UULNAKY CALCULI, 
b'KOM IHK CABINET OF H|{. \V. T. BHKiGS. ( IIA I F PIZK. ) 
Pliotof'nqib lij Salesman. Nashville, Teini. EXTRACT FROM'A REPORT 
ON TnE niSTORY OF 
THE SURGERY OF TENNESSEE, 
COMPRISING THE SUBJECTS OF 
Slone in Bladder, Ovarian Tumors, Vesico-Vapal Fistula. 
MADE TO THE 
TENNESSEE STATE MEDICAL SOCIETY, APRIL 3, 1872, 
-7 
WM. T. BRIGGS, M. IX, 
Professor of the Principles and Practice of Surgery in the Medical De- 
partment of the University of Nashville. 
FROM THE 
NASHVILLE JOURNAL OF MEDICINE AND SURGERY. 
NASHVILLE, TENNESSEE: 
PRINTED AT THE “ UNION AND AMERICAN” BOOK AND JOB OFFICE. 
1874. REPORT ON TENNESSEE SURGERY. 
BY W. T. BRTGGS, M. D., 
Professor of the Principles and Practice of Surgery, in the Medical De- 
partment of the University of Nashville. 
PUBLISHED BY ORDER OF THE SOCIETY. 
Mr. President, and Gentlemen of the State Medical Society: 
At your regular meeting, in 1870, I was appointed to pre- 
pare a History of the Surgery of Tennessee. The task was 
cheerfully accepted, though, it must be confessed, with but a 
faint conception of the many difficulties to be overcome in 
procuring the necessary data. 
In pursuance of this object, circular letters were prepared, 
and sent to every physician in the State whose address could 
be procured, appealing to each one for a report of the history 
of such surgical diseases and operations as may have occurred 
in his own practice, and, when possible, for an account of those 
of deceased or retired physicians, hoping that, as the area 
composing this now great and populous State was, not a 
century ago, a vast wilderness, it might yet be possible to 
place on record a complete history of, at least, the more im- 
portant Surgery since its first settlement. The great majority 
of those addressed have, thus far, failed to respond. The 
cause of so general a failure, on the part of the profession, to 
answer, cannot be easily understood. The importance of the 
subject should certainly have commanded their attention. 
This indisposition to comply with my request, was due, in all 4 
REPORT OX TENNESSEE SURGERY. 
probability, to that carelessness and modesty which is so gene- 
rally characteristic of the profession. 
By reference to the Proceedings of the Society for 1851, it 
will be seen that a Committee, consisting of Drs. Avent of 
Murfreesboro’, Lipscombe of Shelbyville, and Robards of 
Memphis, was appointed to make a report upon the Operative 
Surgery of Tennessee. This Committee has never reported, 
and it is to be presumed their non-performance of this duty is 
to be ascribed to the many difficulties, similar in character to 
those which I have encountered. 
The history of the early Surgery of Tennessee is pretty well 
lost. This may he, in the main, attributed to the fact that the 
physician of the early times not only performed the duties in- 
cident to the practice of medicine, but also did the surgery 
which chance threw in his way—the physician and surgeon 
being merged in one individual, styled “ Doctor.” The Doc- 
tor being constantly and actively engaged in the laborious du- 
ties of his profession, kept no special record of his surgical 
cases, so that the history of surgery died with him. 
At that time, a great portion of what may be properly 
termed chronic surgery, sought relief outside of the State, 
from surgeons who had acquired celebrity. Dudley, of Ken- 
tucky, received a large share of it. McDowell, of ovariotomy 
fame, met with his due proportion, as well as many other sur- 
geons of distinction. In fact, they oftentimes made profes- 
sional visits to our State. Dr. Dudley exsccted a mammary 
gland from a lady near Nashville. Dr. McDowell performed 
ovariotomy near the Hermitage. Prof. Nathaniel Smith, of Bal- 
timore, visited Columbia for the purpose of removing, and did 
remove, a large tumor from the person of a lady in that town, 
and during the same visit to our State, operated for strabismus 
upon the late Gen. R. C. Foster 3rd—probably the first opera- 
tion of the kind performed in Tennessee. 
In later years, Prof. Sam. D. Gross made two professional 
visits to our State—one to Williamson County, and the other to 
Nashville. During the latter he performed, upon the person of REPORT ON TENNESSEE SURGERY. 
5 
the late George W. Martin, the brilliant operation of trephin- 
ing the sacrum, for the purpose of extracting a ball which he 
supposed was resting upon the face of that bone. It was a 
splendid operation, but failed, by reason of error in diagnosis; 
the ball was not where he supposed it to be. 
From what has been said, I would not have the Society to 
believe that our State could not boast of surgeons at that 
time. I need only mention the names of O’Reiley, of Maury 
County; Wallace Estell, of Winchester; William Bonner, of 
Fayetteville; Lipscombe, of Shelbyville; Watson and A vent, 
of Murfreesboro’; Deaderick, of Athens ; and Buchanan, of 
Nashville. I know that you, gentlemen, will pardon me for 
paying special tribute to the memory of him who, for many years, 
was the body and soul of this Society. Tennessee can well be 
proud of Buchanan. The Medical profession cannot boast of 
a more profound thinker and more brilliant operator, than was 
the late A. H. Buchanan. In him was embodied both the phy- 
sician and operator, without which combination no man can be 
a really great surgeon. He was the first in Tennessee to per- 
form amputation at the hip-joint, which resulted in recovery. 
This is one among the many of his brilliant achievements. 
To the deep regret of those who were, by personal acquaint- 
ance, aware of his greatness, his extraordinary knowledge ot 
surgical science was destined to die with him; for there was, 
during the most active period of his life, no journal in our 
State through which he could communicate, to his professional 
brethren, his daily experience; and for the same reason, a re- 
putation, which ought to have been national, was confined to 
the limited sphere of his particular friends. 
To return now to the thread of my history: 
In 1850, the Medical Department of the University of Nash- 
ville was organized, and Prof. Paul F. Eve, our distinguished 
President, was called to the Chair of Surgery. Professor Eve 
even then enjoyed a national reputation; he was the peer of 
any contemporary. Through the agency of his great name, 
which was familiar to every medical man in the entire South, 
surgical cases of all kinds were brought, not only from our 6 
REPORT ON TENNESSEE SURGERY. 
own State, but from every Southern State, to Nashville; and 
as a result, this city has become a great surgical centre. Since 
his advent amongst us, no city can boast of a greater number 
of important surgical operations. 
The improvement in surgery was not confined to our capital. 
The impetus received by the establishment of a Medical Col- 
lege in our midst, was reflected throughout the entire State, 
and not one, of the size and population of ours, can now boast 
of a greater number of excellent surgeons. 
hile regretting my inability, from the causes mentioned, 
to make such a report as all would have desired, I beg leave 
to submit the following, on a few special subjects, which I am 
persuaded will contain nearly all the information that it is 
possible to obtain. 
I would return my thanks to those who have furnished me 
with communications, and especially to Dr. F. K. Bailey, of 
Knoxville, and Dr. J. S. Poyner, formerly of Smyrna, but 
now of Nashville, who have so materially assisted me. 
The first subject to which I will call your attention is 
STONE IN THE BLADDER. 
It is well known that calculous affections arc more prevalent 
in Ohio, Kentucky, Tennessee, and Alabama, than in any 
other portion of the United States. They are as frequent in 
Tennessee as in either of the States mentioned, if not more so. 
The cause has not been ascertained. All attempts to trace them 
directly to the effects of climate, habits of peoples, food and water, 
&c., have proved unsatisfactory. It has been generally believed 
that their formation was favored by the strong limestone water 
which abounds in these States. It would seem reasonable to 
suppose that water, strongly impregnated with lime, constantly 
drank, would, by the changes induced in the renal secretions, 
favor the depositure of calculous matter; but it is a fact that 
a considerable number of stone cases occur in the freestone 
districts—so large a number, indeed, as to show that some 
other reason must be sought to account for their prevalence. REPORT ON TENNESSEE SURGERY. 
7 
It has been supposed that there was some peculiarity of cli- 
mate in our State by which calculous affections were increased 
in frequency. It is true that our climate is very variable,— 
especially in the winter season, it is subject to great and rapid 
changes; and withal, the atmosphere is very moist a greater 
part of this time. The clothing of our people, especially the 
poorer classes, is often insufficient to guard the body from the 
great and rapid changes to which they are exposed. These do 
have more or less influence. 
By some, too, it has been attributed to the food we eat. 
People who are in affluent circumstances, or those of moderate 
means, have an abundance of the best kind of food obtainable 
from any part of the world. Even persons in the lower walks 
of life have a plenty of plain wholesome food. There may be, 
and doubtless is, some fault in the manner of cooking food, 
and more in the manner of eating it—most persons taking it 
very hot, and bolting it without mastication. 
These causes, no doubt, have some effect in increasing the 
tendency to calculous disease. There can be no question that 
the proximate cause in the origin of calculus is a disturbance in 
the normal relations of the constituents of the urine. Any- 
thing that disturbs those relations, will favor deposits in the 
urinary passages; climate, food, water, and clothing, often 
indirectly bring about such disturbance. 
But there is no cause which so frequently effects a change of 
the urine as derangement of the digestive organs. A weakened 
digestion, with an acid and flatulent state of the stomach, con- 
stipation of the bowels, and an irritable condition of the ner- 
vous system, cannot, by any means, produce healthy blood; 
nor can an unhealthy state of the blood produce healthy urine. 
Any influence, therefore, which can affect the digestion, in the 
proper solution of the food, its normal absorption and assimi- 
lation, will act as a predisposing cause in the formation of cal- 
culus. In proof of this, it is well known that a large propor- 
tion of calculous affections are met with in children from two 
to six years of age; and even when met with in those of ma- 
turer years, it is highly probable that the formation commenced 8 
REPORT ON TENNESSEE SURGERY. 
at an early age. At that age, the chylopoetic viscera are very 
much damaged by the process of dentition, and just such a 
condition brought about that is most favorable to the formation 
of stone. 
No stronger proof is necessary to show the close connection 
between this disease and the particular condition of the diges- 
tive organs, than that which is so frequently observed during 
the treatment preparatory to the operation for the removal of 
the calculus. Patients are often so relieved of all sufferings by 
the administration of remedies for the purpose of regulating 
the digestive functions and preparing them for operation, as to 
believe that they are cured, and are willing to abandon the 
operation, until they are warned, by another attack, that such 
relief is only temporary. 
It is my opinion that stone in the bladder is more prevalent 
in our State, and in the others mentioned, for the reason that 
there are more, or a greater combination of causes present, to 
derange the chylopoetic viscera, and through them the urinary 
secretion, wither they consist in the peculiar habits of our 
people, thei“r food, dress, &c., or in the peculiar nature of our 
climate, or in the character of the water they drink, or of all 
combined. 
The early history of this special disease, and the operations 
for its relief, like the early history of the surgery of the State, 
is unknown. If any operations for the removal of stone were 
done in very early times, I have been unable to obtain an ac- 
count of them. The probabilities are, that all cases demanding 
operation were sent otf to other States. In fact, the first opera- 
tion of which I can gain any knowledge, was that performed on 
James K. Polk, then a resident of Maury County, who, in the 
autumn of 1812, sought the skill of Dr. Ephraim McDowell, 
of Danville, Kentucky, for the relief of calculus of the blad- 
der. Little did the great surgeon dream that the poor suffer- 
ing lad, upon whom he was exerting his consummate skill, 
would become the accomplished scholar, the great statesman, 
and the President of the United States. REPORT ON TENNESSEE SURGERY. 
9 
Many calculous patients of our State, as well as those of the 
whole South, were attracted by the brilliant success of Dr. 
Dudley, of Lexington, Kentucky ; and possibly the celebrated 
surgeons of other States may have operated upon some of our 
people. 
The first operation of lithotomy in Tennessee, of which I 
can gain any knowledge, was done about 1812, by Dr. John 
O’Riley, a surgeon of marked ability, residing in Maury 
County. Between 1812 and 1820 he performed the operation 
five times. 
Dr. John H. Ray, of Smith County, was probably the next 
who resorted to lithotomy. His patient, a little boy, aged 9 
years, lived in Alexandria, then in Smith, but since in De 
Kalb County. The operation was performed in 1826. In 
1834 he again performed the operation on a man in Sumner 
County. The operation was successful in both cases. 
Dr. Wallace Estill, the “ mountain surgeon,” who for many 
years resided in Winchester, Franklin County, was distin- 
guished as a lithotomist. He performed the operation fifteen 
times, with but one death. 
Dr. Wm. Bonner, of Fayetteville, was also noted as a litho- 
tomist in early times. 
I have been able to gather the partial history of two hun- 
dred and fifty-nine eases, in which stone has been removed from 
the bladder by different surgeons of our State—(doubtless 
many other operations have been done)—as follows: 
I)r. O’Riley 
NUMBER OF CASES. 
5 
SUCCESSFUL. 
.... 4 
UNSUCCESSFUL. 
1 
Dr. Wallace Estill 
.... 14 
1 
Dr. William Bonner., 
18 
.... 0 
0 
Prof. J. M. Watson... 
2 
.... 2 
0 
Dr. John Waters 
4 
.... 3 
1 
Dr. Esselman 
1 
.... 1 
0 
Dr. R. C. K. Martin 
1 
.... 1 
0 
Prof. R. M. Porter ... 
2 
.... 2 
0 10 
REPORT ON TENNESSEE SURGERY. 
NUMBER OF CASES. 
SUCCESSFUL. UNSUCCESSFUL. 
Prof. B. W. Avent .... 
15? 
Unknown. 
Prof. A. H. Buchanan 
15 
.... 14 
1 
Prof. I). W. Yandel... 
*10 
.... 9 
1 
T)r "Franklin 
.... 3 
0 
Dr. W. M. Gentry — 
2 
.... 1 
1 
Dr. S. S. Mayfield 
1 
.... 1 
0 
Dr Pini’p.fi 
1 
.... 1 
0 
Dr. DeBow 
3 
.... 3 
0 
Dr. W. C. Rogers 
9 
.... 8 
1 
Dr. J. R. Buist 
2 
.... 1 
Ret’d in 6 mos. 
D. Cunningham 
4 
1 
Prof. P. F. Eve 
|80 
.... 71 
9 
Dr. W. T. Briggs 
60 
.... 56 
4 
Dr. T. L. Maddin 
3 
.... 3 
0 
Dr J H. Ray 
2 
.... 2 
0 
Dr. Jetton 
1 
1 
0 
Tennessee alone furnishes the cases to all the surgeons above 
mentioned, except Prof. Eve and the writer. 
Of Prof. Eve’s cases, 
Tennessee furnished 46 
Georgia “ 10 
South Carolina “ 3 
Mississippi “ 6 
Alabama “ 6 
Kentucky “ 5 
Missouri “ 2 
New York “ 1 
North Carolina “ 1 
* Prof. D. W. Yandel, who performed his ten operations while residing 
in Tennessee, kindly furnished me a full history of his cases, which I un- 
fortunately placed away so securely that I have been unable to find it. 
f This includes only the cases of Dr. Eve since his residence in Tennes- 
see. He has operated, altogether, one hundred times. REPORT ON TENNESSEE SURGERY. 
11 
Of Dr. Briggs’ cases, 
Tennessee furnished 42 
Kentucky “ 12 
Alabama “ 3 
Mississippi “ 2 
Georgia “ 1 
SEX 
MALES. 
FEMALES. 
Dr. Eve’s cases 
77 
3 
T)r DpRnw’s r>ns5Ps 
2 
1 
I)r. Brings’ eases 
57 
3 
Dr. Wm, Bonner’s eases 
16 
. 2 
The cases of all the other surgeons were males, I suppose. 
AGES. 
Dr. re’s cases— 
Under 5 years .. ..' 10 
Between 5 and 15 years 30 
Between 15 and 30 24 
Between 30 and 50 8 
Over 50 8 
His youngest patient was 2£, his oldest 77 years. 
The cases of Dr. Rogers, of Memphis— 
Under 5 years 0 
Between 5 and 15 7 
Between 30 and 50 I .... 2 
The cases of Dr. DeBow, of Hartsville— 
Under 5 years 0 
Between 5 and 10 1 
Between 30 and 50 2 12 
REPORT ON TENNESSEE SURGERY. 
Dr. Briggs’ cases— 
Under 5 years 10 
Between 5 and 15 25 
Between 15 and 30 12 
Between 30 and 50 10 
Over 50 3 
His youngest patient was a son of Mr. Jordan, of Dickson 
County, eighteen months old; his oldest was Col. Hancock, of 
Maury County, aged 72 years. 
RACES. 
Of the races, a large proportion of patients were white. 
However, the writer can only speak with certainty of Prof. 
Eve’s, Prof. Buchanan’s, and his own. 
In Dr. Eve’s practice, in the 100 cases operated on here and 
in Augusta, were as follows, viz.: 
Whites 88 
Blacks 6 
Mixed 6 
In Prof. Buchanan’s practice— 
Whites 14 
Blacks 1 
In Dr. Briggs’ practice— 
Whites 57 
Blacks 3 
METHOD OF1 OPERATION. 
It will be seen that, in a very large majority of cases, the 
removal of stone has been by the cutting operation. Thus, of 
the 259 cases reported— 
Lithotomy was resorted to in 250 
Lithotrity “ 9 REPORT ON TENNESSEE SURGERY. 
13 
Of the Lithotomy operations, 
The lateral was performed 112 times— 
78 with Physick’s gorget, 
34 with the scalpel. 
Of these, the following made the incision in the neck of blad- 
der, with gorget : 
Dr. O’Riley 5 
“ Estcll 15 
“ Bonner 17 
“ Watson 2 
“ A vent 15 
“ Buchanan 15 
“ DeBow 3 
“ Waters 4 
“ Esselman 1 
Prof. Eve 1 
The following made the sections with the scalpel, viz.: 
Prof. Eve 1 
Prof. Porter 2 
Dr. IT C. Iv. Martin 1 
“ D. W. Yandel 10 
“ W. M. Gentry 2 
“ Mayfield 1 
“ Rogers 9 
“ Buist 1 
“ Cunningham 4 
“ Ray 2 
“ Jetton 1 
The Bilateral, with the Lithotome-Cache, was performed as 
follows, viz.: 
Prof. Eve 73 
Dr. Franklin 3 
Dr. Briggs 45 
The Supra Pubic operation was performed in two cases by 
Prof. Eve. 14 
REPORT ON TENNESSEE SURGERY. 
The Median was performed by Dr. Briggs in four cases. 
The Medio-Bilateral, in ten cases, as follows, viz.: 
Dr. Pearce 1 
Dr. Briggs ... 9 
In the females operated on—nine in number—the vesico- 
vaginal section was made—by 
Dr. Eve, in 2 cases. Successful. 
Dr. Briggs 1 case. Successful. 
The lateral was made by 
Dr. DeBow, in 1 case. Successful. 
Dr. Bonner 2 cases. Successful. 
The bilateral was resorted to by 
Dr. Eve, in 2 cases. Successful. 
Dr. Briggs 2 cases. Successful. 
RESULT. 
It has been impossible to obtain the result of many of the 
operations performed. I will, therefore, only refer to those in 
which I have positive knowledge: 
Lateral operation 
CASES. 
97 
SUCCESSFUL. 
87 
UNSUCCESSFUL. 
10 
Bilateral operation 
121 ..... 
110 
11 
Median 
4 
4 
0 
Medio-Bilateral 
10 
10 
0 
High, or Supra-pubic.. 
2 
1 
1 
Vesico-vaginal 
3 
3 
0 REPORT ON TENNESSEE SURGERY. 
15 
NUMBER OF CALCULI. 
I have been unable to obtain data in regard to the number 
of stones removed, except in Dr. Eve’s practice, and my own. 
In Dr. Eve’s collection, since his residence in our State, are 
one hundred and sixty-three (163) of which 
1 case furnished 58 
1 “ “ 18 
1 “ “ 17 
2 cases (triple) 6 
4 cases (double) 8 
61 cases (single) 61 
In Dr. Briggs’ collection are seventy-four (74), of which 
1 case furnished 13 
1 “ “ 3 
1 “ “ 2 
55 cases “ 55 
1 case calculous deposit. 
1 case lithotrity (debris not preserved). 
PROPERTIES. 
In the collection of Prof. Eve, as well as in that of the 
writer, arc found the alternating, oxalate of lime, uric, ammo- 
niaco-magnesian, phosphatic, and the cystic oxide calculus. 
The alternating calculi are more numerous than any other 
variety, the nucleus being uric acid or oxalate of lime, va- 
riously coated and alternated. The last covering is always 
phosphatic. 
The oxalate of lime or mulberry is the next in frequency. 
There are some beautiful specimens of this variety in the 
cabinet of Prof. Eve, as there arc in that of the writer. 
There are a few specimens of pure uric calculus among our 
stones. 16 
REPORT ON TENNESSEE SURGERY. 
The triple phosphates form a fair proportion. The mixed 
phosphates are very few in number. 
There are but two or three specimens of the cystic oxyde in 
both collections. 
