,  leav-
ing the wire in its place.   In
the same way we  replace  the remaining silk ligatures with silver wire; both
  * The ligatures cannot always be introduced with as little trouble as in the case just
supposed.  For instance, when the  loss of substance is  very great, the fistula  is so wide
that the needle cannot be made to traverse both sides of it  at once; hence, it becomes
necessary to hook up the ligature as soon  as the needle has pierced the anterior border
of the opening; when it is withdrawn, re-threaded with the distal end of the  same liga-
ture, and passed through  the posterior edge.  In re-threading the needle, care must be
taken to pass the  thread through the eye from its upper or concave surface;  otherwise,
when it is withdrawn, it will be found still hanging to the main thread that is stretched
across the fistula, instead of slipping easily from its free end: which is a very awkward
accident, inasmuch as the patient is subjected unnecessarily to the pain and delay of
having it introduced again. 
20              Sims, Treatment of Vesico- Vaginal Fistula.
ends of which project from the  vulva, the proximal directed downward, and
the distal held upward.
  The next step is  to secure them by means of the clamps.  In Fig. 13 the
wires are represented passed, the two ends of each brought out of  the vulva;
                     Fig. 13.                                  Fig. 14.
the distal a, a, a, to the left; the proximal b, b, b, to the right.  The distal
ends are passed through small oblong holes made in the silver or leaden bar
c, to suit the distances between the points of  suture at d, d, d.  The wires
may be fastened to the bar or clamp c, by being  turned twice around it, or by
being passed through a perforated shot and bent  over it.  This  done, we now
pull upon the proximal  ends bbb, and, as a matter of course, the bar c is
carried into the vagina, up above the fistula, and made to occupy a  bed right
over the orifices d d d.   Here, the crescent-shaped fork is supplanted  by a
modification of it, Fig. 14, broad enough to serve the purpose of a pulley for
all three of the wires.   The next step is to pass  another bar or clamp  on the 
Sims, Treatment of Vesico-Vaginal Fistula.
21
proximal ends of the wires, and to push it along them into the vagina, till it
occupies a position in front of the  fistula,  corresponding exactly with the one
behind it.
  Fig. 15 shows the two clamps, one on  each side of the fistula, and every-
                 Fig. 15.                                   Fig. 16.
C
III
Z2
17.
thing ready for closing it.  The proximal clamp is pushed up by the crescent-
shaped fork, while the wires are held firmly.   This brings the denuded edges
of the fistula into  such close contact that it
would be  difficult  to enter a common sized
probe between them.  The  force necessary
for tightening the clamps will  depend upon
the judgment of the operator; not enough
will allow the parts to gape, while too much,
which is  the  most frequent  fault, will pro-
duce the bad effects formerly alluded to.
   A  simple and  perfect  contrivance now
serves to  hold the clamps in their  proper
places.   A  small  bird shot,  perforated, is
passed along each wire close against the prox-
imal  clamp; when, the wires being held se-
curely, they are gently but  firmly compressed
by means of a long strong  pair of forceps
(Fig. 10), whereby they are made to perform
the office  of a knot  in preventing the clamp
from  slipping off  the wire.  The wires are
cut off about a fourth or  eighth of an inch
from  the shot, and then  bent over, which
effectually prevents their slipping off.
   Fig. 17 shows the appearance of the fistula and suture apparatus after the
 
22              Sims, Treatment of Vesico-Vaginal Fistula.
operation;  the  edges of the opening in apposition;  a clamp on each side of
it; the flattened shot against the proximal clamp; the wires cut off and bent
over the shot, which protects the recto-vaginal surface against their sharp ends,
as well as prevents their slipping.
   The operation, which may have lasted some  twenty or thirty minutes, or,
under any circumstances, not more than an hour, is  now over; and our  pa-
tient is ready for bed, complaining only of fatigue from the constrained posi-
tion.
   There is one peculiarity about the instruments, which greatly facilitates the
operation.   For instance, the tenaculum, the needle,  the blunt hook, and the
crescent-shaped fork,  have their  shafts made malleable, so  that they may be
bent in a direction to keep the  hand of the operator  below the axis  of the
vaginal canal, which  preserves the line of vision unobstructed.