In almost every case that has come under my observation, 
the calculous disease has been accompanied with great chylo- 
poetic derangement, in addition to the urinary disturbance, and 
I have followed the advice given by the great Dudley, in regard 
to the preparation of the system before a resort to operation. I 
have not, however, adhered to his special plan for their prepa- 
ration. The preparatory treatment to which I have subjected 
my patients was such as would restore the general health, and 
allay local irritation. Under the effects of remedies, as elsewhere 
stated, patients are often so relieved that they are almost willing 
to believe that they are cured, but they are then just ready for 
the knife. And if their health is not improved, and their 
suffering mitigated, by treatment, I am always inclined to be- 
lieve some serious organic disease is in progress, and am un- 
willing to operate. For these reasons I have declined to ope- 
rate on five patients affected with calculus. In all of these 
death ensued in a short time. And although the per centum 
of deaths in my operations has been but one in fifteen, I think 
if I had had some of the patients who died, under my imme- 
diate care, prior to the operation, the mortality might have 
been even less. 
The writer having been educated in the school of Dudley, 
had strong predilections for the lateral operation with the 
gorget, but after witnessing the beautiful operations of Prof. 
Eve, he adopted the bilateral, and continued to employ it until 
within the last three or four years, during which time he has, 
for small stones, employed the median, and for larger ones the 
mcdio-bilateral. To claim special success for any particular 
method, because of that method, I think is wrong. Much 
more depends on the condition of the case at the time of the REPORT ON TENNESSEE SURGERY. 
17 
operation. If the patient is well prepared, even a badly exe- 
cuted operation will often succeed; and if his system is in bad 
condition, the most brilliant operation will often end in death. 
There is no operation in which the result is more dependent 
on the thorough preparation of the patient. Besides, every 
case should be carefully and critically examined, and that ope- 
ration adopted which is best suited to the particular case. If 
the stone is large, more especially if accompanied with great 
pathological changes in the bladder, the effect of long-continued 
irritation, the lateral or bilateral will be best adapted; for, 
while they give a good opening for the extraction of the stone, 
they afford a free outlet for the urine, and the secretions of the 
bladder, to pass; by which the pathological changes in the 
bladder are entirely removed. 
If the stone is small, the median is the best, for many rea- 
sons. 
The medio-bilateral—a modification of the median, as its 
name indicates—is best suited for the removal of good-sized, 
or even large calculi, and is the one I have adopted for the 
last two or three years. It has answered my expectations so 
fully that I know you will pardon me for exhibiting an in- 
strument which I have had made for this special operation, 
and for detailing the steps of the operation. 
The instrument (see plate) consists of two blades, curved on 
the flat surface, and sharpened on the outer edges; one blade 
is half an inch longer than the other, and is probe-pointed, to 
fit in the groove of the staff. The blades are fastened at the 18 
REPORT ON TENNESSEE SURGERY. 
junction of the handles, with which they are continuous, by a 
movable pivot screw. The blades do not cross, as do those 
of scissors, but lie one upon the other, and are expanded to 
the desired extent, in making the incision, by closing the han- 
dle. The movable screw on one of the handles, marked A, 
regulates the extent of the expansion of the blades, and when 
placed on the numbers on the handle, shows the size, in lines 
and inches, of the incision made by that expansion. The 
spring on the other blade, marked B, holds the blades together 
during the passage of the instrument through the grooved 
staff into the bladder. The instrument measures, from the 
rings of the handle to its probed extremity, eight inches; its 
probed extremity is half an inch; its cutting-blades, three 
inches; its weight, 1J ounces. 
The patient having been properly prepared, and placed in 
the usual position, the grooved stalf is passed into the bladder, 
made to touch the stone, and handed to an assistant, who is 
directed to draw it well up into the arch of the pubis; the 
surgeon seats himself on a low chair or stool, before the pa- 
tient’s perineum, and introduces his left index finger, well oiled, 
into the rectum ; then, with a sharp-pointed straight bistoury, 
he makes an incision in the raphe of the perineum, commenc- 
ing four lines from the margin of the anus, and continuing 
directly upward in the raph6 to the extent of an inch and a 
quarter to an inch and three-quarters. The first incision goes 
through the skin and subcutaneous tissues; in the next, the 
point of the knife goes directly into the groove of the staff, as 
near the “ perineal point ” as possible. The groove being well 
cleared, the beak of this instrument—which Mr. Stolilman 
(of the firm of Geo. Tiemann & Co.) calls a Cystotome—is in- 
troduced into the groove of the staff, and passed into the blad- 
der. Its blades are then expanded to the extent of from four 
to six lines, and withdrawn. The surgeon’s finger follows its 
withdrawal, and is guided by the staff into the bladder, when 
the staff is removed. The finger should be used as a dilator, 
being turned around in the wound several times. A pair of thin 
forceps should then be passed along the finger into the bladder, REPORT ON TENNESSEE SURGERY. 
19 
directly upon the stone, when it should be grasped and re- 
moved in the usual way. 
The advantage of the above-described operation is its sim- 
plicity, the small liability of wounding the important parts 
on either side of the raph6, the absence of hemorrhage (fre- 
quently not a tablespoonful is lost), and lastly, the power the 
patient has of controlling the discharge of urine during the 
after treatment. 
Before I leave the subject of lithotomy, I would call the at- 
tention of the Society to some interesting facts connected with 
its history. 
In one of my cases—Mr. Stanley, of Kentucky—over a 
week from the date of the removal of a very large stone, a 
small stone passed from the kidney to the bladder, with great 
pain, and was discharged through the perineal wound before it 
had healed. 
In another case, a negro boy belonging to Gen. Harding, 
two years after a successful operation and complete immunity 
from suffering, was seized with paroxysms of stone, which con- 
tinued until an abscess formed in the cicatrix; in a few days 
the abscess broke, and the end of an oblong calculus protruded, 
and was expelled spontaneously, the mother of the boy refus- 
ing to allow me to remove it with the forceps. 
In 1868, I operated on the son of Mr. Douglas, of Nash- 
ville, after satisfying myself and all the physicians present— 
ten or twelve in number—by the touch, and by the click, of 
the presence of stone; found no stone, but calcareous deposit, 
imbedded in the mucus membrane of the bladder, which I 
scraped off with a scoop. My little patient not only recovered 
from the operation, but from all symptoms of the disease. 
Dr. Eve’s forty-ninth case is similar in most respects. 
During the last winter, three cases of stone, aged respec- 
tively two, four, and five and a half years, were presented to 
our medical class, and sounded. The calculus was detected in 
each instance, and, singularly enough, was passed out by the 
efforts of the bladder in a few days after sounding, in each 
case. 20 
REPORT ON TENNESSEE SURGERY. 
In the Nashville Journal of Medicine and Surgery, vol. vii., 
page 101, I find the following unique and interesting case, re- 
ported by J. S. Dyer, M. I)., one of our most distinguished 
physicians, now residing in Ilartsville, Tennessee: 
“ In September, 1846, I was called to see Wm. Green, aged 
9 years, of leuco-bilious temperament. On getting the history 
of his case, I learned that he had had difficulty in passing his 
urine from the age of three months, if not from his birth. 
He was suffering with all the symptoms common to urinary 
calculus. 
“ Being without instruments, I prepared a sound of common 
bucket wire, about four lines in diameter. Thus equipped, 
my partner, the late Dr. Jas. M. Jetton, and myself, set out to 
visit our patient, and explore the hidden recesses of his urinary 
bladder. On introducing the sound, we came in contact with 
the stone. Finding it very difficult to pass the sound under 
it, we feared it was encysted. The parents were very anxious 
to have the stone removed. Dr. Jetton had successfully per- 
formed some important operations. Emulous of professional 
eminence, and encouraged by myself and other friends, he de- 
termined on operating. For this purpose our friend Dr. F. H. 
Gordon, of Rome, was called to assist. He brought his litho- 
tomy instruments, save the largest sized forceps, those being 
thought too large for the size of the pelvis. 
“ On the 10th of October, in the presence of a large crowd 
of neighbors and physicians, at 11 o’clock a. m., the operation 
was commenced by Dr. Jetton in the usual way of performing 
the lateral operation. Nothing unusual occurred, save a slight 
laceration of the urethra, causing it to bleed on introducing 
the grooved staff’, until the bladder was entered and an attempt 
made to grasp and withdraw the stone. It proved to be too 
large for the forceps. When partially seized, the blades of 
the instrument would slip off. For a long time the doctor 
tried to grasp the stone, but with no other effect than to scrape 
off the soft external surface and punish the poor little sufferer. 
The stoutest hearts failed. The tear of sympathy was seen in 
the eyes of those who seldom wept. REPORT ON TENNESSEE SURGERY. 
21 
“ Fatigued and desponding, the doctor requested Dr. Gordon 
to take the seat and try to extract the stone. Dr. G. complied, 
and after two or three fruitless efforts to grasp the stone, he 
laid aside the forceps, and introduced the index finger to as- 
certain the shape and size of the calculus. Finding it uncom- 
monly large, he raised it on the finger, so as to make it project 
the abdomen above the pubis, and show its full size to the 
crowd. It was about the size of a large turkey-egg, complete- 
ly filling the cavity of the contracted bladder. Dr. G. then 
arose from the seat, and declared that no instrument present 
could remove the stone. 
“ A council was then held. Some urged that the operation 
ought to be suspended. But to leave him in this situation, 
death was inevitable. It-would have been better to die under 
the operation, than to linger out a few more days of painful 
siiffering. The fear of censure, the love of approbation, or 
benevolence to suffering humanity, urged a continuation of 
efforts. Dr. Gordon proposed to cleave the stone with the 
spindle of a common spinning-wheel, which was present. 
With that suggestion the writer was at once gratified, and con- 
vinced that the little sufferer might yet be relieved, and cor- 
dially urged its adoption. 
“ Dr. Jetton made further efforts to crush and extract the 
stone with the forceps. In the meantime the spindle was pro- 
cured and prepared by Dr. Gordon, by filing the smaller end 
in the shape of a stone-cutter’s chisel, and not perfectly sharp. 
The writer proposed it should be wedge-shaped, with a short 
bevel, and perfectly sharp, which was readily adopted; and 
Dr. G. soon reduced the instrument to that shape. He then 
placed the spindle and a hatchet on the table, saying to Dr. 
Jetton, 1 Here are your instruments, and the only ones at hand 
capable of removing the stone.’ Dr. Jetton feared that the 
instrument might puncture the bladder, or that the force re- 
quisite to cleave the stone might bruise and cause it to slough. 
It was insisted that both these accidents might be avoided, by 
grasping the spindle firmly around the whirl with the left 
hand, and resting it against the ischii of the boy, so that a 22 
REPORT ON TENNESSEE SURGERY. 
blow with the hatchet could force the spindle no farther than 
the approximation of the metacarpal bones of the hand would 
permit. 
“ Dr. Jetton now gave the plan a trial, and being much fa- 
tigued, requested Dr. Gordon to take the seat again, which he 
did. With severe pain to the boy, he succeeded, with the 
right index finger, in placing the long diameter of the stone 
at right angles with the incision; then having made a blow so 
as to imprint the edge of the little chisel across the stone, he 
always felt with the chisel, before each blow, for the cut he 
had made, and placed the chisel in it. In this way he clove 
the stone into two nearly equal parts, by means of between 
fifty and one hundred heavy blows. Introducing the largest 
forceps in the set, except one, he grasped one half of the stone, 
with both hands upon the handles, but could not crush it. Dr. 
Jetton then grasped the handles also; so that both of them 
grasped with all their power. After bending and straighten- 
ing the handles several times, they succeeded in breaking the 
half of the calculus into several large fragments, which were 
still too large to be passed through the wound. Each frag- 
ment required great force to crush it, so hard was the stone. 
Drs. Jetton and Gordon thus continued to operate conjointly 
and alternately till the whole calculus was crushed and ex- 
tracted. The fragments of this huge stone filled a common- 
sized teacup. 
“ Thus ended an operation commenced with a bucket-wire 
for a sound, and finished with a wheel-spindle. After sunset 
the little patient was put to bed, and an opiate administered. 
Visited next day, and found with some fever. On the follow- 
ing day, erysipelatous inflammation about the wound, which 
yielded readily to saturine lotions. Recovery rapid, but passed 
the urine and foeces through the wound, for the rectum proved 
to be injured. In a few days the foeces measurably ceased to 
pass by the wound, but the urine continued to pass through 
the fistulous opening that followed. No one thought he would 
recover. All rejoiced that he did not die under the operation. 
The fact that he had been inured to hardships and suffering REPORT ON TENNESSEE SURGERY. 
23 
from infancy, must account for his extraordinary recuperative 
constitution. A boy raised on fine carpets and feather beds 
could not recover from such an operation. Yet Billy Green 
recovered. Yea, he not only recovered, but the fistulous open- 
ing healed; and twelve months after the operation, for the 
first time, he passed his urine per urethram. 
“Just twelve months after the operation, I was called up 
by the boy’s father, and told that his son was as bad off as 
ever—that ‘ he could neither pass his water by the cut nor the 
natural way.’ Armed with a silver catheter, I set out to try 
to relieve my little friend. Arrived at day-break. Billy met 
me at the door. 
“‘Too late, Doctor; too late this time/ 
“‘ Why, Billy?’ 
“ ‘ I’ve passed it already; I heard it rattle down on the 
leaves at the door.’ 
“‘How, Bill?’ 
“ ‘ Why the old way.’ 
“ In order to be certain that he was telling me the truth, he 
was placed on the bed, and the catheter introduced without 
any difficulty—two tablespoonsful of urine drawn off. The 
fistula was filled with a fibro-gelatinous substance. 
“ Three months after this I saw the boy frequently during 
two weeks, when passing his father’s camp on the river. His 
health was good, though he complained of some hurting in the 
urethra when passing his urine. His father moved off. I 
have not heard from him since. 
“ This case has not been the means of fame to the operators, 
though it terminated so favorably under such unfavorable cir- 
cumstances. Had the operation been performed in eight or 
ten minutes, instead of more than seven hours, the principal 
operators would have been lauded to the skies, whether the 
patient had ever been allowed to use his urethra or not.” 24 
REPORT ON TENNESSEE SURGERY. 
In the winter of 1870, Prof. Eve presented to our class a 
patient, aged 9 years, from Rutherford County, with stone in 
bladder. The little fellow was pale and emaciated from long 
and constant suffering, and it was the opinion of nearly every 
one who saw him that he would die in a very short time. 
After a few days’ preparatory treatment, the doctor, who never 
refuses the aid of surgery to any, if there is the slightest hope 
of success, performed the bilateral operation on him. 
The incisions were quickly and neatly made, and the finger 
passed into the bladder, only to find a stone so large that it 
could not be brought out. The incisions were enlarged, and 
several attempts made to extract the calculus with forceps of 
different sizes and shapes, but they proved ineffectual. At 
length the stone was grasped by a pair of strong forceps, and, 
after two or three trials, was crushed into fragments, which 
were removed by forceps, the scoop, and the finger. The for- 
ceps and scoop were passed into the bladder not less than 
twenty-five or thirty times. The operation lasted over an 
hour. The patient had a slow, tedious recovery, but was 
finally well. 
In August, 1868, the writer was called to Decherd, in 
Franklin County, to remove a stone from a patient of Dr. 
Anderson’s. 
The patient was a thin, delicate lad, about 12 years of age, 
who had suffered nearly all of his life. Upon introducing the 
staff, a very large stone was discovered. The bilateral opera- 
tion was at once performed. When the finger was introduced 
into the viscus, it was found that the calculus literally filled 
it, and it was with great difficulty that the blades of the for- 
ceps could be passed between the walls of the bladder and 
the stone. Without delay, I crushed the calculus into as 
many fragments as possible (fortunately the stone was soft), 
and occupied myself for half an hour in picking out the 
pieces. After the bladder was cleared and washed out, the 
patient was put to bed, none the worse for the prolonged ope- 
ration. REPORT ON TENNESSEE SURGERY". 
25 
He recovered without a bad symptom, although his rectum 
was wounded, doubtless by the sharp edges of some of the 
fragments, as there was no opening from the incision. The 
opening in the rectum was of no consequence, as it healed up 
in a few days. 
The pieces of calculus, when collected, (many were lost), 
weighed about five ounces. 
The most difficult and embarrassing operation ever per- 
formed by myself was on Col. H , of Maury County. 
The Colonel was seventy-two years of age, six feet one inch 
in height, and weighed between two and three hundred pounds. 
He had suffered many years with calculus, and determined 
to be relieved of it by operation, at all hazards. 
I visited him at his home, and performed the bilateral 
operation. So deep was his perineum, that it was found 
impossible to reach the bladder with the finger, and the for- 
ceps could not be used with success for the same reason. 
Fortunately, a lithotrite was among my instruments, with 
which, after thirty or forty introductions, I removed thirteen 
stones, each about the size of a partridge’s egg. On the day 
following the operation the patient was doing well. In a few 
days, however, he began to decline, and died, in eight or ten 
days, of prostration. 
A 'post mortem examination, made by his physicians, revealed 
the fact that no calculus was left in the bladder, which was 
free from inflammation, though its walls were much thickened, 
and it had formed extensive adhesions to the walls of the 
lower part of the abdomen, by which it was drawn away from 
the perineum. 
I have never had hemorrhage to occur to such an extent as 
to demand the tampon, or other means, except in one instance. 
In the fall of 1868, I was called to Mr. O , of Blount 
County, East Tennessee, and performed the bilateral operation 
on Friday, the day of September. The operation was 
quickly done, and a large stone removed. In a short time af- 26 
REPORT ON TENNESSEE SURGERY. 
terwards it was found that blood was issuing too freely from the 
wound—not per sal turn, but in a steady continuous stream. 
Upon examination, the blood was seen to escape from a number 
of points. The tampon was used in the customary manner. 
The hemorrhage was checked, and the urine escaped through 
the catheter. 
The day following the patient was doing very well, having 
slept nearly all night. I learned afterwards, from his attend- 
ing physician, who had himself performed lithotomy several 
times successfully, that on the Tuesday or Wednesday follow- 
ing, upon withdrawing the tampon, the hemorrhage returned, 
and the patient died iii a short time. 
In this case there was doubtless some abnormal distribution 
of vessels about the neck of bladder. 
LITHOTRITY. 
It may seem strange that, in speaking of the operative 
treatment of calculus, so little mention has been made of li- 
thotrity. The removal of stone from the bladder, by a com- 
paratively painless operation, without injury to the bladder or 
other soft parts, is a surgical feat which cannot be too highly 
commended; and it is, without doubt, the duty of the surgeon 
to make himself familiar with the practice both of lithotomy 
and lithotrity, and to adopt the one which promises the best in 
the particular instance with which he has to do. In deter- 
mining this point, it is necessary to ascertain those circum- 
stances which influence the result in each case. After an ex- 
amination into the condition and surroundings of stone-pa- 
tients in our State, it will not be astonishing to those who un- 
derstand the subject, that so few have been submitted to the 
crushing process. REPORT ON TENNESSEE SURGERY. 
27 
In the first place, a large majority of calculous patients are 
children, under ten years of age. With these, lithotomy is so 
successful an operation, that the surgeon would gain nothing 
by substituting lithotrity for it, even if there were no difficul- 
ties in the latter mode of operation with this class of patients. 
In the second place, when stone exist in the adult, application 
for relief is seldom made until the stone has become very 
large, the bladder inflamed and irritable, and the general sys- 
tem prostrated and shattered—circumstances which are not fa- 
vorable to the crushing operation. 
Thirdly, when a case presents, which is well suited for the 
crushing operation, it often happens that the patient’s circum- 
stances are such that he cannot spend the time necessary for 
the repeated sittings. 
And lastly, our stones are often so hard that they are not 
well adapted for crushing. 
The number of cases operated on by Lithotrity are as fol- 
lows : 
Prof. Eve 
AGE. 
20 ... 
NUMBER 
OF SITTINGS. 
RESULT, 
Prof. Eve 
30 ... 
1 
u 
Prof. Eve 
38 ... 
20 
(( 
Prof. Buchanan 
65 ... 
3 
« 
Prof. Maddin 
38 ... 
u 
Prof. Maddin 
32 ... 
u 
Prof. Maddin 
40 ... 
u 
Pr. J. R. Buist 
28 ... 
38 
(( 
Dr. Briggs 
40 ... 
4 
it 
I attempted the operation in two other cases, but abandoned 
it, because the patients would not submit to the delay necessa- 
ry. They were lithotomized successfully. 28 
REPORT ON TENNESSEE SURGERY. 
OVARIOTOMY. 
Ovarian Tumors are of frequent occurrence in our State. 
Since his residence in Nashville, the writer has been consulted 
in fifty or sixty cases of the kind, and other physicians have 
met with equally as many. They were as numerous in the 
early settlement of the country, in proportion to the number 
of inhabitants, as at the present time; but so little was known 
of them, that they were seldom recognised. In fact, it is only 
recently that surgeons have been able to make out clear and 
satisfactory diagnoses in such cases. It is true that Dr. 
Ephraim McDowell did, with unerring certainty, make out 
the exact nature and the condition of these cysts, and upon 
his thorough knowledge of his cases, based his operations— 
the first of the kind in the world; but he was far in ad- 
vance of the profession, not only in our country, but in that 
of the old world also. For when he reported some of his 
cases in the Eclectic Repertory of 1818, their correctness was 
doubted, both at home and abroad, and it was a long time be- 
fore he received the proper credit. 