   Of the Catheter.—Surgeons have always felt that  something more was ne-
cessary to cure a case of vesico-vaginal fistula, than merely closing it mecha-
nically.   The urine has been the great cause of failure.  To prevent its per-
colation through  the closed opening  has  been regarded, heretofore, as almost
insuperable.   The catheter was tried by all, but its frequent introduction had
a direct tendency to disturb the healing process, and  to hasten the mischief it
was intended to obviate;  while all attempts to  secure  it permanently in  the
bladder by any external contrivance has proved abortive.
   Desault used a large gum-elastic catheter, " fixed to an apparatus resem-
bling a truss, by means of  a movable silver plate, provided with  an aperture
for its removal."   Tying it to the hairs of the  vulva, and  other  equally use-
less expedients have  been resorted to.
   According to Chelius, the operation of paracentesis vesica) was practiced by
Wutzer, who, he says, had the greatest  success  in the  treatment  of this dis-
ease, having cured three cases out of eighteen.   He compliments the efforts of
his countryman by saying,  " That he has importantly contributed to perfecting
the operation, and, by the addition of paracentesis vesicae, in order more com-
pletely to draw off the urine, has advanced considerably farther than his pre-
decessors."
   Wutzer gives  specific directions for puncturing the bladder above the pubes:
 after which a  tube  is to be introduced, and " fixed immovably by means of
 wing screws in  the cleft  of a  previously well fitted  belly girdle, after which,
 the patient should be carefully  conveyed to a bed previously prepared, placed
 on her belly, upon suitably cut out leather cushions, and properly buckled in  it
 with suitable leather  straps."   I allude  to this  method of Wutzer, merely to
 show what desperate efforts have been made to prevent the urine from escaping
 through the fistula during  the process of treatment.
    With me, as with others, this has been the most serious obstacle to the suc-
 cess of the operation; for, if a single drop of  urine finds its way through the 
Sims, Treatment of Vesico- Vaginal Fistula.              23
fistulous orifice, it is sure to be followed by more, and thus  a failure to some
extent is almost inevitable.
  Knowing that something to  draw off the  urine  continually was absolutely
indispensable  to  success, and  seeing  that all other operators  had failed  to
secure a catheter in the bladder  by any justifiable external means,  I con-
ceived the idea of contriving for this purpose, a self-retaining instrument.   A
sponge tent was the first thing suggested  to my mind.   I supposed, if  a long
narrow piece of sponge could be safely introduced into the bladder, that it would
absorb  the  urine as fast as secreted, which, by  capillary  attraction, would
pass along the sponge, and escape  without coming in contact with the  fistula.
Accordingly, a piece of fine sponge some three  or four inches long, narrow
in the middle, larger at each end, with a strong silk thread passing through
its whole length to prevent its being torn, or broken, was  first used.   (Fig.
18.)   Concealed in a bi-valve  catheter, it was readily introduced, the  middle
portion c, enveloped in gold  beater's skin
lying in the urethra, the  small  flat end a,      lg'
occupying  the cavity of the bladder, while        a
the  larger extremity b, hung out between     0y&
the labia.  It acted the  part of a syphon ad-
mirably, every drop of urine passing through
it;  but unfortunately for  my  patients (two
of whom were experimented on with it), it
became  encrusted  and perfectly  saturated
with calculous deposits, rendering its removal
painful, difficult, and even dangerous.  This
expedient, promising so much in theory, and
performing  so ill in practice,  was necessa-
rily abandoned.
   Following up the  idea of a  self-retaining
apparatus,  I next  hit  upon   the  following
contrivance.   I took a piece of  gum-elastic
bougie (No. 5 or 6), some four or five inches
long, and made a longitudinal split an inch
long entirely through it, beginning about a
fourth of an inch  below the  rounded end.
(Fig. 19.)   A piece of silver  wire, a little
longer than the catheter, was passed along it and fastened neatly at its  vesical
or split extremity.   Traction on  the lower end of the wire caused the sides of
the split to open (Fig. 20), which  allowed the urine to  pass off freely, while
the bulging at a a held it securely in the bladder.   This seemed, at first, to
promise success, but after trying it in various cases for about twelve months,
it, like its predecessor the sponge, had to be  laid aside.   There were several
i 
24              Sims, Treatment of Vesico- Vaginal Fistula.
       20.     reasons for its failure.  If made of a larger catheter than
               a No. 5 or 6, it would not  open  and close with  regularity,
               and  hence, would  press unequally and  injuriously on  the
               fistula;  whereas, when made of a No. 5 or 6, its calibre was
               not large  enough to  permit a  free discharge of  the muco-
               purulent secretion  which always attends the use of silken
               sutures; and this compelled its removal, at least two or three
               times a day, for the purpose of cleaning  it out.   Hence, its
               frequent introduction, with the consequent disturbance to  the
               parts from the  opening and  shutting of the split  end, inter-
               fered with the  healing process to such an extent as to make
               it necessary to  give up its use entirely.
                 Foiled in this, I  devised  another instrument on  the self-
               retaining  principle.  It was a large  silver catheter, curved
               in opposite directions, giving it a sigmoid form  (Fig. 21).
               The end a was carried up  behind  the  symphysis pubis, the
               part c lay in the  urethra, while  the extremity b hung down
               between the nates.
                 This was the first  successful approximation to what was
               really wanted.  When the patient lay on the  back, the end
               b was  lower  than   the base  of  the bladder, which  made it
               literally a syphon;  when she turned on either side, it had a
               semi-rotation that still kept the end a upward, while the outer
               extremity hung downward over  the  thigh, inviting  the easy
               passage of the  urine.
                 To insure  a  free discharge of  the muco-purulent  secretion
               along with the  urine, I made a long narrow slit on each side
instead of the holes, as here represented.  To see how the instrument would
                                 Fig. 21.
answer, I introduced it into the bladder of a patient having a very large fistula.
Feeling well satisfied with its performance, I attempted to remove it and found 
Sims, Treatment of Vesico- Vaginal Fistula.              25
 it impossible to do so.   Folds of mucous  membrane had projected into the
 fenestra, and  thus locked it up in the bladder: they were disengaged by the
 finger passed up through the fistula.  The two long openings were then closed
 and several round ones made, about the  size of those represented.  They
 were larger than in ordinary catheters, on account of the abundant tenacious
 secretion before alluded to.
   I operated on a case, and applied what I then supposed to be a faultless in-
 strument.  Everything progressed well for five or six days, the catheter remain-
 ing in the bladder intact for that length of time;  but  now it became neces-
 sary to remove it for  the purpose  of  cleaning out the  mucus and urinary
 concretions that were  obstructing the free  egress of the water.  But  here I
 was foiled.   I could pull  it  down  for, perhaps,  an inch, when it suddenly
 stopped; then by letting it go, it would slip back  into the bladder with a sort
 of jerk.  It  evidently  seemed  to be  fastened there by some means that I
 could not exactly comprehend.   Every reasonable effort to remove it proving
 abortive, I, at last, pulled it out by main force.  On its removal, the secret of
 its  retention was explained by  the shreds of mucous membrane (some an inch
 long) hanging from each orifice on the  under and  lateral surfaces  of the ca-
 theter.   The long-continued presence of an instrument in the urethra,  which
 was entirely too large for it, irritated and inflamed the lining membrane, and
 caused  it  to  throw out granulations.  These, with the  granulations of the
 fistula, shot little granules through the holes in the catheter, which spread out
 into button-shaped knobs on its inner surface, thereby preventing its removal.
 The injury done to the part,  and the pain  inflicted on  the patient, may very
 well be imagined.
   This instrument was variously modified  (always keeping  in  view the self-
 retaining principle); but it was not reduced to its present simple form until
 about three years after  this.  I will not detain the reader longer with a state-
 ment of the troubles  and disappointments that were encountered before I got
 it perfected,  particularly as it  will be necessary, in giving the history of in-
 dividual cases, to speak of these amongst the causes of failure in some of the
 operations.
  The urethra in  some women is less than an inch long, while in others it
 may be an inch and a half;  besides, it may be so small in some, that a  No. 5
 catheter is  as large as can be borne  with any degree of comfort, while others
 will take a No. 9 or 10, and  retain  it easier than one  smaller.  Thus, it  is
 evident, that almost every case may require  its  own  catheter, peculiar in
 length, diameter, and curvature.