It is somewhat surprising that his brilliant success as an 
ovariotomist, in a State so near to our own, had not induced 
some of our early physicians to attempt the removal of dis- 
eased ovaria. Such was not the case, however. Ovariotomy 
has been performed less often in Tennessee than any other 
capital operation. For a long time, a majority of the mem- 
bers of the profession everywhere believed it was so hazardous 
an operation, that it was unjustifiable; and since its recogni- 
tion as a proper and legitimate procedure, the influence of 
several distinguished surgeons and obstetricians of our State, 
against it, is still felt. In fact, it is only in the last few years 
that patients, so afflicted, could be induced to entertain, for a 
moment, the proposition for their removal. REPORT ON TENNESSEE SURGERY. 
29 
Many of the cases coming under the writer’s observation 
were well suited to the operation for extirpation, and he was 
often anxious to give them the advantage of it. A large ma- 
jority of the patients declined so slim a chance, as they 
thought, for recovery, preferring to risk themselves to nature’s 
efforts. In a very large proportion of those which he could 
follow up and keep under surveillance, the result was death in 
a few years. A few struggled on, in suffering, for eight or ten 
years, but they were exceptional cases. 
Such is the experience of all physicians. And yet, after a 
very careful inquiry, we can learn of not more than ten or 
twelve operations for the removal of ovarian tumors. 
The first attempt at ovariotomy, in our State, was made by 
a distinguished and learned physician of our city, Dr. James 
Overton. In 1818, Dr. Overton removed from Lexington, 
Kentucky, where he had filled a professorial Chair in old 
Transylvania, to Nashville. His enthusiasm had been greatly 
excited by the brilliant operations of the renowned Dudley, 
but more especially by the then new operations of Dr. Eph. 
McDowell, of Danville, Kentucky, for the extirpation of en- 
larged ovaria. He was exceedingly anxious to obtain surgical 
celebrity in his new locality. It was not long before an op- 
portunity presented itself, which, in his imagination, was to 
immortalize him as a surgeon. 
He was called to a lady with an enormous abdominal tumor 
of eight months’ standing, and after a careful examination, 
satisfied himself, and the family of the patient, that it was a 
case of ovarian tumor, and that nothing but slitting open the 
abdominal walls, and removing the diseased mass, offered any 
hope of relief; and as the lady had heard of the wonderful 
success of the Kentucky surgeon, she became anxious to be 
relieved. 
Dr. Bowling, in a biographical sketch of Dr. Overton, in 
the Nashville Journal of Medicine and Surgery, describes the 
operation and its results, in his inimitable way, as follows. 
(It should be premised that the patient lived nine or ten miles 
from Nashville) : 30 
REPORT ON TENNESSEE SURGERY. 
“ Early on a bright June day, in the year 1818, (a year me- 
morable in Nashville annals as witnessing the arrival of the 
first steamboat), a solitary horseman might have been seen 
emerging from the little city in the direction of the city ferry. 
At Haysborough, seven miles above Nashville, long a powerful 
rival of 1 the town below,’ but long since defunct, the horse- 
man drew up at a hotel, ordered breakfast, and that his steed 
should be bated. 
“ While breakfast was being prepared, the traveller stepped 
across the street to a physician’s office, and, finding the doctor 
in, introduced himself as Dr. Overton, mentioned the charac- 
ter of the operation he was to perform that day in the neigh- 
borhood, and politely invited the medical gentleman to ‘ be 
present.’ The invitation was cordially accepted, and after 
breakfast the twain proceeded to the house of the patient. 
“ There was a large apple-orchard near the house, and to 
each tree a half-dozen horses were fastened, some bearing 
men’s saddles, some women’s saddles, and some, of less lofty 
pretensions, compromising with an untanned sheep-skin, fixed 
to their backs by a red cirsingle, while not a few were nude, 
save a rope halter, necessary for ‘ safe bind, safe find.’ The 
medical gentlemen, dismounting, were vainly looking for a 
hitching point, when a laughing negro approached in a trot, 
and relieved them of their charge, stating that ‘ white folks 
told him to take the doctors’ horses to the stable.’ 
“ Dr. Overton was elaborately dressed, and, along with the 
French language, had acquired a good deal of French polite- 
ness. The large yard in front of the dwelling was densely 
crowded with men, women, and children, with not a few 
friendly curs, who, having no affairs of their own, are always 
busying themselves with those of other folks. Dr. Overton, 
uncovered, but holding his polished hat against his left 
shoulder with gloved hand, that all the world might bear 
witness that he had* a hat, made his way through the dense 
crowd, which instinctively shrank into smaller compass to 
make way for him, bowing and smiling right and left, as he 
advanced, which salutation not being directed to any one in HISTORY OF TENNESSEE SURGERY. 
31 
particular, each threw himself on his reserved rights and re- 
turned it with a stare. Such were the shadows of coming 
events. 
“ Within sat the anxious patient, holding within her that 
which was destined to make her surgeon immortal. The ope- 
rating table, cushioned and pillowed, and garnished with nap- 
kins and sponges and bowls of water, for the convenience of 
light and spectators, was placed in a large piazza, and near it 
a small stand sparkled and glittered with unfleshed instru- 
ments, like a casket of rubies. 
“The patient being placed upon the table, and all things 
ready, the crowd gazing in agony of expectation, the surgeon 
selected a burnished scalpel, (his hand being ungloved for the 
occasion), and holding it between the sun and his eye, said to 
his assistant, in an under-tone, 1 To hold it like a pen is axiom- 
atic ; it gives the digital apparatus perfect control of it. In 
its achievements, indeed, it may be compared to a pen. That 
little instrument, controlled in its movements by genius and 
cultivation, secures immortality. But it is either posthumous, 
or dimly mingles with the lengthened shadows of the sun-set 
of life. This, under the guidance of science, secures it in the 
fresh morning of existence.’ 
“ An assistant being now appointed for each extremity, and 
the patient exhorted to be firm and courageous, the surgeon 
proceeded dexterously to divide the integuments from the um- 
bilicus to the symphysis pubis. A few more strokes of the 
scalpel in the direction of the linea alba exposed the surface 
of the enormous tumor. It was remarkably smooth and po- 
lished, and there were noticeable irregular movements in it, 
difficult, at first, to account for. 
“1 Better not go on/ said the assistant. 
“ The wound was closed with sutures and adhesive strips, 
‘ and a compress and bandage completed the dressing/ as sur- 
geons say. 
“About 3 o’clock p. m., on that same fright June day, two 
horsemen might have been seen threading their way, tandem, 
through an unbroken forest, in the direction of Haysborough. 32 
HISTORY OF TENNESSEE SURGERY. 
Not a word had been spoken since they mounted their horses, 
though several miles had been passed over. Overton was the 
first to break silence. 1 Doctor/ said he, ‘ did you never notice 
that every thing, as well as diseases, runs in families? Now 
this woman’s father was always being tricked, or tricking some 
one else. Staggering about through fields, behind his forked 
stick, or divining rod, looking for mineral water, and gold and 
silver mines, and finding nothing but disappointment. And 
here is the daughter, with a stout husband, and the mother of 
three children, such an infernal fool as not to know that she 
was with child, but deliberately turns herself up to be split 
open in the gaze of the multitude. The whole seed, breed, 
and generation of them, are tricksters all; and now they have 
played me a h of a trick. Do you suppose Haysborougli 
would support a lawyer? Nashville is as full as a tick of at- 
torneys and counsellors; and preaching, even if one could 
hold his tongue between sermons, won’t pay.’ 
“ This unfortunate case terminated Dr. Overton’s career as 
a medical man. ‘ I did not,’ said he to the author, 1 retire 
from the practice; I was victorious even in defeat. The prac- 
tice retired from me, and left me in triumphant possession of 
the field.’ 
“ He always insisted, moreover, that his operation conferred 
a great boon upon science, but that the medical asses of his 
generation were too stupid to avail themselves of it. That 
before his operation, obstetricians were perplexed to determine 
the quantum of force yielded by the abdominal muscles in the 
parturient effort; ‘ Now,’ said he, ‘ my patient was delivered 
of a healthy, living child, a few days after the operation, by 
the uterine effort alone, for as to the abdominal muscles in that 
case, it is very clear that I had fixed them for slow traveling.’ ” 
It is well enough to state that the patient recovered perfect- 
ly, and named the child after the intrepid surgeon. 
This is not the only case in which such a mistake has been 
made. I learned from a medical friend that a surgeon of a 
neighboring State, who prided himself on having made twen- REPORT ON TENNESSEE SURGERY. 
33 
ty-five ovariotomies, had made just such an error as Dr. Over- 
toil did—he exposed the tumor (uterine, instead of ovarian), 
and actually plunged a large trocar into the organ. Nothing 
but a stream of bloody water escaped. Recognizing his mis- 
take, he filled the opening in the uterine tumor with a piece of 
sponge, and closed the abdominal walls over it. The lady 
gave birth to a dead child the next morning, and died on the 
second day afterwards. 
The first operation of ovariotomy performed in Tennessee 
was done by Dr. McDowell himself, in 1832, on the person of 
Mrs. Overton (a relative of the Doctor), whose husband resid- 
ed near the Hermitage. The operation was eminently success- 
ful, the patient living many years afterwards in the enjoyment 
of good health. 
It is said that Dr. McDowell had agreed to come to Mr. 
Overton’s residence, perform the operation, and remain with 
the patient as long as necessary, for the sum of five hundred 
dollars. When the Doctor was about to leave, Mr. O. gave 
him a‘check, which he took, without noticing it particularly. 
Upon presenting it at one of the banks in Nashville, fifteen 
hundred, instead of five hundred dollars, was handed him. 
Thinking it was a mistake, the Doctor sent his servant back 
to Mr. Overton’s residence to have the check corrected. But 
Mr. O. sent him word that it was not a mistake—that his ser- 
vices were richly worth that amount, together with his lifetime 
gratitude. How seldom is it, at the present day, that the 
heart of the surgeon is gladdened by such a recognition of his 
services. 
The next ovariotomy, so far as can be learned, was done by 
the writer, on a negro woman belonging to Mr. Iladcliffe, of 
Nashville, in the fall of 1857. The case was reported in the 
Nashville Journal of Medicine and Surgery, and, on account 
of its interest, is copied in full in this report: 
“ Harriet, a small and delicate looking negress, about 38 years 
of age, the mother of several children, had suffered from ute- 34 
REPORT ON TENNESSEE SURGERY. 
rine distress for a number of years, supposed by her mistress 
and herself to be prolapsus uteri, for the relief of which I was 
requested to visit her in July last (1857). I found her debili- 
tated, and considerably emaciated, with indigestion and con- 
stipated bowels; and when actions were procured, they were 
attended with great pain. Micturition was impossible, unless 
the finger was introduced into the vagina for the purpose of 
pushing the uterus out of the way. She had constant bearing 
pains and uneasiness through the pelvis. She stated that her 
menstrual secretions had been regular, but attended with an 
aggravation of all her symptoms, and she was confined to her 
bed for four or five days at each period. 
“ An examination per vaginam revealed the uterus situated 
at the os externum; its os and cervix apparently healthy; 
body and fundus free and movable. Posterior to the uterus, 
and filling up the whole recto-vaginal cul de sac, was a hard 
globular tumor, almost as large as a foetal head, and to the 
touch resembling it very closely. It was firmly impacted in the 
pelvis, but could be pressed up slightly by the finger; it could 
be felt above the pelvis, in the left iliac region, about the size 
of a cocoanut. From a careful examination, I learned that it 
was not connected with the uterus; in fact, the uterus could 
be pressed out of the vagina, and the finger passed over its 
whole surface, between it and the tumor. My diagnosis was a 
fibrous tumor, originating from the left ovary, and from its 
pressure on the surrounding parts, giving rise to all the suffer- 
ing she had endured. 
“ A few days subsequent to my examination, she was visited 
by Professor Watson, who, after a close examination, fully 
concurred with me in the diagnosis, and coincided in the opi- 
nion that nothing but an operation offered any prospect of 
cure; but in view of the hot weather, it was thought best to 
postpone the operation, and in the meantime to attempt to 
improve her general health by appropriate constitutional treat- 
ment. 
“ About the first of October we again met, Professors Eve 
and Bowling having been added to the consultation. Our pa- REPORT OX TENNESSEE SURGERY. 
35 
ticnt had improved somewhat in her general health, but the 
tumor had made considerable progress. It could now be seen 
and felt, mounting up into the abdomen, and had encroached 
so far upon the vagina that the uterus was thrust entirely from 
that cavity, and had almost blocked up the urethra and rec- 
tum. The result of the consultation was a confirmation of 
previous opinions. 
“ Having explained the nature of the case to her master, 
and to the patient, stating the utter impossibility of any relief 
except by a very doubtful and hazardous operation, with the 
possibility of her being cut off sooner if the operation were 
performed, after due deliberation, they concluded to have the 
operation. 
“ October 15th, 11 o’clock, A. m.—The temperature of the 
room having been brought to 80°, and everything in readiness, 
the patient, with great composure, took the position on the ta- 
ble, her shoulders supported by a pillow, and her feet resting 
on a chair. Anaesthesia having been induced by a mixture of 
ether and chloroform, I proceeded to operate, assisted by Pro- 
fessors Eve and Watson, and Dr. A vent, of Murfreesboro, and 
in presence of a number of physicians and medical students. 
An incision, seven inches in length, was made directly through 
the linea alba into the abdominal cavity. One vessel of con- 
siderable size was wounded, but ceased to bleed before the 
ligature was applied. The patient making some involuntary 
movements just as the incision into the cavity was effected, 
caused a large mass of the bowels to escape; Prof. Eve secured 
and covered them with a warm cloth. The hand was passed 
into the cavity, to discover whether the tumor was adherent 
or free. Fortunately, it had formed no adhesions, except at 
its lower part, and these were easily broken up, and the tumor 
brought through the incision. The pedicle was two or three 
inches wide, and about one inch thick. Several large vessels 
could be felt pulsating in it. A needle, armed with a firm 
strong ligature, was passed through the pedicle, an inch and a 
half from the tumor, and firmly tied by Prof. Eve, after which 
the tumor was removed. No hemorrhage followed. 36 
REPORT ON TENNESSEE SURGERY. 
“ After waiting a short time to see if any bleeding would 
occur, the stump of the pedicle was returned, and the ligatures 
brought out at the lower part of the wound. The bowels, 
after being gently sponged and cleared of all foreign matter, 
were replaced in the cavity of the abdomen, the wound 
brought together and retained by the interrupted sutures, 
placed about an inch apart, and supported by adhesive plaster 
and bandages. 
“ During the operation the pulse continued good, and no 
untoward symptom occurred. The anaesthesia, which had been 
profound, soon passed off, and our patient expressed herself as 
being comfortable. 
“ She was placed in bed, and one grain of sulph. morphia 
administered. Through the day she continued comfortable; 
had slight coldness and shivering, which soon passed off. 
Slight reaction in the evening; retention of urine; relieved 
by catheter; ordered one grain of morphine at bed-time. 
“ October 16, A. M.—Had passed a pleasant night; not much 
pain ; some nausea; no soreness of abdomen ; no swelling, and 
very little discharge from the incision; pulse 130; skin hot; 
no appetite; drew off 6 oz. of highly-colored urine. Ordered 
thin gruel for diet, warm fomentations to the abdomen, and 
continued the opiate. 
“ Evening.—In consequence of taking more opium than in- 
tended, she was partially narcotized during the day; pulse 
130 to 140; but firm; no abdominal swelling; very little dis- 
charge from the incision. Drew off urine. 
“ October 17.—She continued to sleep through the whole 
night, but was easily aroused this morning. Since daylight 
she has been vomiting a greenish fluid ; suffering pain in lower 
part of the abdomen; pulse very rapid; countenance anxious, 
and expressive of anguish; great tenderness of abdomen; 
limbs drawn up. Ordered calomel and opium through the 
day, and a large blister over whole abdomen. 
“ From this period she continued to grow worse, exhibiting 
all the signs of intense peritonitis, which resisted all our efforts, 
and on the evening of the fourth day she died. From the REPORT ON TENNESSEE SURGERY. 
37 
time of the operation till her death, I had the constant advice 
and assistance of Professors Eve and Watson, each of whom 
visited the patient two or three times a day. In consequence 
of being called off early the next morning, I did not make a 
post mortem examination. 
“ The tumor was oval in shape, firm and hard in consist- 
ence, measuring seven inches in the long diameter, and four in 
the transverse; weight, six and a half pounds. At its upper 
part is the small portion of pedicle, having several large ves- 
sels passing through it. A section of the tumor presented the 
usual fibro-cartilaginous appearance, to which class of tumors 
it belonged.” 
Prof. T. L. Madden, in 1859, performed the operation on a 
lady from , Tennessee, in the Shelby College Hospital. 
The tumor was unilocular, with adhesions. The patient made 
a rapid recovery. 
A surgeon from New York (name forgotten) visited a lady 
near Columbia, and extirpated an ovarian tumor in 1864. 
The patient died in a few moments after the operation was 
finished. 
Mrs. M , of Franklin, Tennessee, visited Boston in 
1865, and was relieved of a large ovarian cyst by Dr. IT. R. 
Storer. She returned to her home in a short time perfectly 
restored. 
Mrs. A , of Rutherford County, visited Louisville in 
the spring of 1864, and had an ovarian tumor extirpated by 
Prof. Henry Miller. She died on the third or fourth day, of 
peritonitis. 
In 1866, the writer performed his second operation on Mrs. 
C Carthage, Tennessee. Dr. W. D. Horton, who 
kindly watched the case, and kept accurate notes of it, fur- 
nishes the following report: 
Mrs. McC , Smith County, Tennessee, aged 41, married, 
never had children ; has had tumor four years; general health 
not good. 38 
REPORT ON TENNESSEE SURGERY. 
The operation was performed on the 23rd of May, 1866, in 
presence of Drs. Eve, Buchanan, Maney, and Horton. Great- 
est circumference, thirty-eight inches. Pulse before the ope- 
ration, 95; just after it, 110. The operation lasted forty mi- 
nutes ; the patient bore it well, being fully under the influence 
of sulphuric ether. A little brandy and water was given 
once, and repeated when she was removed from the table. 
The incision extended from a point one and a half inches 
below the umbilicus to within two inches of the symphysis 
pubes. On opening the peritoneum, a large quantity—esti- 
mated at six quarts—of ascitic fluid escaped. A tumor about 
the size of a child’s head was found on the left side, ruptured 
while breaking up some slight adhesions. Several quarts of 
dark gray gelatinous fluid escaped. This necessitated the 
opening out the abdominal cavity, which was carefully done. 
The sac was now pulled out, and its pedicle—the left broad 
ligament—transfixed with a needle, armed with double liga- 
ture, and each ligature, including half the pedicle, separately 
tied. The sac was then divided by scissors one inch above the 
ligatures. There being some hemorrhage, a second ligature 
was applied in the same manner as the first, but passed lower 
down. 
Another tumor, nearly the same size, was now discovered 
on the right side. It was punctured, and the contents care- 
fully evacuated; but there was more difficulty in drawing out 
the sac than was the case with the first, as the adhesions were 
much more extensive. After its adhesions were broken 
through, it was separated in the same manner as the first. 
The operation was now delayed some time by the hemorrhage 
which followed the rupture of the adhesions. After it had 
ceased, the two pedicles were drawn out of the lower part of 
the wound, and there fixed, by tying the ends of the ligatures 
over a director placed at right angles to the abdominal in- 
cision. 
The edges of the wound were now brought together, and 
retained by silver sutures, and the usual dressings applied and 
retained by a flannel (many-tailed) bandage. REPORT OX TENNESSEE SURGERY. 
39 
Shortly after she was put to bed, gave sulph. morphine 
gr. ss. 
2 p. m.—two hours after the operation.—Has been dozing 
most of the time; pulse 115; pretty comfortable, but com- 
plains of slight soreness; slight oozing from wound. Morph, 
sulph., gr. £. 
4.30 p. M. — Complaining of great pain. Gave morph, 
sulph. gr. 
9 P. m.—Severe pain and some nausea; gave morph, sulph. 
gr. ss. She vomited immediately, and felt great relief. The 
vomiting caused some flow of reddish fluid from the lower 
part of the wound. Pulse 126. Shortly after this she slept a 
little; on waking up she was free from pain ; the pulse was 
stronger, also the voice, and she was quite cheerful. 
A little before 12 p. m. the patient began to grow weaker, 
and the pulse rose to 145 beats. Gave sss. of brandy. 
At 12 o’clock drew 3v. of urine, and at 6 drew siii. 
A half hour after 12 repeated the brandy; vomited again. 
About 1 A. m., May 24th, there being no improvement in 
pulse, gave 3iss. champagne, which she immediately ejected. 
Hypodermic injection of sol. morph. (Magendies), gtt. x., over 
epigastrium ; became immediately quiet, and slept over three 
hours. 
At 4.30 A. m. she became very restless; pulse 160, and very 
weak. Gave wine again, and she again vomited. Urine 
drawn, about 3 ii. 