  Fig. 22 is a correct representation of the self-retaining catheter, and exactly
 of the size and shape that is most generally required.  It may sometimes be
curved a little more.  The end c is introduced and lodged up behind the sym-
physis pubis;  the  part from a to b lies  in  the  urethra;  while  the  outer ex-
 tremity d,  hangs  down  immediately below the meatus urinarius; this down-
ward projection at d serves the double purpose of preventing it from slipping 
26              Sims, Treatment of Vesico- Vaginal Fistula.
into the bladder, and of preserving its parallelism.  If this part is too straight,
running in the direction of the axis of the main channel from a to b, the in-
strument, after a few hours' use, will revolve on its own axis, and the end c
may be turned to one side, or even so far round as to impinge on the fistulous
opening.  Should this accident happen, the instrument is not well suited  to
the case.  It is either too long, too short, too crooked; or, what is more likely,
not curved down enough below the meatus.
   When well fitted to the case, it can be worn with great ease to the patient;
and never turns, nor slips out, it  matters not whether she  lies on the back  or
side.   It is perfectly self-retaining, being  held in the bladder by an internal
pressure against the symphysis pubis, and by an external pressure on the  outer
end  exerted  by the  labia  overlapping it, and hiding it  entirely from  view.
The holes should  be small, about as represented in the drawing.
   Thus, I have, as briefly as possible, described the mechanical apparatus ab-
solutely necessary for the  successful treatment of vesico-vaginal fistula.
   Of the After-Treatment.—The operation finished, the patient is placed  in
bed, and the  catheter introduced into the bladder.  A moment will suffice  to
show the urine leaking from  its outer extremity.
   A large anodyne should now be given,  such as morphia, laudanum,  pare-
goric,  or whatever we may know  will best agree with  the patient.   The
bowels are to  be kept perfectly  quiescent, till  the  success or failure of the
operation is ascertained.   I have often  kept them locked up for  three and
four weeks without any bad  consequences  whatever to  the general system.
In but two instances, that I recollect, have  I ever permitted them to be opened
under ten or  fifteen days from the time of the operation.   This is very  easily
done.  Previously to  the operation some  light laxative medicine  must  be
given: after  it, the  diet  must be of a constipating character.  I generally-
direct my patients to live on tea and  crackers, allowing coffee if preferred,
and prohibiting meats, fruits, saccharine substances, and all  articles of food
made of Indian,  or common corn meal.   Formerly, I allowed as little  water
as possible; but latterly, since the introduction of silver sutures, and the per-
fection of the catheter, I  have not  thought  its interdiction necessary.  To
assist the diet in producing constipation I  order some form  of opium  in  as
large doses as can be borne, at least twice in  the  twenty-four hours.   Old
fistula  cases are generally used to opium; and where they are not, they soon
learn its beneficial effects.   It calms the  nerves, inspires  hope, relieves the 
Sims, Treatment of Vesico- Vaginal Fistula.             27
scalding of the urine, prevents a craving for food, produces constipation, sub-
dues  inflammatory action, and  assists the  patient, doomed  to a fortnight's
horizontal position, to pass the time with pleasant dreams, and delightful sen-
sations, instead of painful forebodings, and  intolerable sufferings.
   There is not the least necessity for the patient's assuming the erect posture,
even for a moment: thus, by diet, opiates, and quietude, a  perfect state of
constipation can be kept up as long as we could possibly want it in any case.
All this facilitates the healing process, which is effected by the  " first inten-
tion ;"  or, if it fail, it does so only at one or two points, which may be subse-
quently closed.
   The  catheter is to be removed as often as necessary to keep it clear of con-
cretions and mucus, which, in a  few  cases, may be twice a day; in some,
once; while in others, it may be allowed to remain two or three days, or even
longer.  It is to be carefully watched, and  must not be permitted to remain
long  enough to become obstructed.   I have seen a failure result from a neglect
of this precaution.
   The patient's comfort  is greatly promoted, by washing the vulval opening
twice a day, or oftener, with warm or cold water, as may be preferred.