12 m.—Has been almost pulseless since daylight; extremi- 
ties cold ; face and neck covered with cold perspiration. Spt. 
ammon. aromat., in drachm doses, given three times every 
half hour; stopped on account of excessive vomiting. Beef 
tea and brandy every two hours, by rectum, which she re- 
tained. Mustard to epigastrium. But in spite of mustard 
frictions to extremities, hot bricks, hot cloths, &c., persistently 
applied, no symptom of reaction appeared. Urine drawn olf 
at 11 A. m.—3iss., dark and thick. 
5 p. m.—Worse; respiration more rapid—thoracic—30 to 
the minute; has been drowsy, but is now quite restless; con- 40 
REPORT ON TENNESSEE SURGERY. 
tinned nausea and vomiting; has taken small bits of ice on 
stomach, which she calls for frequently—nothing else. Evi- 
dently sinking fast. 
Died at 6.15 p. M. 
Dr. McCullough, of Trenton, Tennessee, removed a large 
cyst (441bs.) from a young lady of Gibson County, in 1870. 
The patient died in a short time. 
Dr. Murfree, of Murfreesboro’, operated on Mrs. C , of 
Rutherford County, in 1.871, and his patient recovered. He 
has kindly placed the report of the case at my disposal, as 
follows: 
Mrs. Joseph B. C , aged 30 years, of Wilson County, 
Tennessee, mother of two healthy children, came under my 
charge in the spring of 1871, for treatment for an abdominal 
tumor. 
The tumor had been discovered about ten years previously, 
and had regularly increased in size. For the last few years, 
she had suffered greatly from its presence; its weight was an- 
noying. There was slight disturbance of respiration, and 
constipated bowels; but above all, she suffered almost intole- 
rable pain from spasmodic contractions of the intestines. 
In the early formation of the tumor it was movable, and, 
by pressure with the hand, it could be made to readily glide 
from one side of the abdomen to the other. When she pre- 
sented herself for examination, a large, hard tumor was felt 
on the right side of the abdomen, in the lumbar region, on a 
line extending from the umbilicus to the anterior superior 
spinous of the right ilium. It was about the size of an ordi- 
nary foetal head, and entirely disconnected from the surround- 
ing tissues. The tumor was hard, inelastic, and unconnected. 
After a full and deliberate consultation by Drs. Crosthwait, 
Clayton, Fletcher, and myself, we unanimously concluded that 
the removal of the tumor was necessary. 
The lady had suffered so much, and her general health was 
so much impaired, that she expressed her willingness to sub- 
mit to any operation that offered a hope of relief. REPORT ON TENNESSEE SURGERY. 
41 
On the 26th of June, 1871, with the assistance of the above 
named gentlemen, I performed the operation. An incision 
was made over the tumor, about six inches in length, in the 
direction of the fibres of external oblique muscle, through the 
skin and cellular tissue. The muscular fibres were separated 
with the handle of the bistoury, as far as was practicable, and 
the groove director was used when the parts required to be in- 
cised. This incision was very carefully and cautiously con- 
ducted, the patient being fully under the influence of chloro- 
form. The peritoneum was raised upon the groove director, 
and divided. The omentum was gently pushed aside, which 
revealed the tumor, consisting of a cyst containing clear se- 
rum. The cyst was evacuated and destroyed. 
Another cyst was detected, situated lower in the cavity, but 
was so far from the incision as not to be readily reached, and 
it was not deemed prudent to extend the incision. 
The wound was now brought together by stitches carried 
through all the tissues, and its sides neatly co-adapted. Ad- 
hesive strips, extending several inches beyond the wound on 
both sides, were applied, and a soft compress and bandage 
completed the dressing. 
The patient was put in bed, and readily recovered from the 
influence of the chlonflform. She did well for the first two 
days, but on the third a diarrhcea took place, with some evi- 
dence of commencing peritonitis. On the fifth day, however, 
these symptoms subsided, and the patient began to recover. 
Suppuration was quite free. Cold-water dressing was applied 
continually after the third day. 
The patient recovered well. The sutures were removed, 
the wound cicatrized, and in two months the patient returned 
to her home greatly improved. 
In the fall, she, with her husband, removed to Illinois, tra- 
veling in a wagon. I heard from her during the month of 
February of this year (1871), at which time her health had 
greatly improved. 
It is proper to state that there was an error in our diagnosis 
—for we were all satisfied that it was a fibrous tumor, and did 42 
REPORT ON TENNESSEE SURGERY. 
not expeot to meet with a serous cyst. An exploring needle 
was passed into the tumor, but not penetrating the cyst, or 
from other causes, no serum escaped. 
In December, 1871, I performed my first successful opera- 
tion of ovariotomy. The following is the history of the 
case: 
Mrs. W , of McMinnville, Tennessee, a tall, well-formed 
lady, with fair complexion, light hair, and blue eyes, aged 28, 
married eleven years, without issue, consulted me early in the 
fall in reference to an enlargement of the abdomen. She had 
first noticed the swelling three years ago, at which time it 
gave rise to no uneasiness—was not tender nor painful. It 
gradually grew larger, but was still unaccompanied with pain 
or other distress, until within the last six months; since that 
time she has suffered very much from the pressure on the va- 
rious organs; her general health, which had been perfect, was 
beginning to give way, and her menstruation, which has never 
been regular, returning every three weeks, was very painful, 
but not excessive. 
Upon examination, I found the abdomen as large as at 
the full term of pregnancy, equally developed on both sides, 
smooth and uniform on its surface. By percussion, a distinct 
fluctuation was elicited, showing conclusively that the enlarge- 
ment was composed chiefly of fluid. By it, also, it was dis- 
covered that the whole surface of the enlargement was dull, 
proving that the fluid was contained in a sac situated anterior 
to the bowels. In fact, the exact boundaries and position of 
the tumor could be traced out by percussion, showing that all 
of the lower and lateral parts of the cavity was occupied by 
the sac, and that it reached up to the transverse arch of the 
colon. By grasping the walls of the abdomen in the hand, 
they could be made to slide over the tumor. This, in con- 
junction with the fact that the patient had always enjoyed 
good health, has never had pain or tenderness in the abdo- 
men, encouraged me in the hope that there were no adhesions. 
My diagnosis was, therefore, a unilocular ovarian cyst, free REPORT ON TENNESSEE SURGERY. 
43 
from adhesion, and probably originating from the right ova- 
rium. 
Feeling perfectly confident in my diagnosis, and the patient 
being in a good constitutional condition, I had no hesitation 
in advising her to submit to an operation for its removal; to 
which she cheerfully agreed. 
Accordingly, on the 1st of December, the atmosphere of the 
room having been rendered moist by the evaporation of water 
carbolized by the atomization of carbolic acid, and kept at a 
temperature of 80° Fahrenheit, and the patient having been 
carefully etherized by Prof. Bowling, the operation was done 
in the presence, and with the assistance, of Profs. Eve and 
Nichol, and Drs. Horton, Sneed, and Franklin. 
An incision, four inches in length, was made in the linea 
alba, about equally distant from the umbilicus and pubis— 
passing through the integument, superficial fascia, and a layer 
of fat. The other tissues were divided carefully on a grooved 
direction, in the usual manner. Upon opening the perito- 
neum, the white glistening walls of the cyst were exposed, 
over which numerous and large veins were seen meandering. 
The fingers, now passed into the incision, were swept over the 
anterior surface of the tumor, without finding any adhesions. 
The cyst being fixed* by tenacula, Spencer Wells’ trocar and 
canula was plunged in between the large veins, and the fluid 
carried off* through the tube attached to its extremity; about 
three gallons of a straw-colored fluid, not very thick, was dis- 
charged, when the cyst was easily drawn through the incision, 
the assistants pressing the edges of the incision firmly against 
the sac, so that not a drop of the fluid, or of blood, was ad- 
mitted into the peritoneal cavity. 
The pedicle of the sac was broad and thin, and originated 
from the right broad ligament. The left ovary was examined, 
and found perfectly healthy. The pedicle was perforated 
through its middle with a needle, armed with a stout double 
hempen ligature, and the two portions tied separately. It was 
divided with the 6craseur, about an inch from the ligatures. 
The stump of the pedicle was then drawn outward, and lodged 44 
REPORT ON TENNESSEE SURGERY. 
in the abdominal wound, where it was retained by a strong 
silver pin passed through the abdominal walls and its central 
portion, and fixed by the thread passed around it, as in the 
hair-lip suture. Thus the end of the stump, with its liga- 
tures, were entirely outside the abdomen. 
The union of the wound was then completed by two more 
pins passed through the abdominal walls (including the peri- 
toneum), with three silver sutures passed superficially between 
each pin. A compress, wet with a solution of carbolic acid, 
and a flannel bandage, finished the dressing. 
The ether had produced nausea and vomiting, when first 
administered, but afterwards had an admirable effect. The 
patient was quieted perfectly, and was carried to bed before 
its effects had been dissipated. The operation was completed 
in about ten minutes. 
The effects of the amesthetic passed off gradually, and the 
patient expressed herself as very comfortable. There was no 
violent shock, and no reaction ; her pulse, just after the opera- 
tion, was 85, and at night the same. She complained of slight 
pains, of a burning, stinging character, about the wound. 
Twenty-five drops of the tincture of opium was ordered every 
four hours, the catheter to be used every six hours, and perfect 
quietude enjoined. 
December 2nd, morning.—The patient slept nearly all night, 
and is feeling very well this morning; pulse 88, skin moist, 
tongue clean; has appetite. Catheter has been used twice; 
urine free. Wound looking well, and perfectly dry. 
It is useless to follow out the daily record of the case. It 
will be sufficient to say that the patient continued to do well, 
without a single bad symptom. On the fourth day she passed 
urine without the catheter, and continued to do so; her bowels 
acted voluntarily on the sixth. The pins and sutures were 
Removed on the seventh day, the wound having healed by the 
first intention, except immediately about the stump, which was 
in a sloughy condition, with some ulceration around. One of 
the ligatures came away on the sixteenth day; the other, with 
assistance, on the twentieth, at which time the wound around .REPORT ON TENNESSEE SURGERY. 
45 
the stump was nearly healed. She sat up on the sixteenth 
day, rose and moved about the room on the twenty-first, and 
in a few days had entirely recovered. 
The cyst, which was of good size, (it, with its contents, 
weighed twenty-five pounds,) presented thick, firm walls, 
white and glistening externally; smooth, vascular, and of a 
rose-tint internally. The fluid contained was of a straw-color, 
glutinous, but not thick, and measured more than three gal- 
lons. 
In March, 1872, Mrs. W , of Alexandria, who had 
several times consulted me in reference to a large abdominal 
tumor, hearing of the successful issue of the case above re- 
corded, sent for me to visit her at her home, and remove it, if 
I thought advisable. The history of her case is interesting, 
and I give it in full, as follows: 
Mrs. W , of Alexandria, Tennessee, aged 40 years, a 
spare tall lady, with dark hair and eyes, and the mother of 
five children, had suffered with a tumor of the abdomen for 
more than twelve years. When first noticed, it was not larger 
than an infant’s head, and was then situated in the right iliac 
region. It was firm, smooth on its surface, movable, and not 
sensitive upon pressure. It continued to grow until, in a few 
years, the abdomen had become as large as at the full term of 
pregnancy, and was irregularly nodulated on its surface. 
In 1861, she was first tapped by Drs. Thomas Sneed and 
McConnell, by which she was relieved of thirty or forty pounds 
of a thick glutinous fluid. The abdominal swelling disap- 
peared entirely, after the tapping, with the exception of a 
small hard lump in the right iliac region. 
The fluid gradually re-accumulated, and in about twelve 
months the enlargement was as great as before, and she had 
again to submit to the removal of the fluid. Almost every 
year, for the next three or four years, she has had to be tapped, 
in order to obtain relief. 
In the spring of 1865, she came to Nashville to consult Dr. 
McConnel, Dr. Eve, and myself, in reference to the extirpa- 46 
REPORT ON TENNESSEE SURGERY. 
tion of the diseased mass. It was decided to give her tempo- 
rary relief by tapping, and postpone the operation of removal. 
Six gallons of the thick glutinous fluid was removed. The 
small hard tumor that was discovered at the former tappings, 
was easily recognized, originating, apparently, from the right 
broad ligament. Up to this time, she had enjoyed the most 
perfect health, and had given birth, without difficulty, to seve- 
ral children. 
In the following year, 1866, she became enciente, which, 
with an increased accumulation in the sac, caused much dis- 
tress by the great distension. After mature deliberation, she 
was tapped, with great relief, and continued thus to her full 
term. 
After her confinement, the fluid seemed to gather more ra- 
pidly, and she was tapped every few months. In fact, during 
the last year it was deemed necessary to withdraw the fluid 
every month or six weeks. Her health became very poor; 
emaciation was going on rapidly, and there was a certainty of 
death in a short time, unless permanent relief was obtained. 
I was summoned by letter to meet Drs. Sneed and Tubb at 
the house of Captain W , on the 5th of February, for the 
purpose of considering the propriety of a radical operation. 
I failed to meet the engagement. The patient was so much 
distressed by the great accumulation, that her physicians tapped 
her, and made another engagement for me, on the 6th of March, 
as it was always a week or ten days before she recovered from 
the effect of the tapping. 
On the day appointed, I visited Mrs. W at her home, 
near Alexandria. I found her a tall, well-formed lady, greatly 
emaciated, yet able to be up and attend to her domestic duties, 
with an enormous abdomen, although she had been tapped 
only a month since, and eight gallons of fluid withdrawn. 
Upon placing her in the horizontal position, and exposing the 
abdomen, I ascertained that the whole cavity of the abdomen 
was filled with the morbid growth. Its surface was smooth, 
with here and there an irregularity; it was dull on percussion, 
with distinct fluctuation. There was no pushing out of its 47 
REPORT ON TENNESSEE SURGERY. 
lateral walls, no pouching in Douglas’s cul de sac. The walls 
of the abdomen were closely adherent to the tumor in front, 
and could not be rolled over it with the hand. A tape-line 
around the upper part of the abdomen proved its circumfer- 
ence to be fifty inches. I concurred with her most excellent 
physicians, Drs. Sneed and Tubb, in the opinion that it was a 
case of multilocular ovarian tumor, extensively adherent, and 
that the only hope for relief was in its extirpation. 
The patient, after hearing a full and frank explanation of 
the dangers and difficulties of the operation, without a mo- 
ment’s hesitation determined to have it done. 
On the next morning, the 7th of March, suitable prepara- 
tions having been made, and assisted by Drs. Sneed and Tubb, 
her medical attendants, Drs. Fletcher and Sneed Jr., of Alex- 
andria, and Dr. J. S. Poynar, of Nashville, who had accom- 
panied me, Mrs. W was placed on the table and brought 
under the full effects of ether by Dr. Fletcher, who, during 
the whole time, managed it with great skill. 
An incision was made in the linea alba, from four inches 
below the umbilicus to within three of the pubis. By a few 
strokes of the knife, the tissues were divided, and the bluish 
surface of the peritoneum exposed. It was found so closely 
adherent to the walls of the tumor, caused, doubtless, by the 
repeated tappings, that it was very difficult to separate them. 
In endeavoring to do so, an opening was made into the sac, 
and the thick glutinous fluid poured out freely. Dr. Poynar, 
with his hands on each side of the incision, pressed the abdo- 
minal walls close to the collapsing tumor, and thus prevented 
the fluid from entering the peritoneal cavity. After careful 
manipulation, a finger was insinuated between the peritoneum 
and sac, when the adhesions on the anterior surface were di- 
vided by careful dissection, until the hand could be passed in. 
Extensive and almost continuous adhesions were found on the 
anterior and left lateral portions of the tumor. Those on the 
superior and lateral surface were not very firm, and were easily 
broken off by the hand; but those on the lower anterior as- 
pect were firm and strong, requiring a separation with the 48 
REPORT ON TENNESSEE SURGERY. 
scalpel. The omentum majus was extensively attached to its 
upper part, but was carefully separated; very broad and 
strong adhesions to the abdominal wall were encountered on 
the right side, and to the coecum and vermiform process; 
while below, the tumor was closely connected with the blad- 
der, uterus, and broad ligament of left side. There were also 
two or three long bands attaching it to the posterior walls ol 
the abdomen. 
After drawing olf the thick fluid from two of the largest 
cysts, by means of a Spencer Wells trocar, I severed these ex- 
tensive adhesions with the hand, scalpel, and eeraseur, and 
turned the immense cyst out of the abdomen. The pedicle, 
which was large, and contained arteries equal in size to a crow’s 
quill, came from the right side. It was secured temporarily 
with a strong hempen ligature, and separated. 
So well had Dr. Poynar held the walls of the abdomen to 
the surface of the cyst, that very little, if any, of the fluid, 
escaped into the cavity; but the blood from arteries divided 
in separating the adhesions, accumulated in the pelvic cavity, 
and between the folds of the bowels, requiring the free use of 
the sponge. A liberal use was made of Peaslee’s fluid serum, 
whenever the hand was carried into the cavity, and while the 
blood was being sponged out. 
It was then discovered that two or three vessels in the torn 
portion of the omentum—two from the adhesion connected 
with the bladder, and one from that of the vermiform pro- 
cess, were pouring out blood slowly, but constantly, and caus- 
ing an accumulation of blood in the cavity. These were all 
secured by delicate silver ligatures, and returned into the ab- 
domen. 
All hemorrhage having now ceased, the abdominal and 
pelvic cavities were thoroughly cleansed. After waiting a few 
minutes to make sure that no source of hemorrhage had been 
overlooked, the pedicle was brought out the lower part of the 
wound, and secured by Dawson’s clamp; after which an acu- 
pressure-pin was passed deeply in the tissues, from side to side, 
transfixing the pedicle below the clamp; over this the figure REPORT ON TENNESSEE SURGERY. 
49 
of 8 suture was passed. The wound was then closed by silver 
sutures passed through the entire wall, including the perito- 
neum. A flannel compress and bandage was applied, and the 
patient placed in bed. 
She bore the operation remarkably well, the pulse never 
flagging for a moment. After she was in bed, she came from 
under the influence of the anaesthetic pleasantly—was cheerful 
and happy. There was very little depression from shock. 
I remained with her until 2 o’clock the next morning, and 
with the exception of slight burning pain in the wound, she 
suffered none; her urine passed off freely through the self- 
retaining catheter; she took some light nourishment, and slept 
well under one-sixteenth of a grain of morphia. 
The neoplasm, upon examination after removal, was found 
to be a multilocular cyst of immense size. Its walls were 
thick at some points, thin at others; white and shining exter- 
nally, smooth, polished, and vascular, internally. In the por- 
tion of the wall near the pedicle were two or three plates of 
bony formation,.several inches in diameter. 
The greater part of the tumor wras made up of three large 
cysts, while in the lower portion were a great many smaller, 
varying in size, the largest being the size of a hen’s egg. 
The fluid contained rin the cyst, the greater part of which 
had been removed during the operation, was straw-colored, 
thick, gelatinous. 
The cyst, with its fluid-contents, weighed eighty-five pounds. 
Letters from her attending physicians, from day to day, in- 
formed me of her steady improvement and ultimate recovery, 
with scarcely an unpleasant symptom. 
A few months after the preceding case, I performed ova- 
riotomy again with success. The patient, Mrs, R of our 50 
REPORT ON TENNESSEE SURGERY. 
County of Davidson, a tall, delicate-looking lady, 35 years of 
age, the mother of five children, the youngest only four months 
old, had observed, after her fourth pregnancy, that her abdomen 
remained large and protuberant, and that it increased gradu- 
ally in size. Her general health, however, continued good, 
and she paid but little attention to the swelling. She again 
became pregnant, and the swelling, which had before not been 
very large, became so increased in size that she was alarmed, 
and consulted her physician, who told her that she had ascites, 
and gave medicine for that disease, of course without avail. 
She became enormously large before the birth of the baby, 
and suffered greatly from the distention of the abdominal 
walls. Her labor, which came on at full term, was natural, 
and of short duration. I had been frequently consulted in 
regard to her case, but had not visited her until a few days 
after the birth of the child. At that visit I made a thorough 
examination of the case, and satisfied myself that she' had 
a large ovarian cyst, unilocular, and adherent, at least, to the 
anterior wall of the abdomen. She was advised to wean the 
babe, and, after she had fully recovered from her puerperal 
state, to have the tumor extirpated, to which she cheerfully 
assented. 
Accordingly, in October last, she came to the city, and 
placed herself under my care. After thorough preparation, 
the operation was performed in the usual manner. A large, 
thick, unilocular cyst, filled with dark treacle-like fluid, was 
turned out, after breaking up extensive adhesions on its ante- 
rior and lateral parts. Its pedicle, which was broad and vas- 
cular, was secured with Dawson’s clamp. 
The patient was put to bed in half an hour after she took 
her position on the table, the operation lasting not more than 
ten minutes. 
She had no shock, nor other troublesome symptom, but re- 
covered fully, and was up in three weeks. 
Thus it will be seen that only twelve operations of ova- 
riotomy have been performed on patients of our State. .REPORT ON TENNESSEE SURGERY. 
51 
The whole number is as follows: 
OPERATOR. 
CASES. 
SUCCESSFUL. 
UNSUCCESSFUL. 
Dr. Ephraim McDowell 
1 ... 
1 
0 
Prof. H. Miller 
1 ... 
0 
1 
Dr. H. R. Storer 
1 ... 
1 
0 
Some Surgeon of New York. 
1 ... 
0 
1 
Prof. T. L. Maddin 
1 ... 
1 
0 
Dr. McCollough 
1 ... 
0 
1 
Dr. Murfree 
1 ... 
1 
0 
Dr. W. T. Briggs 
5.... 
3 
2 
Total 1 
12 ... 
7 
5 
The above table shows a pretty high rate of mortality, but 
it will be remembered that only forlorn cases—cases of long 
standing, that were already nearly dead from the disease— 
submitted to the operation. Besides, it is a well-established 
fact that the early operations of every surgeon are least suc- 
cessful. So, as the first operations of our State do not present 
a very good showing, it is to be hoped that the next twelve 
cases will give us not more than the usual death-rate—that is, 
one to two and a half tor three. 
It is generally believed that, while ovariotomy is necessarily 
a very fatal operation, it is one easy of performance, and that 
any one of ordinary skill can do it. There never was a 
greater mistake. Prof.. Thomas, in his most excellent work 
On the Diseases of Women, says: 
“ The operation of ovariotomy is at present, in this country, 
often performed by men inexperienced in the diagnosis and 
treatment of ovarian tumors. The statistics of seme of the 
best operators prove that they have been progressively suc- 
cessful, as they have advanced in experience, and learned to 
avoid the dangers attendant upon the procedure, and we must 
conclude that they who operate for the first or second time, 
must damage the array of reported cases, and increase the rate 
of mortality. I know full well that it may be objected to this 52 
REPOET ON TENNESSEE SURGERY. 
statement, that if inexperienced men never operated, where 
would our supply of new surgeons come from ? In reply to 
this I would remark, that if the professional relations of any 
man make it likely that he will be frequently called upon to 
perform this or any other operation, he should prepare himself 
to meet the demand upon him ; but I cannot think it incum- 
bent on any practitioner, upon whom no such demand is likely 
to be made, to undertake so formidable an operation, if the 
services of skilful and experienced men be attainable for its 
perfoTiTOance. I sincerely believe, as the result of observation, 
that the third influence which I have stated as marring the 
statistics of the subject, is by no means an insignificant one, 
at least in the United States. My impression is that if the 
histories of all the single operations performed by different 
practitioners in this country were published, they would pre- 
sent a lengthy, and by no means pleasing, exhibit.” 
Certainly there is no operation that requires more attention 
to detail—none that is more likely to be followed by sad re- 
sults—if every point is not attended to, from the very first 
incision to the final dressing of the wound; nor is the after- 
treatment of less importance. With strict attention to these 
points, the mortality from ovariotomy should not be greater 
than that from most other great operations in surgery. 
The various other operative methods which have been pro- 
posed and tried by the profession, for the cure of ovarian tu- 
mors, have not been resorted to in our State. Oftentimes, 
under a mistaken diagnosis, medical treatment has been used 
very assiduously, until it was found that no impression had 
been made on the disease, but, on the other hand, that great 
injury had been done to the general system. 
Tapping is then often resorted to, with, usually, temporary 
relief, and is repeated every month or two until the patient, 
exhausted by the great drain on the system, dies. 
As a general rule, I believe that it would be better if tap- 
ping were not resorted to, except for the purpose of diagnosis. 
Not that I believe it so dangerous an operation as some of our 
authors imagine; for, of the many I have submitted to it REPORT ON TENNESSEE SURGERY. 
53 
myself, and of others 1 have seen do it, 1 have never yet met 
with, or seen, an unpleasant result. It is sometimes so ur- 
gently demanded to ward off threatened dissolution, and to 
alleviate suffering, that it cannot be entirely dispensed with. 
And in a few exceptional cases it has been followed by a per- 
fect cure. It is probably only in cases of cyst of the broad 
ligament that such a result follows. 
In 1856, I saw a case, with the'late Prof. A. H. Buchanan, of 
an encysted dropsy of the left ovary,.or broad ligament, which 
was tapped, giving exit to a thin clear serum, amounting to 
several gallons. The fluid never re-accumulated, and the pa- 
tient has remained in perfect health since. 
During last summer, I was invited to visit a case in con- 
sultation with Drs. C. K. Winston and Buist. The lady, aged 
26, was the mother of one child, and had noticed a swelling 
in her right side some months previously, which had grown 
rapidly, and attained to considerable size. At first, men- 
struation was regular and her health good, but for six months 
her periods had ceased, and she had, in the last month or two, 
increased in size so rapidly that she had attained an enormous 
magnitude; and the swelling was accompanied with so much 
discomfort, and with so great a difficulty of respiration, that 
relief in some form was urgently demanded. 
Upon careful examination, I was satisfied that she was the 
subject of an ovarian tumor, and was pregnant. She was 
tapped in the usual way, and four gallons of a thick, gelati- 
nous, straw-colored fluid, was withdrawn, with entire relief to 
all the urgent symptoms. She went to term in a pretty fair 
condition, gave birth to twins, and, to our great relief, the 
tumor had entirely disappeared; nor has there been any re- 
appearance. 
In this case, the cure was doubtless the result of pressure 
of the growing uterus on the emptied sac, causing its entire 
obliteration. 
I have met with two cases of rupture of the cyst, in both of 
which death ensued in a very short time. 
The first, a delicate lady, about 60 years of age, with a mo- 54 
REPORT ON TENNESSEE SURGERY. 
derate sized cyst, in stepping from her carriage, fell, and struck 
her abdomen on the edge of the curb stone. She did not com- 
plain much at the moment, but, in a few hours, she was seized 
with vomiting, accompanied with great prostration of all the 
vital powers, and died in six or eight hours. 
The second was a middle aged lady, with a small cyst, who, 
during an attack of dysentery, threw herself violently on the 
bed, after a very painful action from the bowels, the bed-rail 
striking on the most prominent part of the tumor. She was 
at once taken with vomiting, with great pain throughout the 
abdomen, and great prostration of the vital powers. She died 
the following night. 
In neither case was a post mortem allowed; but the great 
and sudden shock to the system, together with the disappear- 
ance of the tumor, satisfied me of the nature of the trouble in 
both. REPORT ON TENNESSEE SURGERY. 
55 
VESICO-VAGINAL FISTULA. 
In a clinical lecture to the Summer Class of 1868, I said 
that there were not less than one hundred cases of vesico- 
vaginal fistula in our State. It was thought, at the time, to 
be an exaggeration, but I have since relieved so large a 
number, and have received communications from so many 
others, that I am sure I did not exaggerate. 
Unfortunately, our poor women are, perhaps, in a ma- 
jority of cases, entrusted to female midwives, who are igno- 
rant of every principle of the obstetric art, and whose only 
motto is to wait, in every case, for the efforts of nature to re- 
lieve the patient, without a knowledge of any mode of relief, 
(except, in a few instances, the administration of ergot,) or of 
the time when relief should be given. It is not astonishing, 
then, that we have so many cases; in fact, it is somewhat 
strange that cases of injury of the vesico-vaginal septum do 
not occur more frequently. Nature is, however, so admirable 
in all her parturient processes, that that great function is car- 
ried to a safe termination, both as regards mother and child, 
in a large majority of cases. The occurrence of vesico-vagi- 
nal or vesico-rectal fistula is exceedingly rare in comparison 
with the great number of cases of labor; yet, as I have men- 
tioned, they are sufficiently common. 
The most common cause of this disease is pressure on the 
vesico-vaginal septum, by the child’s head being detained too 
long in the pelvic excavation. When there is the slightest 
disproportion between the child’s head and the maternal 
pelvis, when there is mnl-presentation of the child’s head, or 
when the mechanism of labor does not proceed regularly, the 
active pains force the presentation against the septum so con- 56 
REPORT ON TENNESSEE SURGERY. 
tinuously, or with such violence, as, either by the disturbance 
of the circulation and innervation, to cause a slough or to set 
up an acute vaginitis of a high grade, which, at the end of 
several weeks, may terminate in a slough of sufficient thick- 
ness to involve the whole septum. In rapid delivery, either 
natural or artiticial, a portion of the vagina may be caught 
and pressed to such an extent as to lead to the formation of a 
fistula. 
Obstetric manipulation, either manual or instrumental, may 
produce the accident, by lacerating or contusing the vagina, or 
by setting up such an inflammation as will terminate in the 
destruction of a portion of the vaginal walls. But it is pro- 
bable that many cases attributed to this cause are really the 
result of delay in their employment. 
There is a disposition on the part of many accoucheurs to 
postpone the use of the instruments in the hope that the natu- 
ral pains will overcome the difficulty. The old aphorism that 
“ meddlesome midwifery is bad,” has caused many fistulse. 
For while this maxim, so strongly impressed upon the mind 
of the practitioner, is inducing him to hesitate for fear he will 
be meddlesome, the violent and prolonged pressure is causing 
such changes in the vaginal walls as will result in fistula; and 
when, at last, a resort to instruments can be no longer delayed, 
the unfortunate result is attributed to them, and not to the 
pressure exerted by the child’s head; whereas, if timely aid 
had been given, in many cases, all trouble would have been 
prevented. 
Other causes, besides those mentioned, may produce fistulse. 
Idiopathic vaginitis sometimes results in that way; the pres- 
sure from a pessary, or large calculus, may cause an opening 
in the septum; ulceration, either cancerous or syphilitic, often 
destroys the walls between the canals. 
From whatever cause it may come, a patient suffering from 
vesico-vaginal fistula is truly an object of commiseration. 
The urine passing over tissues not prepared by nature to bear 
it, inflammation of the part results, the vagina becomes red, 
swollen, very tender, and covered with urinary concretions; REPORT ON TENNESSEE SURGERY. 
57 
the vulva, perineum, thighs, and buttocks, are red, excoriated, 
swollen, and covered with a vesicular eruption, and from the 
clothes and body arise such an unpleasant odor of decomposing 
urine, that the poor sufferer is prevented from entering society 
or from enjoying the pleasures of the family circle, and is even 
regarded by the husband with feelings akin to disgust. 
Such a condition could not fail to enlist the sympathy of the 
physician and surgeon, and cause him to make strenuous 
efforts for its relief. 
From an early period we have accounts of persevering and 
methodical attempts to cure the distressing malady. The at- 
tention of Ambrose Pare was directed to it, and he tried its 
cure by operation in 1570. In 1663, Roonlmysen, an eminent 
practitioner of Amsterdam, proposed to treat vesico-vaginal 
fistula on the same surgical principle as harelip, viz., by par- 
ing the edges, of the fistula, and bringing them together with 
silk sutures, but there is no evidence that he ever put his pro- 
position into practice. 
In 1720, Voelter, of Wurtemburg, and Fatio, of Basle, 
carried out the suggestion of Roonlmysen, but failed to effect 
a cure in both cases. 
The procedure fell into oblivion until Naegle, of Heidclburg, 
recalled the attention of the profession to it in 1812, after 
which success occasionally attended this method, but most ge- 
nerally failure was the result. 
In 1829, Roux, of Paris, tried the twisted suture, with me- 
tallic bars and ordinary thread. 
In 1834, Gosset, of London, employed the knee-elbow posi- 
tion, the lever speculum, the metallic suture, and the perma- 
nent catheter; but his suggestion did not impress the pro- 
fession. 
In 1839, Hayward, of Boston, reported three cases cured by 
vivifying the vaginal margin of the fistula, and closing it with 
silk suture. 
In 1846, Metzler, of Prague, used the lever speculum, knee- 
elbow position, gilded needle, perforated shot, and the perma- 
nent catheter. 58 
REPORT ON TENNESSEE SURGERY. 
In 1847, Mettauer, a distinguished surgeon of Virginia, 
after using the leaden suture and the permanent catheter with 
great success, made the statement that, in his opinion, every 
case of vesico-vaginal fistula should be cured, and that his 
success justified the assertion. 
Previous to 1852, however, most surgeons had despaired of be- 
ing able to effect a radical cure of vesico-vaginal fistulse. Cooper, 
Abernathy, Dieffenbach, Dupuytren, Desault, Lawrence, Lallc- 
mand, Guthrie, and Lisfrane, exhausted all their resources in 
vain attempts to close the vicarious opening. Vidal said : “ I 
do not believe that there exists, in the science of surgery, a 
well-authenticated complete cure of vesico-vaginal fistula—a 
fistula due to a loss of substance from the bas fond of the 
bladder.” 
Velpeau, than whom I acknowledge no higher authority in 
surgery, said of these fistulfe: “ To attach the borders of an 
opening, when we do not know where to grasp them; to shut 
it up by means of needles or thread, when we have no point 
apparently to secure them ; to act on a movable partition 
placed between two cavities, hidden from our sight, and upon 
which we can scarcely find any purchase, seems to be calculated 
to have no other result than to cause unnecessary suffering to 
the patient.” 
Sir James Y. Simpson, of Edinburgh, said : “1 have often 
seen cases operated on, and in many different ways, and have 
sometimes tried to operate myself; but, until lately, I never 
saw a cure.” 
Matters are now, however, happily changed ; almost every 
case of vesico-vaginal fistula is curable, unless there is some 
constitutional vice to interfere with the processes of adhesion. 
Success is the rule, failure the exception. 
The transcendant glory of having discovered and perfected 
a method by which vesico-vaginal fistula may be cured with 
as much certainty as surgical diseases belongs to our own 
countryman, and a native of our own sunny South, J. Marion 
Sims, and a just pride swells the heart of every American 
surgeon when he refers to his brilliant achievements in uterine REPORT ON TENNESSEE SURGERY. 
59 
surgery. Dr. Sims, in 1852, published his experience in the 
treatment of this intractable malady in the American Journal 
of the Medical Sciences, and claimed to have discovered, first, 
the lever speculum by which the vagina could be distended 
and explored ; second, the silver suture, which, producing no 
irritation or ulceration, unless the parts held together were 
very much stretched, could, therefore, keep the edges of the 
fistula in close contact for an indefinite length of time; third, 
the sigmoid catheter, which, being self-retaining, would keep 
the bladder empty during the process of cure. There can be 
no question that these are the means by which vesieo-vaginal 
fistula may be easily cured, and they have been unanimously 
adopted throughout the civilized world. 
A history of this important discovery will no doubt be in- 
teresting to you, gentlemen, and to all practitioners, and there- 
fore I make the following extract from the address of Dr. 
Sims, delivered before the Academy of Medicine, in New 
York: 
“ For the first ten years of my professional life, the treat- 
ment of any disease peculiar to woman was ignored as far as 
possible. Surgery was my ambition, and it was gratified, for 
my head and heart and hands were full. This was due, not 
to any particular merit on my part, but to a fortunate position 
among a liberal and enlightened profession in the noble State 
of Alabama, a profession which, for intelligence and a chival- 
ric esprit de corps, is not behind that of any other State in 
this great confederacy. 
“ Thus situated, a case of vesieo-vaginal fistula was sent to 
me in July, 1845, which was investigated more because I had 
a surgical reputation to sustain than from any particular in- 
terest in the subject. It was, of course, dismissed as incura- 
ble. Two months after this another presented, which received 
a like verdict. Two cases in such quick succession, in a coun- 
try town, at that time, formed an era in one’s life. Imagine 
my surprise when, a few weeks after this, a gentleman called 
to consult me about a third case. I told him promptly that it 
was useless to sond Iier to me, as the injury was wholly incu- 60 
EE PORT ON TENNESSEE SURGERY. 
rable. He suggested that there was a possibility of my being 
mistaken in my ready diagnosis, when I replied that a leakage 
of urine following a protracted labor, was an infallible sign of 
a vesical fistula. But my remonstrances were unavailing, for 
he sent her to town in spite of me. 
“ I investigated the case thoroughly, reading every author 
I could find on the subject, but to no purpose, for all was 
darkness and confusion ; and thus I was on the eve of sending 
her home, when a little incident occurred that formed the 
turning-point of my professional career, and without which, 
the discovery that has engaged our attention to-night would 
not have been made. 
“ A lady was riding in the suburbs of the city of Montgo- 
mery, Alabama; her pony, taking fright, jumped suddenly, 
when she fell to the ground, striking on the sacrum. I saw 
her soon afterward ; her sufferings were extreme, as she had 
rectal and vesical tenesmus from a sudden retroversion of the 
uterus. To. replace the dislocated organ was the indication of 
relief. Following the teachings of learned professors, the pa- 
tient (covered with a sheet) was placed on the knees, with the 
pelvis elevated and the thorax depressed, when, by manipula- 
tion through the vagina and rectum, I hoped to replace it. 
“ Introducing the right fore-finger into the vagina, but re- 
membering how a nervous gentleman had suffered a few days 
before from a rectal examination, I concluded not to subject 
this lady to the same disagreeable operation, particularly as it 
seemed possible to overcome the difficulty if my finger was 
only a little longer. My middle finger is more than half an 
inch longer than the index, but it could not be used without 
its fellow; and thus the two were passed, and in a few seconds 
I could not touch the uterus, or even the walls of the vagina, 
and the fingers were swept round, as it were, ‘ in empty no- 
thingness/ which was to me, at the moment, a most puzzling 
mystery; and, while I was endeavoring to unravel it, my pa- 
tient exclaimed, ‘ Oh, doctor, I am relieved !’ My office was 
ended, for my mission was to relieve her, but how it was done 
I could not understand. While I stood doubting and won- REPORT ON TENNESSEE SURGERY. 
61 
dering, my patient, now easy, threw herself down on her side, 
producing thereby a sudden escapement of air from the va- 
gina ; and thus the whole mystery of the accidendal reduction 
of the dislocated uterus was explained on the principle of at- 
mospheric pressure. 
“And what was its rationale? When the patient was in 
the position described, there being a natural tendency of the 
pelvic viscera to gravitate toward the epigastric region, it 
would require no great vis a tergo to produce the desired re- 
sult in a recent case of this kind. One finger, however, was 
not long enough to throw the organ up, nor were the two; but 
when they were both introduced, in my varying manipulations 
and strenuous efforts, the hand was accidentally turned with 
its palm downward, which thus brought the broad dorsal sur- 
face of the two parallel fingers in contact with the vulvar 
commissure, thereby elevating the perineum and expanding 
the sphincter muscle, which allowed the air to rush into the 
vagina under the palmar surface of the fingers, where, by its 
mechanical pressure of fifteen pounds to the square inch, this 
canal was dilated like a balloon, and the uterus replaced by 
its pressure alone. This accident—there are no accidents in 
the providence of God!—this incident, then, occurred just at 
the right time. Had it happened six months sooner, its im- 
portance would not have been duly appreciated. Had it been 
six days later, the golden opportunity for its practical applica- 
tion would have been lost forever; for my mind had been 
sorely perplexed by the obscurity surrounding the investiga- 
tion of the cases alluded to, and I said to myself: ‘ If, by this 
position, the atmospheric air can be made to dilate the vagina 
to such an extent, even with a force strong enough to reduce a 
dislocated uterus, why will not the same principle allow me to 
explore this region, and examine accurately any injury or dis- 
ease to which it may be liable?’ 
“ Full of thought, I hurried home, and the patient (with 
vesico-vaginal fistula), who was to have left on the next day, 
was placed in the position described, with an assistant on each 
side to elevate and retract the nates. I cannot, nor is it need- 62 
REPORT ON TENNESSEE SURGERY. 
ful to, describe my emotions, when the air rushed in and di- 
lated the vagina to its greatest capacity, whereby its whole 
surface was seen at one view, for the first time, by any mortal 
man. With this sudden flash of light, with the fistulous open- 
ing seen in its proper relations, seemingly without any appre- 
ciable process of ratiocination, all the principles of the opera- 
tion were presented to my mind as clearly as at this time. 
And thus in a moment, in the twinkling of an eye, new hopes 
and new aspirations filled my soul; for a flood of dazzling 
light had suddenly burst upon my enraptured vision, and I 
saw in the distance the great and glorious triumph that await- 
ed determined and persevering effort. From this moment my 
high resolve was taken; nor did I think or care for the per- 
sonal sacrifices I should have to make. I thought only of re- 
lieving the loveliest of all God’s creation of one of the most 
loathsome maladies that can possibly befall poor human na- 
ture ; and in this I honestly confess that I was stimulated by 
feelings of national pride, as well as by a desire to advance 
our glorious profession. 
“ Full of sympathy and enthusiasm, thus all at once I found 
myself running headlong after the very class of sufferers that 
I had, all my professional life, most studiously avoided. Ran- 
sacking the country around, my medical brethren soon disco- 
vered, and placed at my disposal, some seven or eight cases of 
vesico-vaginal fistula that had been quietly laid up as incura- 
ble. Building a little hospital as a special field of experiment, 
I readily got control of these cases, all of them healthy young 
negro women; promising to perform no operation that would 
endanger life or render their condition any worse. Having 
no proper instruments and no instrument-maker, dentists, 
jewelers, and blacksmiths, were laid under contribution, and 
soon such rude instruments were made as were suggested by 
the peculiar wants of individual cases. This occupied a pe- 
riod from the 9th of December, 1845, to the 10th of January, 
1846, when the first operation was performed. 
“ Several medical friends, among whom were Drs. Boling, 
Holt, Ames, Baldwin, Jones, McWhorter, and Henry, were REPORT ON TENNESSEE SURGERY. 