   For this purpose a  common bed-pan is placed under the nates, as she lies
 on the back: when the water may be thrown into the os externum, over the
 mons,  vulva, and inguinal regions, by means of a syringe holding  some six
 or eight ounces.   The water has sometimes  to  be thrown with considerable
 force to remove the urinary deposits from the nates and genitals.
   The patient may lie on the back, or on  either side, changing her  position
 whenever she  pleases; but in no instance is she  allowed to raise up in bed.
   Some women  are more  cleanly than others  in protecting  themselves and
 clothing from  the urine.   Most of them prefer old cloths to absorb it, which
 are changed as frequently as necessary for  comfort.
    On  the third  or fourth  day after  the  operation, I usually examine the
 sutures to see if  all is right.   This must be  done with  as little exertion on
 the part of the patient as possible.   On the sixth or seventh, I examine them
 again, and if they are doing no mischief, it  is much better not to remove them
 till  the  ninth or  tenth  day.  The removal of the  clamps is occasionally
 troublesome, but by a little care  it can be done with sufficient ease  to both
 patient and operator.   The flattened  shots are first clipped off, then by a
 blunt  hook, the anterior clamp is readily elevated from its bed and removed;
 after which, the  posterior one, with the wires attached,  may be hooked  up,
 pushed backwards, disengaged entirely, and  then lifted out with the forceps.
    This accomplished, place the patient in  bed again, and continue the use  of
 the  catheter, with the recumbent position, for several days longer, to  prevent
 any strain or  traction on the delicate new cicatrix.
    By allowing  the patient to get up  too soon, and  evacuate the contents  of
 the  bladder spontaneously, there  is danger of rupturing the cicatrix, but  by
 persevering with the catheter and position, till  it has time to become  well or- 
28              Sims, Treatment of Vesico-Vaginal Fistula.

ganized, there is no danger.   This will take usually fifteen days from the per-
formance of the operation.
  In other parts of the body, most surgeons have witnessed the  sudden dis-
ruption or  gradual yielding of a freshly  cicatrized wound, which had been
submitted to undue  motion, or  too strong distention.   A case of this kind
recently occurred in my practice.   A negro woman (aged  27) had  a small
tumour on the dorsal aspect of the  right thumb, involving the skin.    It was
removed  by two transverse elliptical incisions;  the edges of the wound were
brought together and dressed with collodion, while the  thumb was bandaged
to a straight splint to prevent any motion  in the joint or traction  on the cica-
trizing wound.   It healed by the first intention; the dressings were removed
on the seventh day, but the splint was continued on the palmar aspect of the
thumb for  seven days longer.  It was  then laid  aside, as I  supposed the
cicatrix to be strong enough to resist the flexure of the thumb.   Everything
went  on  well for  three  or four  days longer, when  the patient, who was a
cook, suddenly lifting a boiling pot from  the fire, was alarmed by the snapping
asunder of  the  cicatrix on  the back of the thumb, which  made a noise so
loud as to be heard all over the room.   The cicatrix had burst open through
its whole extent; the blood flowed freely and the woman was greatly frightened.
It was dressed precisely as before; it healed up as kindly; and by preserving the
same  precautions  for a  longer time, the  cicatrix  remained permanently or-
ganized, the skin in the neighbourhood yielding, and accommodating itself to
the motions of the thumb as perfectly as it ever did before any loss of  tissue.
If such an accident as this can occur after  eighteen days of cicatrizing, we
need  not be surprised at the  gradual or sudden yielding of a cicatrix in the
vagino-vesical structure in a shorter space of time.
  I have now completed what I have to say in a general way on  the subject
of the operation for vesico-vaginal  fistula.  It remains to detail individual
cases,  which  will prove the  curability of  the  disease, and  also illustrate the
varieties and complications to which it may be liable.   The cases that occurred
to me early  and which were  given  to me for the sake of  experiment, will
show the difficulties that had to be overcome, the many disappointments that
had to be borne, and the ultimate success that crowned my efforts after  the
perfection of the mechanical contrivances; which, as  it will be seen,  was the
work not of a day, and the result, not of  accident, but of long, laborious and
persevering application.
   But this communication has already reached to  such an extent that I must
postpone the relation of my cases to a future opportunity. 
 
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