63 
invited to the inauguration of the experimental series. When 
the mechanical contrivances were exhibited, the peculiarities 
of each case pointed out, and the principles of the operation 
explained, they thought my plan of procedure promised well, 
while some were but little less enthusiastic than myself in 
hopes for the future. 
“ The first was a very simple case, and one that any tyro in 
surgery could now cure in a week’s time. The fistula was an 
inch and one-quarter long, transverse, in the base of the blad- 
der, with an abundance of tissue. Its edges were accurately 
adjusted, and I expected to effect at once a magical cure; but, 
greatly to my surprise and mortification, it was a failure. 
However, the size of the opening was reduced from that to 
one not larger than a No. 4 bougie; this encouraged me con- 
siderably, and the same operation was tried on another case, 
with a like unfortunate result; and after this, with various 
and constantly-varied modifications on others, till each one 
had suffered numerous operations, but all to no purpose. 
“ And thus I worked on, not for weeks and months, but for 
long weary years, before a single case was cured. My repeated 
failures brought a degree of anguish that I cannot now depict, 
even were it desirable. All my spare time was given to the 
development of a single idea, the seemingly visionary one, of 
curing this sad affliction, which not unfrequently follows the 
fulfillment of the law pronounced by an offended God, when 
he said to the woman : ‘ In sorrow and suffering thou slialt 
bring forth children.’ 
“ Soon my friends began to despair of my efforts, and, one 
by one, became tired of such profitless work. At last Dr. B. 
R. Jones, my partner, an accomplished physician, who had 
stood firmly by, giving his valuable advice and assistance, im- 
portuned me to cease my efforts; thus opposed at home, and 
deserted by the professional brethren who once cheered me on 
by their personal presence, I now stood alone—alone, did I 
say ? No! I was not alone, for I felt that I had a mission, if 
not of a divine character, at least but little short of it—of di- 
vine origin. I felt that the God who had called me to this 64 
REPORT ON TENNESSEE SURGERY. 
good work, and inspired me with new views for its accom- 
plishment, was with me, and would not desert me. I could 
not have ceased my labors if I had tried, for something told 
me that the fullness of time had arrived, that the work had to 
be done, and that, if I should fail, God, in his wisdom, would 
raise up some one as an instrument to carry it forward to a 
glorious consummation. I was not alone, then; nor was I 
alone in another sense, for I had succeeded in infusing my 
own courage and enthusiasm into the hearts of the half dozen 
sufferers who looked to me for help, and implored me to repeat 
operations so tedious, and, at that time, often so painful, that 
none but a woman could have borne them. 
“ To the indomitable courage of these long-sutfering women, 
more than to any other single circumstance, is the world in- 
debted for the results of these persevering efforts. Had they 
faltered, then would woman have continued to suffer from the 
dreadful injuries produced by protracted parturition, and then 
should the broad domain of surgery not have known one of 
the most useful improvements that shall forever hereafter grace 
its annals. 
“ In my first experiments the quilled suture was used, se- 
curing the ligatures by passing them through little canulte 
that projected from the vulva. The canulse were firmly sol- 
dered to the proximal quill, and, when the ligatures were 
tightened and wrapped round the end that projected from the 
vagina, the fistulous edges were neatly coaptated by the qnills. 
This is introduced merely to show the slow degrees by which 
practical truths are sometimes developed. After using this 
machine, variously modified, for nearly three years, giving 
attention, mostly, to the perfection of the self-retaining cathe- 
ter, I at last concluded that the projecting canulfe were a chief 
cause of failure, and consequently determined to dispense with 
them. But how to secure the ligatures was the question. A 
detail of the numberless expedients resorted to is useless; suf- 
fice it to say that I was at last driven completely to the wall. 
I had resolved never to repeat another operation till I had 
devised some plan of fastening the quill suture without the REPORT ON TENNESSEE SURGERY. 
65 
canulse; of tying a knot where I conkl not reach it with the 
fingers. Thus ray brain was sorely puzzled ; I had not per- 
formed an operation for nearly six weeks, and my devoted pa- 
tients were begging me, from day to day, to 1 try only one 
more time.’ Notwithstanding their importunities, I had de- 
termined, first, to invent a knot for my sutures; but it seemed 
that my usual readiness of expedient had now deserted me. 
My brain was oppressed; my heart was heavy; but never, for 
one moment, did I despair of eventual success. 
“ At last I happened to remember that, when a boy, I used 
to make sinkers to my fishing-lines by cutting a shot half in 
two, laying the line in the cut, and then compressing the shot 
on it with my teeth. I cannot express the delight that filled 
my heart at this simple suggestion. The idea occurred to me 
on the night of the 14th of November, 1848. The contem- 
plation of its beauty, simplicity, and perfect adaptation to the 
purpose, gave me a sleepless night; for there I lay, with ethe- 
realized brain, performing, in imagination, a magical cure on 
each of my devoted patients. This was, as I thought, the 
consummation of all my plans. After a struggle for three 
years, victory was about to crown my efforts. IIow I longed 
for the morning, that I might put to the test of experiment 
what seemed so beautiful in theory! But I was doomed to 
wait another twenty-four hours before proving my principle ; 
for, just as I was preparing for the operation, a call to the 
country appropriated the day, and thus the longest day of my 
life was lengthened out by hope deferred. But, bright and 
early on the succeeding morning I applied the quill suture, 
secured by the perforated shot. It was all I could desire. I 
was never so well satisfied with any operation in all my life. 
How anxiously I waited for its results! I had at last gotten 
rid of the canulse that had so long been a serious obstacle to 
success, and everything was propitious; but these bright hopes 
were of short duration, for I soon had unmistakable evidence 
that the operation was a total failure. What was th° cause of 
it'.' ‘Why,’ said 1, ‘it must be because the silver quills are 
too large.’ So I began to lessen their size, till they were not 66 
REPORT OX TENNESSEE SURGERY. 
more than a line in diameter, and, on account of the expense 
of silver, lead was substituted; but, notwithstanding these 
modifications, there was no more success than at the beginning. 
WI lat now was to be done? The principles of the operation 
were clear, and its mechanism seemed to be perfect. At first 
1 had supposed my failures were due to the imperfection of 
the catheter; that was perfected. Then I laid the blame on 
the method of securing the sutures by means of the eanulse; 
they were replaced by the perforated shot. And then I looked 
to the si/e of the quills, and reduced them, so that they bur- 
rowed nicely in the tissues. It then seemed that success was 
inevitable; but still disappointment awaited me at every 
turn. 
“Thus far, all my experiments were conducted on the prin- 
ciples of a rational inductive philosophy. The operation was 
mechanically perfect, but with no better results tnan when it 
was rude and clumsy. There must be a reason for all'this. 
What was it? ‘ Why/ said I, ‘perhaps it is the nature of the 
material more than in its principle of action.’ What a happy 
thought! Of course it was, for a silk thread, introduced un- 
der the skin, and allowed to remain a week, becomes a seton, 
giving rise to the suppurative process, and certainly the same 
thing must occur with it in the vagina ; and how, then, could 
there be cohesive union? Here, then, was the difficulty at 
last! How strange it now seemed to me that this fact had not 
long ago forced itself upon my mind. Now the question 
arose, ‘ Was there a substitute for siik that would answer the 
same purpose, and yet not poison the animal tissue V Why, 
lead remains indefinitely in the body, becomes sacculated, and 
produces no poisonous or suppurative effect. Dr. Levert, of 
Mobile, had demonstrated the innocuousness and efficiency of 
leaden ligatures on the arteries in the lower animals, and Met- 
tauer and Dieffenbach had actually used leaden sutures in these 
very cases; and I had, in my various experiments, tried them 
in two cases of vesical and one of rectal fistula; but, fortu- 
nately for science, the clumsy leaden wire was unsuccessful in 
my hands. Was there any other metal that could be sub- REPORT ON TENNESSEE SURGERY. 
67 
stitilted for lead, possessing its valuable property of harm- 
lessness ? 
“ In this train of inquiry, what would be more readily sug- 
gested to the reasoning mind than silver, gold, and platinum? 
Just at this stage of affairs I happened to pick up a piece of 
brass wire that had been used in a pair of old-fashioned sus- 
penders, made before the days of India-rubber; it was as fine 
as ordinary sewing thread. I took it to a jeweler, who imi- 
tated it in silver. I was now quite as anxious to see the re- 
sult of an experiment with this, as I was, seven months be- 
fore, to see the perforated shot applied. On the 21st of June, 
1849, it was done. 
“ A young colored woman, who had never murmured at the 
preceding failures, was placed on the operating table for the 
thirtieth time, and the silver sutures were applied, with the 
leaden bars and the perforated shot. In all previous opera- 
tions, the urethra, in a day or two, would become red ahd 
tender, and the urine loaded with thick, tenacious mucus, 
thus showing the inflammatory process, which was adverse to 
union ; but, after this operation, the urine remained perfectly 
limpid all the time, and on the eighth day the parts were per- 
fectly healed, the suture apparatus remaining just as it was 
placed, with the cross-bars somewhat burrowed in the vaginal 
tissue. 
“ I shall not dwell upon my feelings at this time. At last 
I had attained for what I had worked nearly four years ; and 
it was but a few weeks before all the cases were cured that 
had been the subject of experiment for so long a time. I was 
anxious to get a few more cases, to settle some doubtful points, 
before publishing to the world my discovery; but, unfortu- 
nately, with the realization of my dreams, and in the full 
fruition of my most sanguine hopes, came a sad reverse. An 
exacting practice, and the extreme mental tension of the past 
four years, had produced a collapse, long foreseen by friends, 
without my consciousness of its approach. Having contracted 
the chronic disease of a warm climate, which is almost uni- 
versally fatal, and struggled hard for more than two years, 68 
REPORT ON TENNESSEE SURGERY. 
and, as it seemed, hopelessly, against my fate, thus seeing that 
death was inevitable, and fearing that I might die without the 
world’s reaping the benefit of my labors, I determined to give 
my experience, crude as it was, to the profession that I loved 
so much. And, accordingly, in October, 1851, my paper ‘ On 
Vesico-vaginal Fistula’ was dictated, and sent to Dr. Isaac 
Hays, of Philadelphia, who published it in the American 
Journal of the Medical /Sciences, for January, 1852, as my last 
free-will offering on the altar of science. I little thought of 
living to see it in print; but it has pleased an all-wise God to 
restore me again to health, and, by a mysterious providence, 
to place me in your midst, where I have found naught but 
friends and kindness.” 
Previous to 1852, no attempt had been made, in our State, 
to heal vesico-vaginal fistula by operation. The subjects of 
that disease were abandoned as incurable, and were left to 
pass their miserable existence as best they could. Now and 
then attempts were made to heal them by caustics, but without 
success, in any case, so far as can be learned. 
In 1847, a case occurred near Nashville, in a favorite slave 
of a wealthy planter, which was seen and treated by every 
prominent physician of the city, by nitrate of silver, and even 
by the actual cautery; and though the fistula was not larger 
than a crow-quill, it was not benefitted in the least, and the 
poor woman suffered until her death, which took place a few* 
years afterwards, from pneumonia, with a lesion which the 
merest tyro in surgery could now cure without any trouble. 
When Dr. Sims taught the members of the profession 
that vesico-vaginal fistula could be cured, and the method by 
which so desirable a result could be effected, the news spread 
with rapidity over the mountains and valleys and plains of 
our State, as well as over all other States, causing many poor 
unhappy women, who had long since given up in despair, to 
hope for relief from their sufferings, and a restoration to so- 
ciety, from which they had been driven. As was natural, 
numbers so afflicted sought relief at the capital of the State; REPORT ON TENNESSEE SURGERY. 
69 
but although many were operated on by several different sur- 
geons, in 1853, 1854, and 1855, not one was cured, nor even 
partially relieved. Most of them, with hopes blasted, returned 
to their homes, determined to submit to their fate. Two of 
the number, however, concluded to visit Dr. Sims himself, 
before giving up their chance of cure. 
Mrs. R , who had already submitted to two or three 
operations, although five months advanced in pregnancy, vi- 
sited New York, and was cured in the first operation, by Dr. 
Sims. She returned home, was delivered of a fine boy at 
term, and has enjoyed excellent health ever since. 
Mrs. L , a poor widow, submitted to four or five opera- 
tions for the cure of a vesico-vaginal fistula, without success. 
Her condition was so bad, that a distinguished surgeon pro- 
posed to close the whole vaginal canal, and make of it a re- 
ceptacle for the urine, by paring the edges of the labia majora, 
and uniting them with sutures, except a small opening at its 
upper part, through which the urine might pass. The patient 
consented, and the operation was done. The union failed to 
take place. She was afterwards sent, through the charity of 
some kind ladies, to Dr. Sims, who cured her fistula by the 
first operation, leaving her perfect in every respect. 
The first successful operation for vesico-vaginal fistula, in 
our State, so far as I can learn, was done at Memphis, in 1856, 
by the late Dr. II. R. Robards, Professor of Surgery, at that 
time, in the Memphis Medical College. lie reports, in the 
Memphis Medical Record, two operations, as follows: 
u The two cases of vesico-vaginal fistula are reported, not 
with the view of throwing any additional light upon the dis- 
tressing affliction, or of adding any new operative procedure 
for its relief; but, as various modes have been recommended 
by different surgeons, all possessing more or less merit, it may 
be well to report, at least, the result of any practical operation 
in every case, so that the advantages and disadvantages may 
be seen by those who have no special partiality for any par- 
ticular operation. 70 
REPORT ON TENNESSEE SURGERY. 
“ The one so generally and favorably known, at this time, 
as Dr. Marion Sims’, in many respects possesses advantages so 
greatly superior to any other, that, however it may be modi- 
fied, 1 presume there are few intelligent surgeons who would 
not adopt at least his plan of bringing the parts into view, and 
the general principles that he has recommended. 
“ The first case was that of Mrs. H , of this county—a 
healthy married lady, about twenty years of age, who had 
fistula, produced in the usual way, with the first child, to wit: 
protracted labor, pressure, violence, sloughing, etc. About 
six months standing, immediately above the neck of the blad- 
der, transverse, one and three-quarters of an inch in length, 
and half an inch wide. The vagina, neck, and mouth of the 
womb, healthy, and the edges of the fistulous opening not so 
thick and indurated as usual, consequently it was a favorable 
case for an operation. Dr. A. K. Taylor and myself performed 
it without the slightest difficulty, after Dr. Sims’ plan. The 
lady left the city two days after the operation, and we did not 
see her again for more than a week, when the sutures had cut 
their way out and been lost. There was an opening left, 
through which a common size silver probe could readily pass, 
and through which the urine dribbled. A single suture and 
two short clamps were sufficient to complete the cure in five or 
six days more. 
“ The next case was that of Mrs. S , of Mississippi, 
about 23 or 24 years of age, rather fieshy, and of a lymphatic 
temperament. The fistula was situated higher up in the vagi- 
na, and the edges thicker and harder than the other. The ge- 
neral health of this patient had also suffered more, the nervous 
system being very much shattered. The induration of the 
edges was so great as to blunt the edges of our best knives, 
and had a cartilaginous appearance. The clamps were applied 
in the same manner as in the other, except that the precaution 
was taken to include a larger portion of tissue between the 
clamps, as ulceration and sloughing was feared in consequence 
of the contracted and unyielding nature of the parts. 
“ Alter the operation had been completed, the permanent REPORT ON TENNESSEE SURGERY. 
71 
catheter was introduced, as usual, but she found great difficulty 
iu retaining it. Cold applications were made, and strict rest 
enjoined. 
“ Examined the next day. No urine was discovered to es- 
cape, and the case seemed progressing favorably. 
“ The next, or the third day, the symptoms were the same; 
urine passed through the urethra. On examination, however, 
one of the clamps seemed buried too deeply in the tissues, and 
ulceration was going on to some extent ; still we hoped to ac- 
complish adhesion before any serious damage could result from 
that cause. , 
“ On the fifth day the clamps had to be removed; adhesion 
was found to have taken place, but the clamp on one side had 
ulcerated through the coats of the vagina and bladder, the 
consequence of which was another fistulous opening, not so 
large as the other had been, but just as inconvenient. 
“Another operation was performed as soon as the integrity 
of the parts had been sufficiently restored to authorize it, and 
great care was taken to adapt the foree put upon the sutures 
to the predisposition to ulceration, and the soft sloughy char- 
acter the tissues had now assumed. Only enough was used to 
insure perfect co-aptation, and the sutures were entered and 
passed out into sound tissues. Notwithstanding all which, 
and close watching, the same result followed. 
“ A third operation, and, I believe, a fourth, met with no 
better success. The weather being exceedingly hot, we ad- 
vised the patient to postpone any further attempt at a cure 
until the weather was more favorable, and the integrity of the 
parts had been more thoroughly restored. 
“ The operation, in this case, I regard as only a partial fail- 
ure, and whatever there was of failure is owing, in my opi- 
nion, to the only objection that can be urged against the ope- 
ration, and that is, the liability to ulceration caused by the 
pressure of the clamps; but how that difficulty is to be reme- 
died, unless it be by making the clamps wider, somewhat after 
the manner of the suture, lately recommended by Dr. Doze- 
man, of Montgomery, Alabama, I cannot tell. The operation 72 
REPORT ON TENNESSEE SURGERY. 
of Dr. Bozeman is plausible, and under existing cireuinstances, 
I shall be disposed to try it the first case I have, believing, 
however, that two buttons will answer better than one, and 
that the same objection may be urged against this, as has been 
against Dr. Mettauer’s, that the sutures themselves are liable 
to cause ulceration and cut their way through before adhesion 
has taken place. Indeed, with the exception of the protection 
which the button affords to the edges, the plan of Dr. Boze- 
man possesses no advantage over Dr. Mettauer’s, in my esti- 
mation. As to the manner of bringing the parts in view, and 
the general principles of the operation, there can be no doubt 
but that Dr. Sims is entitled to the merit of first making the 
operation practicable, and that whatever imperfection it may 
possess, will yet be remedied by his inventive and ingenious 
mind. The cases reported by Dr. Bozeman, treated on his 
plan successfully, are remarkable, and even if it should prove 
less successful in other hands, entitle him to much credit for 
those he has treated.” 
In 1860, I performed the first successful operation in Nash- 
ville, and the second successful one in the State, I suppose. 
As it was a singular and interesting case, in many respects, I 
will read the report of it, as published in the Nashville Jour- 
nal of 3Iedicine and Surgery of that year: 
Case I.—“ Mrs. W , of West Tennessee, came to our 
city in June last, seeking relief from a vesico-vaginal fistula, 
and placed herself under my care. She was a lady of about 
40 years of age, the mother of four children, the last of whom 
was still-born, and whose birth gave rise to the accident. 
“ Her last labor took place about the middle of July, 1859, 
and was unusually long—she being in charge of a female 
midwife for several days before a physician was called. Upon 
examination, finding a shoulder presentation, he turned and 
delivered the child. After the birth, she had a very severe 
spell of sickness, lasting several days. When she recovered, 
it was found that she could not retain her urine; it passed off 
continually, whether in the erect or horizontal position, pro- REPORT ON. TENNESSEE SURGERY. 
73 
ducing groat excoriation of the labia and thighs; and upon 
walking much, it would wet even her stockings and fill her 
shoes. This condition had continued to the time of her visit. 
At first her general health hud been good, but more recently 
it had given wav, and she was suffering from indigestion, loss 
of flesh, and general debility. 
“ An examination, per vaginum, revealed a large fistula 
situated at the junction of the vagina with the cervix uteri, 
about one and a quarter inch in the transverse by three-quar- 
ters to one inch in the antero-posterior diameter; the cervix 
uteri was thrown upwards into this opening, so that the poste- 
rior lip of the os uteri formed the posterior boundary of the 
fistula. 
“ Although this was an unpromising case for an operation, 
in consequence of the high position and size of the opening, 
and the bad health of the patient, yet, in view of her unfortu- 
nate condition, it was determined to give her the benefit of a 
chance for relief; and after full consultation with Professors 
Eve, Bowling, and Watson, 1 determined to leave the cervix 
uteri in the opening as it was, and to attempt to unite the va- 
ginal with the uterine lip of the fistula, thus throwing the os 
uteri into the cavity of the bladder. 
“ She was placed under preparatory treatment, which, in a 
week or ten days, so improved her general health that I 
thought her in good condition for the operation. Accordingly, 
having had her bowels freely evacuated the night before, I 
proceeded to operate, assisted by Professors Eve and Watson, 
and Messrs. Binns and Seward, medical students. 
“Having placed the patient in position, on her knees and 
fore-arms, with the head and shoulders depressed and nates 
elevated, the speculum of Sims was introduced, and the recto- 
vaginal septum well raised, thus illuminating the vaginal ca- 
vity so perfectly that the fistula was brought fully into view. 
The edges were then freely pared at the expense of the vaginal 
mucus membrane. After waiting for the bleeding to cease 
and the patient to rest, I proceeded to deposit the metallic 
sutures, which I found to be a very difficult matter, owing to 74 
REPORT ON TENNESSEE SURGERY. 
the position of the opening and the mobility of the cervix 
uteri; but, after many fruitless attempts, success crowned my 
efforts, and six sutures were deposited to my notion. I used 
the staphyloraphy needle in he j>ort aiguille, and passed it 
through the posterior lip first. Then the sutures were passed 
through the perforations of Dr. Bozeman’s ‘ button and it 
being carried home, was fastened by the perforated shot. 
“ The lady bore the operation without a murmur or groan. 
She was placed in bed, an opiate administered, and the self- 
retaining catheter introduced. She continued to do extremely 
well, (except that she could not bear the catheter at all, but 
fortunately had the power of passing urine every few minutes, 
without effort, asleep or awake,) until the fifth day, when she 
was attacked with chill, followed by high fever, great abdomi- 
nal pain and tenderness. 
“ Active antiphlogistic treatment was used in vain, until I 
was compelled to purge her freely, after which she improved 
rapidly. No urine had escaped through the fistula until she 
had the spell of sickness; afterwards, it escaped freely. 
“ I let the button remain until the twelfth day. Upon an 
examination of the suture at that time, the button was found 
very loose, and tilted up against the fistula. The wires were 
cut, and the whole removed, and, to my astonishment, I found 
the fistula cicatrized to a great extent, leaving only a small 
round opening, not larger than a goose-quill. 
“ The patient’s health had suffered greatly during her con- 
finement, and our effort was directed now to its restoration, 
hoping that the fistula would completely heal by local applica- 
tioi s. Notwithstanding her general health became greatly 
better—in fact, entirely restored—no change of the fistula was 
effected; her urine still escaped per vaginam. I should men- 
tion that her menses came on, and passed partly by the bladder 
and partly by the vagina. 
“On the 25th of July, her bowels having been freely emp- 
tied and her diet restricted to a cracker and a cup of tea for 
several days, the operation was again performed. More diffi- 
culty was experienced in denuding the edges of the opening, REPORT ON TENNESSEE SURGERY. 
75 
and a great deal more in depositing the sutures. I could effect 
nothing with the needle used previously, nor with the com- 
mon needle of the pocket-case. I succeeded with Bozeman’s 
straight needle placed in the needle-holder at an obtuse angle; 
after passing it through the anterior lip, f depressed the han- 
dle, gei itly forced it through the posterior lip, and catching 
the point as it emerged, pulled it forward ; five sutures were 
deposited, and the button applied and fastened as before. 
“ It will be sufficient to add that she had no trouble after 
this operation ; no urine escaped through the opening, and she 
passed it ad libitum, not being able to use the catheter; her 
bowels remained constipated for fourteen days. 
“On the twelfth day I removed the button, and found the 
fistula perfectly cicatrized. 
“ Five days afterwards she menstruated entirely through the 
bladder—not one drop per vaginam. 
“In three weeks she went home, by railroad and stage— 
having to stage it sixty or seventy miles. Since her arrival, 
we are informed that she is doing well. 
“It will be seen that I did not adopt the recommendation 
of Sims and Bozeman, to disengage the neck of the womb 
from its position in the bladder, because I believed the ope- 
ration would offer a better chance for success without.” 
From the date of my last operation, no other was done in 
the bounds of tmr State (at least I have been unable to learn 
of any) until 1868. Nor have I been able to hear of but one 
operation, except my own, up to the present time. 
Dr. W. E. Rogers, of Memphis, reports a successful opera- 
tion on a lady of Memphis, aged 22, for a fistula one inch in 
length by three-quarters of an inch in width, produced by 
long-continued pressure. She was cured by one operation. 
The following comprise the cases operated on by myself 
since the beginning; of 1868: 
o o 
Case II.—In June, 1868, Mrs. T , of Wilson County; 
her labor, forty hours’ duration; head of child detained 
in the pelvic cavity for fifteen hours. Delivered of a large 76 
REPORT ON TENNESSEE SURGERY. 
still-born child after ergot had been administered. Fistula 
situated an inch below the os uteri, oval in shape, an inch 
in the transverse by half an inch in the antero-posterior 
diameter. Vagina constricted to such an extent that it was 
with difficulty the fistula could be examined. The strictured 
vagina was relieved by incision and dilatation, and the fistula 
was elosed by one operation. The patient returned home in 
th ree weeks, with the functions of her bladder entirely 
restored. 
In a few weeks after the preceding, I operated on the fol- 
lowing : 
Case III.—“ Mrs. C , aged 20, a stout, athletic woman, 
from West Tennessee, was sent to me by Dr. McCall, of Henry 
County, for the cure of vesico-vaginal fistula. On the 25th of 
December, 1807, she was taken in labor, and after three days 
of ineffectual efforts, she was delivered of a large male child 
by cephalotomy. On the day after her delivery, she'was 
seized with peritonitis, and for three weeks it was thought im- 
possible for her to recover. At the end of that time, however, 
she became convalescent, and gradually got well. When she 
began to convalesce, it was discovered that her urine dribbled 
from her constantly, but the exact period at which it com- 
menced was unknown. Since that time she has never retained 
a drop of water; whether she was lying, sitting, or standing, 
the urine constantly passed from her; consequently, the labia 
and surrounding parts, as in every case, were inflamed and ex- 
coriated, and so painful, from the constant irritation, that she 
could get no rest without opiates; and this, together with the 
noisome smell of decomposing urine from her saturated cloth- 
ing, rendered it one of the most pitiable cases a surgeon has to 
meet. 
“ Several days were occupied in relieving the local irritation 
by frequent ablutions, and the free use of glycerine, before an 
examination could be made. 
“ The examination revealed the fact that the vagina was ob- 
literated to within an inch and a half of the external parts, 
with the exception of a small opening through which passed REPORT ON TENNESSEE SURGERY. 
77 
the urine and menstrual discharges. This opening was oval 
in shape, about three-fourths in the transverse by one-fourth 
in the antero-posterior diameter. 
“ For the purpose of exploring the parts above, I deter- 
mined to dilate the opening, and, if necessary, to incise the 
constricted vagina. Accordingly, I introduced a sponge-tent, 
and, upon its removal in six hours, I could easily pass the in- 
dex finger through the opening into a large cavity, which I 
supposed was the upper part of the vagina, and immediately 
divided the intervening septum with a probe-pointed bistoury, 
at several points, and introducing an clastic air-bag, distended 
it as much as the patient could bear; by gradually increasing 
the size of the bag, in five or six days all traces of the obstruc- 
tion were removed. I then proceeded to make an examina- 
tion. 
“ Having placed her in the antero-lateral position of Sims, 
the perineum was elevated by the lever speculum, and the an- 
terior part of the vagina brought forward by the depressor. 
The whole vagina, nearly to the external part, was filled with 
a cherry-red tumor, the inverted vesical mucus membrane, nor 
could it be retained sufficiently to make a clear diagnosis until 
the position of the patient was changed to the knees and 
elbows ; then the tumor having been reduced, it was discovered 
that the whole of the vesico-vaginal septum, together with the 
cervix uteri, had been destroyed, and that the cavity opened 
by the operation was formed in front by the anterior wall of 
the bladder, above by the remains of the cervix uteri, and 
posteriorly by the posterior wall of the vagina. 
“ I had never met with a more unpromising case, but be- 
cause of her deplorable condition, I proposed to her husband 
and herself the obliteration of the vagina just below the for- 
mer constriction, with a view of removing the great annoy- 
ance consequent on the constant passage of urine. After full 
deliberation, they accepted the proposition. 
“ Aeeordingly, after due preparation, our patient was placed 
on a table, before a bright sunlight, in (lie knee and elbow po- 
sition, the perineum elevated by the Sims speculum. The 78 
REPORT ON TENNESSEE SURGERY. 
mucus membrane of the vaginal wall was seized by the hook, 
and dissected off until the circle of the vagina was completed 
fully half an inch in breadth. Six silver sutures were depo- 
sited at very short intervals, with great difficulty and after 
many trials. The wires were brought together seriatim, twist- 
ed, cut off at about half an inch from the attachment, and 
brought forward so as not to fret the vagina. The patient 
was put to bed, and the self-retaining catheter adjusted. 
Opium was given at regular intervals, and perfect quietude 
enjoined. 
“ Mrs. C had no trouble after the operation; the urine 
passed by the catheter, which, however, became frequently 
blocked up with sabulous matter, and had to be often removed 
and cleansed. Her menstruation came on prematurely, pass- 
ing with the urine by the catheter. 
“ On the twelfth day the sutures were removed ; adhesion 
was found to have taken place throughout the whole circum- 
ference of the canal, except a small space at the left angle, 
through which urine passed freely. She was enabled, how- 
ever, to retain a considerable quantity of urine, and to pass it 
per vias naturalis, at pleasure.” 
In two or three weeks after, the small opening mentioned 
was closed by two sutures, and perfect adhesion resulted. My 
patient returned to her home with the power of retaining her 
urine for any ordinary period, and of discharging it whenever 
she chose. She had no trouble from its retention in the un- 
natural receptacle. 
Case IV.—Mary, colored, aged 32, from Williamson Coun- 
ty, was confined with her fourth child in May, 1867. She was 
attended by a negro midwife, and, farther than the fact that 
she was in hard labor for forty hours, and gave birth to a still- 
born babe, no history could be obtained of her case. On the 
day after her labor, she discovered that her urine passed by 
the vagina. She had been operated on two or three times in 
the country, but without avail. 
Upon examination, a large crescent-shaped fistula was found REPORT ON TENNESSEE SURGERY. 
79 
just below the cervix uteri, about cue and a half inches long 
and half an inch broad. The cervix uteri had been severely 
lacerated, from before backwards. 
After a few days’ preparation, Mary was brought before a 
part of our Medical class, and the fistula closed with twelve 
sutures. On the twelfth day the sutures were removed, and 
the case discharged cured. 
Case V.—Mrs. S , of Overton County, aged 27, the 
mother of three children, was taken in labor with her last 
nearly two years previous to her visit. Her labor was pro- 
tracted to sixty hours. She thought, but was not certain, that 
she was delivered with instruments. She had severe fever for 
several weeks afterwards. When she got up she found she had 
no control over her bladder. She had sutfered greatly from ex- 
coriations, &c., produced by the passage of urine over her per- 
son, but was not aware that anything could be done for her 
relief until recently. 
An examination revealed a small oval fistula, an inch and a 
half from the neck of the bladder, through which the end of 
the index finger could be readily passed. It was closed by six 
sutures. On the thirteenth day afterwards the sutures were 
removed, and the patient discharged well. 
Case VI.—Mrs. H , of llhea County, aged 35, the 
mother of six or seven children (some of whom were born 
since her injury), had been the subject of a vaginal fistula for 
more than ten years—produced by a prolonged labor. She 
had been operated upon several times without success, when 
she heard of the successful result of the preceding case. She 
immediately came to Nashville, and placed herself under my 
care. 
About an inch from the neck of the bladder, a fistula, of ob- 
long shape, an inch in the long diameter, was brought into view. 
The edges were formed of cicatricial tissue, and some bands 
passed up from the vagina to the cervix uteri. The lady, 
when she came under my observation, was three months ad- 
vanced in pregnancy. Notwithstanding, I determined to pro- 
ceed to an operation for her relief. The incision made em- 80 
REPORT ON TENNESSEE SURGERY. 
braced the cicatricial tissue around the fistula, removing it en- 
tirely. The denuded parts were then brought together longi- 
tudinally, by twelve sutures. In fourteen days they were re- 
moved, and the fistula was found cured, except a small opening 
not larger than a knitting-needle, at the left angle of the cica- 
trix, which was afterwards closed by two sutures. 
Case VII.—Sarah , colored, aged 20, from Davidson 
County; first birth; in labor over one hundred hours; was 
attended by a colored midwife. She noticed the dribbling of 
urine in two weeks after her labor, and nearly a year after- 
wards entered the hospital. 
The examination revealed a small fistula, circular in shape, 
not more than a quarter of an inch in diameter, with cicatri- 
cial edges. After due preparation, she was submitted to ope- 
ration. The hardened edges of the fistula were removed, the 
freshened surfaces brought into apposition with six sutures, 
the usual after treatment pursued, and in ten days the sutures 
were removed, and the patient discharged well. 
Case VIII.—Mrs. McC , aged 27, of Carroll County, 
Tennessee. She had been married eight years, and had given 
birth to three children; always had difficulty in her labors, in 
consequence, it was thought, of white swelling in her right 
hip when a child. She had had a slight lameness in her right 
limb ever since, though, upon measurement, no difference 
could be detected. The last labor continued three days and 
nights, and had to be terminated by craniotomy. Two weeks 
after her confinement, when she got up, urine passed by the 
vagina, with subsequent incontinence. 
On introducing the finger into the vagina, a very tense band 
was felt, encircling the canal, more than an inch from the ostium 
vagina. Above this band the fistula was felt, of sufficient 
size to easily admit the point of the index finger. As it was 
impossible to expose the fistula to the sight until the cicatri- 
cial bands had been freely divided, the scissors were freely 
used for that purpose; after which, the upper part of the 
vagina could be readily explored. The fistula was a trans- 
verse one, extending nearly across the vagina, and situated a ItErORT ON TENNESSEE SURGERY. 
81 
short distance below the cervix. The anterior lip of the cer- 
vix uteri was nearly destroyed. 
The fistula was closed by twelve sutures. In fourteen days 
they were removed, and the patient was sent home well. 
Case IX.—Mrs. A , of Alabama, aged 34, the mother 
of four children. About eighteen months before her visit to 
our city, she had given birth to a still-born child, after a te- 
dious labor, without any special complication. She had a long 
spell of puerperal fever following, and when she got up, found 
she could not retain her urine. Her health had not been good, 
and she was yet pale, emaciated, and feeble. 
Upon examination, a fistula, that would just admit the end 
of a female catheter, was found, situated at the junction of the 
vagina with the anterior lip of the cervix uteri, and very 
nearly circular in shape. 
After several weeks’ preparation she was submitted to ope- 
ration. 
Incisions were made on the lateral borders of the fistula, 
running well up into the anterior lip of the cervix uteri, and 
six sutures passed transversely, thus closing the opening longi- 
tudinally. The sutures were removed on the twelfth day, 
when the opening was thoroughly healed. 
Case X.—Mrs. M , of Kentucky, aged 24, the mother 
of three children. The injury was produced at the birth of 
the last, from a shoulder presentation. She was in labor 
fifteen hours, and was delivered, after considerable difficulty, 
by turning. Had fever afterwards, with great soreness and 
pain in the region of the uterus and bladder. Water passed 
through the vagina after ten days. She had been sulfering 
from the accident a year and a half. 
Upon examination, I found the genitalia in a state of 
inflammation, and encrusted with deposits of lime. The 
fistula was oblong in shape, and extended from just below the 
cervix uteri to within half an inch of the neck of the bladder; 
its edges were occupied with cicatricial tissue. 
After thorough preparation, local and general, she was sub- 82 
REPORT ON TENNESSEE SURGERY. 
miffed to tlic operation. Incisions were made so as to embrace 
and remove the hard modular tissue on the edges of the open- 
ing. Then the opening was closed with twelve sutures in the 
axis of the vagina. In a few days after the operation she had 
an attack of vomiting, which lasted the greater part of twenty- 
four hours. When the sutures were removed, on the twelfth 
day, the upper three-fourths of the opening was closed, but 
the lower fourth was not. 
After a month had elapsed, and the health of the patient 
had been improved by treatment, the opening was again 
closed, by six sutures. They were removed on the tenth day, 
and the patient sent home well. 
Case XI.—Mrs. D , of Carroll County, Tennessee, aged 
35, had, three years previous to her coming to Nashville, given 
birth to her first child, at full term. The labor was tedious, and 
the head of the child was detained, for eighteen or twenty hours, 
in the bony pelvis. She got up with an incontinence of urine, 
which had continued during the three years. She was a large 
fleshy lady, weighing nearly two hundred pounds, so 
that it was with no little difficulty that an examination was 
made. 
A small fistula, not more than the eighth of an inch in dia- 
meter, was found about half an inch below the cervix, and 
a little to the right of the mesial line. The vagina was capa- 
cious and free, but its folds would come in the way in spite of 
my best efforts. The knee-elbow position was resorted to with 
some better success. The edges of the little opening was tra- 
versed by the hook, and while held up, was abraded with scis- 
sors, and three sutures used to close the opening. In ten days 
the sutures were removed. The operation proved an entire 
failure. 
After three weeks’ rest, the operation was again undertaken. 
"With great trouble the fistula was pretty well exposed. For 
half an inch around the opening the vaginal mucus membrane 
was removed by scissors, in shape of an (), and the incision 
gradually deepened as it approached the fistula. The abraded 
surfaces were then brought together by six sutures in the axis REPORT ON TENNESSEE SURGERY. 
83 
of the vagina. After twelve clays the sutures were removed, 
and the patient discharged well. 
Case XII.—Mrs. S , of Mississippi, aged 40, had been 
the subject of a vesico-vaginal fistula for several years, pro- 
duced by the birth of her child. The labor was tedious and 
prolonged, without any special complication. Her health had 
since been bad, and was still so when she came under my ob- 
servation. She had been submitted to several operations, 
without any benefit, and was very despondent as to the result 
of another. 
The examination revealed a fistula at the junction of the 
urethra with the bladder, oblong in shape, three-fourths of an 
inch in length by one-fourth in width, with soft pliable edges. 
After several weeks’ preparation, by general and local means, 
her general health was improved, but she continued despond- 
ent. The operation was easily performed, the opening being 
closed with six sutures. She bore the operation well, but 
seemed much depressed afterwards. 
On the fourth day, menstruation came on very profusely, 
and, in spite of means used for controlling it, continued until 
the tampon had to be used. She was left very feeble and weak 
from the hemorrhage. 
On the ninth day the sutures were removed, and there was 
no union of the edges of the fistula. 
The woman, although very feeble, got up for a day or so, 
but was then taken with cerebritis, caused, as was thought, by 
an embolus, and in three or four days she died. 
Case XIII.—Mary , colored, aged 24, from the south- 
ern part of Davidson County, had been afflicted with fistula 
for nine months, from the effects of a protracted labor with 
her first child. She first noticed the incontinence of urine 
twelve days afterwards. 
The examination revealed an oval fistula, nearly an inch 
from the neck of the bladder, through which the index finger 
could be readily passed. Above the opening, the canal of the 
vagina had been rendered impervious by close adhesions. 84 
REPORT ON TENNESSEE SURGERY. 
The health of the patient being good, the extensive adhe- 
sion was divided up to the cervix uteri, with the scissors and 
finger; after which, a glass plug was inserted, and retained 
until the raw surfaces were completely cicatrized, and the va- 
gina rendered pervious. Then the operation for closing the 
fistula was performed in the usual manner. Fourteen days 
afterwards the sutures were removed, and the patient dis- 
charged well. 
Case XIV.—Mrs. P , aged 32, of Wilson county, Ten- 
nessee, was the mother of five children. The last labor, which 
occurred two years before her visit to the city, was unusually 
prolonged in consequence of the size of child’s head, which had 
eventually to be reduced by craniotomy, before it could be de- 
livered. She had violent vaginitis, with fever, and after 
ten days’ severe suffering incontinence of urine came on. She 
gradually recovered, with the exception of the last mentioned 
symptoms. 
Upon examination a long vaginal fistula was seen, extending 
from the cervix nearly to the neck of the bladder, with hard, 
thin cicatricial edges. The perineum was also extensively rup- 
tured. The operation for its closure was performed at once, 
fourteen sutures being required. In ten days they were re- 
moved, and the fistula found entirely cured. 
Case XV.—Mrs. W , aged 25, of Cheatham County, 
had had fistula about a year, caused by the birth of her first 
child. Her labor was exceedingly tedious, lasting ninety 
hours. Xo instruments were used. She had a long spell of 
fever after her delivery. When she got up, she found she had 
no control over the passage of urine. 
Inspection revealed an oblong fistula situated about a half 
inch below the cervix uteri, its transverse diameter measuring 
an inch and one-fourth, its antero-posterior a half-inch. Its 
edges, which were soft and pliant, could be readily approxi- 
mated. 
After a few days’ preparation, the operation for its cure was 
performed. Ten sutures were used. On the twelfth day the 
sutures were removed, and the patient discharged well. REPORT ON TENNESSEE SURGERY. 
85 
Case XVI. — Mrs. S , aged 22, from Montgomery 
County, Tennessee, had been suffering, from a vesico-vaginal 
fistula, situated at the has fond of the bladder, about three- 
fourths of an inch in length, and running obliquely to the 
axis of the vagina. About eighteen months before her visit 
she had been delivered of her first child, after a prolonged and 
difficult labor, by the aid of ergot. A few days after her de- 
livery, she discovered her urine passing off involuntarily. 
Iler health being good, an operation was resorted to without 
delay. Six sutures were used. On the tenth day they were 
removed, and the patient discharged well. 
Case XVII.—Mrs. II , aged 35, from Perry County, 
had been the subject of a vesico-vaginal fistula for ten or 
twelve years, occasioned by a labor of seventy hours’ duration, 
which was terminated by a forceps delivery of a still-born 
child. Eight or nine years previous to her visit, she had been 
operated on several times, by a distinguished surgeon, without 
avail. 
An examination revealed a crescent-shaped fistula, situated 
a short distance above the neck of the bladder, an inch and a 
quarter in its long diameter, which was transverse to the axis 
of the vagina. Through this opening, a large tumor, formed 
of the vesical mucus membrane, protruded. Her general 
health was not good ; she was anemic and sallow, from chronic 
malarial poisoning; she was very much depressed by her un- 
pleasant condition, and not at all sanguine as to the result of 
another operation. 
Several weeks were consumed in getting her in proper con- 
dition for the operation. The opening, after being thoroughly 
refreshed, was brought together by sixteen silver sutures. In 
twelve days they were removed, when the opening was found 
completely closed. 
Case XVIII.—Mrs. T , aged 31, from Warrpn County, 
the mother of three children. The birth of the last caused 
the injury; she was in labor sixty hours; no instrument used. 
Dribbling of urine commenced in a few days afterwards. 
Upon inspection I found great inflammation and excoriation 86 
REPORT ON TENNESSEE SURGERY. 
of genitalia, so that an examination was exceedingly painful. 
The fistula, oval in shape, and measuring half an inch in its 
long diameter, was transverse to the axis of the vagina, and 
situated in the trigone vesicse. The health of the patient was 
very good. 
After a few days’ preparation the operation was performed, 
the opening being closed by six sutures. On the tenth day 
they were removed, and the opening found closed, except at 
the left angle, where an opening, not larger than a rye straw, 
was found, through which the urine freely escaped. 
The second operation was performed, after three weeks, two 
sutures being used, with the effect of completely closing the 
opening. 
Case XIX.—Mrs.-M , aged 28, from DeKalb County, 
after a tedious labor, lasting seventy hours, was delivered, 
without instrumental assistance, of a still-born babe. She 
was quite ill afterwards, and, when she began to sit up, found 
she had no control over the passage of her water. She had 
continued feeble and anemic until her visit to our city for re- 
lief. At that time, a year had elapsed since her confinement. 
Upon examination, an oblong fistula was discovered in the 
vesical triangle, about an inch in diameter, in the axis of the 
vagina. 
After improving her general health, the opening was closed 
by eight sutures. At the end of ten days she was discharged 
well. 
Case XX.—Mrs. T , aged 41, from Hickman County, 
mother of four children—three living, the last still-born. The 
last labor, which gave rise to the accident, was prolonged to 
forty-eight hours, and was completed without instrumental 
assistance. In a few days her water was discovered dribbling 
away. Upon examination, a small oval fistula was found in 
the trigone vesicse, not more than a quarter of an inch in its 
long diameter. 
Her health being good, an operation was done at once. The 
opening was closed by four sutures. After ten days they were 
removed, and the patient discharged well. REPORT ON TENNESSEE SURGERY. 
87 
Case XXI.—Mrs. P , aged 24, from Hickman County, 
mother of two children. In her first labor, great difficulty 
was experienced, and the delivery was effected after cranioto- 
my. Incontinence of urine existed from that time. After 
she got up, she had bad health for a length of time, but be- 
came pregnant two years after her first delivery, and gave 
birth, at term, to a living child. 
At the time of her visit to Nashville, her health was very 
good, but she was suffering greatly from her local trouble. 
Upon examination, an oblong opening, oblique to the axis 
of vagina, was found, situated about an inch above the neck 
of the bladder, nearly an inch in diameter. 
After its margins were well denuded, the fistula was closed 
by the introduction of eight silver sutures. The patient was 
discharged cured. 
Case XXII.—Mrs. M , aged 25, from Wayne County, 
in her first labor, gave birth to a still-born child, after sixty 
hours of terrible suffering. In eight or ten days afterwards, 
she found that she had no control over the passage of the 
urine. Having endured the suffering for five years, she was 
encouraged to hope for relief by the cure of a patient in an 
adjoining county. 
Upon examination, an opening through the vesico-vaginal 
septum was discovered, just above the neck of the bladder, 
circular in shape, and an inch in diameter. The operation for 
its cure was successful. 
Case XXIII.—Mrs. G , aged 22, of Wilson County, 
nine months before her visit, had given birth to a still-born 
babe. Her labor was protracted to ninety hours, and was ter- 
minated by craniotomy and evisceration. She suffered in- 
tensely from inflammation of the vagina and surrounding 
parts, followed by extensive sloughing. About ten days after 
her delivery, she noticed the dribbling of water. 
On examination, a transverse opening was discovered about 
half an inch from the meatus, an inch in its long diameter, 
severing the urethral canal entirely, its two extremities being 88 
REPORT ON TENNESSEE SURGERY. 
half an inch apart. In addition, the poor patient had a rup- 
ture of the perineum, extending an inch into the rectum. 
Her general health being good, she was submitted to opera- 
tion as follows: 
The whole extent of the fissure was denuded of its mucus 
membrane, including the edges of the urethra on each side, as 
far as its lining membrane. Nine sutures were used, three on 
each side of the urethra, and three on that canal. Of the 
urethral sutures, one on each side passed through the vaginal 
edge of the fissure and the edge of the urethra, the middle 
one passing only through the vaginal tissues over the divided 
extremity. A catheter was passed through the canal into the 
bladder, when the sutures were twisted, thus approximating 
the edges. 
On the twelfth day the sutures were removed, and the open- 
ing found to be closed completely. 
In a few weeks she discovered that she had not recovered 
complete control of her bladder. While lying down no urine 
escaped, but when she got up, a part escaped through the 
meatus. 
Two or three months afterwards, the ruptuml perineum 
was closed by operation, in the hope that it would cure the 
incontinence, but, although much improved, she has not yet 
attained complete control of the bladder. 
Case XXIV.—Mrs. S , aged 38, from Kentucky, the 
mother of three children, the birth of the last of which gave 
rise to the accident. The labor was tedious, but terminated 
without instruments. She noticed water passing off involun- 
tarily after a week. 
Upon examination, a small circular opening in the trigone 
vesieje was discovered. It was closed by five silver sutures. 
The patient went home well in two weeks. 
It will be seen that the number of operations for vesico- 
vaginal fistula in Tennessee, of which an authentic history REPORT ON TENNESSEE SURGERY. 
89 
could be obtained, is twenty-eight, of which the following is a 
summary: 
OPERATOR. 
NUMBER OF OASES. 
SUCCESSFUL. 
UNSUCCESSFUL. 
I)r. H. 11. Robards .. 
2 
.... 1 
1 
Dr. W. E. Rogers.... 
1 
.... 1 
0 
Dr. T. L. Maddin.... 
1 
.... 0 
1 
Dr. W. T. Briggs .... 
24 
.... 23 
1 
NUMBER OF OPERATIONS PERFORMED 
OPERATOR. 
IN SUCCESSFUL CASES. 
IN UNSUCCESSFUL CASES. 
Dr. IT. R. Robards. 
2 
4 
Dr. W. E. Rogers... 
1 
0 
Dr. T. L. Maddin... 
0 
1 
Dr. W. T. Briggs.. -j 
r In 5 cases 2 
In 18 cases 1 
0 
1 
Of this number, twenty-five (25) were white and three (3) 
colored. 
The fistulas occurred, from 
First labor 18 
Second labor 2 
Third labor 3 
Fourth labor 4 
Fifth labor 1 
MANNER OF DELIVERY. 
Natural efforts 17 
Ergot 2 
Version 2 
Forceps 3 
Craniotomy 4 
SITUATION OF FISTULA. 
Urethra 1 
Trigone vesicae ] 8 
Bas Fond 7 
Extending from bas fond to trigone vesicae 2 90 
REPORT ON TENNESSEE SURGERY. 
In the management of vesico-vaginal fistula, the prepara- 
tion of the patient, the operation, and the after treatment, 
will demand the attention of the surgeon. 
In no operation in surgery is success more dependent on 
the constitutional condition of the patient than in this. The 
same rules should guide us in the preparation of the patient 
for this as for other important operations; every means should 
be used to improve the general health, so that the digestive 
organs may be active in the performance of their function, 
the various secretions naturally eliminated, and the blood 
state normal. It may require a few days, or a few months, to 
put a patient in proper condition—but whether a few days or 
months are required, it should not be neglected. 
Nor is attention to the condition of the parts immediately 
involved less important; all inflammatory action must have 
subsided, the edges of the fistula must have become thickened, 
well supplied with blood-vessels, and sufficiently firm to bear 
the traction of the sutures. 
Especial attention should be directed to cleanliness, by in- 
jections of tepid water or warm soap-suds, or, what I regard 
better, chlorate of potash and glycerin—say a drachm of pot- 
ash with an ounce of glycerin to a pint of tepid water—to be 
used at once, and repeated every two or three hours. 
If the edges continue thin and pale, scarifications over 
their surface, with the application of the solid nitrate of 
silver every two or three days, will cause them to become more 
voluminous and vascular in a short time. Should the edges 
of the fistula, or other parts of the genitalia, become encrusted 
with earthy deposits, they should be washed with a weak so- 
lution of one of the mineral acids, and at the same time the 
nitric or nitro-muriatic acid should be given internally. 
For the relief of excoriations consequent upon the urinous 
stillicidium, nothing has proved so beneficial in my hands as 
the oxide of bismuth and glycerin, in the proportion of one 
part of the former to two of the latter. After each bathing, 
TREATMENT. REPORT ON TENNESSEE SURGERY. 
91 
this preparation should be freely applied over the parts af- 
fected. 
Should complications of any character exist, they should, if 
possible, be removed. 
One of the most frequent is stricture of the vagina, which 
may vary from the slightest diminution in the caliber of the 
canal to its almost complete obliteration. This stricture may 
be removed by incision or dilatation. In either method there 
is a strong tendency to relapse. Success is more generally at- 
tained by a combination of the two methods. Slight incisions 
should be made through the mucous or submucous tissues, at 
a number of points, and then dilatation effected with sponge- 
tents, slippery elm bougie, or the elastic bags. 
An operation should not be attempted for two and a half or 
three months after confinement, for the system does not recover 
from the disturbing influence of the parturient act sooner. 
Before this time has elapsed, inflammation, to which woman is 
then most susceptible, is liable to be excited, either in the pe- 
ritoneum, uterus, or the pelvic cellular tissue; or a local in- 
flammation of the parts involved may ensue, which, though 
not dangerous to the patient’s life, may yet be sufficient to de- 
stroy the promise of the best-executed operation. 
It is important, too, to choose a time four or five days after 
a menstrual period for the operation. 
On the day previous, a purgative, which will evacuate the 
whole alimentary canal thoroughly, should be administered, 
so that the bowels may not be disturbed for several days after- 
wards. 
Without referring to the various modifications of the opera- 
tion for the radical cure of vesico-vaginal fistula, I will take 
the liberty of detailing to the Society the procedure which I 
have adopted, claiming nothing new in connection with it. 
Time for Operation.—The morning of a bright day should 
be chosen, and a room should be selected which has windows 
on its southern or southeastern side. 
Assistants*.—Three or four assistants will be required, though 
I have often got along without difficulty with two—one to 92 
REPORT ON TENNESSEE SURGERY. 
hold the speculum and the other to cleanse and hand the 
sponges. 
Instruments Essentially Necessary.—Sims’ lever speculum ; a 
tenaculum, with long shaft and a short turn at its extremity, 
nearly at right angle; a pair of long rat-toothed forceps, 
slightly curved; two long-handled scalpels, with short narrow 
blades; two pair of long angular scissors; one pair of scissors 
curved; four or five long-handled sponge-holders; Stohl- 
man’s canulated needle; a blunt hook, with long handle; 
shield for supporting the wires while being twisted; forcep 
for twisting the wires; a coil or two of fine annealed wire, 
made of virgin silver. 
Basins of water, hot and cold, with sponges, cloths, &c. 
A table, three feet high, four or five feet long, and two or 
two and a half wide, covered with several folds of blankets or 
quilts. 
I prefer not to use any anfesthetic. 
Operation.—Everything being ready, the patient dressed in 
a loose gown and a pair of drawers, is placed on the table, 
and brought before a large window, through which a flood of 
sunshine is passing. She lies on her left side, with the thigh 
bent at right angles with the pelvis—the right a little more 
flexed than the left; the left arm Behind the back, the chest 
brought down flat on the table, the sternum touching it, and 
the buttocks brought to the edge of the table. (In some few 
cases, the fistula is best exposed in the knee-elbow position, 
but, as a rule, the position described is better.) The speculum 
is now to be introduced, and handed to an assistant, who is 
directed to draw it back towards the rectum when the air 
rushes into the vacuum and distends the vagina so that every 
part, except that upon which the blade rests, is satisfactorily 
exposed. 
With the long tenaculum in the left hand, the mucous mem- 
brane, near the middle point of the anterior lip, is seized, 
nearly half an inch from the border of the fistula, and made 
tense; then the point of the knife is entered just behind the 
tenaculum, and passed through the vaginal mucous membrane REPORT ON TENNESSEE SURGERY. 
93 
to the submucous cellular tissue. It is next carried across the 
anterior lip of the fistula, and, if possible, around its whole 
circumference. Sometimes, however, the incision cannot be 
carried continuously around the opening, and then the tenacu- 
lum is again brought into requisition, and the point of the 
knife carried through the mucous membrane at nearly the same 
distance from the posterior edge of the fistulous lip, and car- 
ried across to join the anterior incision at an acute angle. 
With the rat-toothed forceps, the edge of the incised mucous 
membrane next to the fistula is seized, and dissected from be- 
fore backwards on the anterior lip, and from behind forward 
on the posterior, until the vesical mucous membrane is reached, 
when the separated membrane is snipped off with the curved 
scissors. The angle of the incision should receive especial at- 
tention. In fact, this whole stage of the operation is all im- 
portant, and the successful issue of the case depends upon its 
proper performance. To simply pare the edges of the fistula, 
as is sometimes recommended, is not sufficient; the vaginal 
mucous membrane, to the extent of from one-third to half an 
inch, should be removed from the margin of the opening. 
As this part of the operation is being accomplished, the 
sponge-holder is frequently called into requisition, for, often, 
the bleeding is pretty free. It most generally ceases sponta- 
neously ; if troublesome, however, the use of iced water will 
check it; or it may be necessary, in some cases, to twist the 
small vessels with a pair of long artery-forceps. 
Another difficulty that is sometimes encountered in this 
stage of the operation is the protrusion of the vesical mucous 
membrane. Usually, this is easily managed by passing a soft 
sponge through the opening into the bladder, allowing it to 
remain until the sutures are ready for adjustment. 
This much having been accomplished, the patient, if much 
fatigued, should be allowed to place herself in a more comfort- 
able position, and rest for ten or fifteen minutes. 
The second step of the operation is the introduction of the 
sutures. The direction in which the approximation of the 
sides of the fistula can best be effected, must be determined; 94 
REPORT ON TENNESSEE SURGERY. 
most generally it is best done transversely, but in some in- 
stances, as when the fistula is long and narrow, and runs in 
the axis of the vagina, it will be approximated best in the 
longitudinal direction; or, in other instances, we may bring 
them together obliquely. Our remarks in reference to passing 
the sutures will apply to the closure of the opening trans- 
versely. 
In my earlier operations, I used short, stout, spear-pointed 
needles, straight and curved, armed with silk passed through 
the eye double, held in the grasp of a long-handled needle- 
carrier. After the needle had passed through both lips 
of the fistula, and the silk deposited, the silver wire was placed 
in the loop of the silk, and bent over, so as to be fastened to 
it. The opposite end of the silk was then seized and drawn 
out, carrying the silver to its place. For several years I have 
been using, with great satisfaction, a canulatcd needle, known, 
most generally, as Stohlman’s needle. Jt consists of a handle, 
to which may be connected differently-shaped canulated nee- 
dles. The handle itself is perforated, which perforation is 
continuous with the hollow of the needles, and upon the side 
of the handle, near its junction with the needle, is a serrated 
wheel, fixed on a spring, which may be forced in, by pressure 
of the finger upon the opening. The wire is inserted at the 
end of the handle, and after it is passed beyond the little 
wheel, may be projected forward or backward by pressing and 
turning the wheel. 
The tenaculum is now inserted into the anterior lip, near 
one of its angles, so as to steady and make its edge tense; the 
canulated needle, properly armed, is entered half an inch from 
its incised border, carried downwards and forwards until its 
point emerges in the denuded portion, at its junction with the 
vesical mucous membrane. The tenaculum performs the same 
service for the posterior lip; the needle, carried across the 
opening, is made to enter the abraded edge of the posterior lip, 
as near the mucous membrane of the bladder as possible, and 
carried far enough forward to emerge half an inch from its 
abraded margin. As the needle is emerging on the mucous REPORT ON TENNESSEE SURGERY. 
95 
surface of the posterior lip, the blunt hook should be used to 
aid the passage of the point of the needle, by pressing the 
parts towards it. The wire is now to be shot forward, by 
pressing and turning the wheel; as soon as it emerges from 
the instrument, it should be seized, drawn downwards, and 
held while the needle is withdrawn, leaving the silver wire in 
place. 
The remaining sutures are to be passed in the same manner, 
at the distance of two lines from each other, until a sufficient 
number have been deposited to close the opening. 
One who has never used this beautiful instrument cannot 
imagine the ease and celerity with which the sutures may be 
placed. 
This finishes the second stage of the operation, and the 
patient can again rest a few minutes. Then the first suture, 
having been isolated from the others, and drawn together 
with the fingers, is seized with the twisting forceps, slipped 
into the fissure of the shield, and twisted until the edges of 
the wound are brought accurately in contact. In the same 
manner the remaining sutures should be seized and twisted, 
until the lips of the entire wound are closely approximated. 
Care should be taken to have the lips of the wound drawn 
evenly together, and to have the sutures neither too tight nor 
too lax. This can be easily tested, first, by passing an ordi- 
nary silver probe through the loop of wire; if it passes with- 
out force, the sutures are not too tight. Next, by injecting 
tepid water into the bladder; if the wound does not permit 
the escape of a drop of the fluid, they are not too loosely 
applied. Each suture is now clipped about half an inch from 
its insertion, and pressed down flat against the vaginal wall. 
The parts are thoroughly sponged, and the bladder washed 
out with tepid water, the patient placed in bed, and an opiate 
administered as after other operations. 
AFTER-TREATMENT. 
The most troublesome and unpleasant part of the manage- 
ment of vesico-vaginal fistula) since Dr. Sims first demon- 96 
REPORT ON TENNESSEE SURGERY. 
strated their curability to the world, has been the after-treat- 
ment which was thought to be essential to the successful issue 
of the operation. 
The introduction and retention of the catheter, for the pur- 
pose of keeping the bladder empty, and of preventing the 
urine from coming in contact with the freshly united edges of 
the fistula; the absolute maintenance of the horizontal posi- 
tion, the patient being compelled, the greater part of the time, 
to lie on the back, and the control of the intestinal movements 
by the regular administration of opiates, have been believed 
to be so important to the successful issue of the operation, that 
a neglect of either would inevitably result in a failure. Such 
had always been my belief, consequently I had paid especial 
and strict attention to the after-treatment recommended by Dr. 
Marion Sims, and followed by almost every surgeon who had 
attempted to operate. 
In my first case, from excessive irritation of the bladder, 
caused by the catheter, the patient was unable to bear its pre- 
sence for a moment, and passed her urine by the urethra as she 
lay in bed. The cure was as perfect as any I have since had; 
still I was not impressed with its importance as I should have 
been. 
In 1869, while attending the meeting of the American Me- 
dical Association, at New Orleans, I heard Dr. M. Schuppert, 
of that city, read a paper before the Section of Anatomy and 
Surgery, on the abandonment of the usual after-treatment of 
vesico-vaginal fistula. Dr. Schuppert had operated on a suffi- 
cient number of cases to establish, beyond a doubt, the sound- 
ness of the practice. Of six cases, five were cured by the first 
operation. 
Simon, of Heidelberg, is, without doubt, the first who ad- 
vocated the practice. Spencer Well, the distinguished ova- 
riotomist, adopted it. Alfred Meadows, of London, recom- 
mends it. But in our country, so far as I know, Dr. Schup- 
pert and myself are the only operators who have adopted it as 
a rule. Dr. Schuppert reports a case which Dr. Samuel Chop- 
pin, of New Orleans, had failed to cure by two operations with REPORT ON TENNESSEE SURGERY. 
97 
the ordinary after-treatment, while in the third all after-treat- 
ment was abandoned, with the result of a perfect cure. I do 
not know, however, whether Dr. Choppin abandoned the usual 
after-treatment in his subsequent cases. 
I commenced the trial of the plan very cautiously. 
In the first case (Case VI.) I ordered the catheter to be re- 
moved, and left out for an hour or two at a time each day, from 
the date of the operation, but to be retained at night; and that 
the patient should change her position in bed at pleasure. 
The result was successful. 
In the second (Case VII.), after the first twenty-four hours, 
I directed the catheter to be withdrawn, and to be used every 
two or three hours, except at night, when the instrument was 
to be left in the bladder. The patient was allowed to sit up at 
pleasure. The result was successful. 
In the next case (Case VIII.), the catheter was used every 
two or three hours for the first day; afterwards, however, the 
patient passed the urine by her natural efforts, at will. She 
was not confined to the bed at all, but went where she pleased. 
She was in the habit of evacuating her bowels only once a 
week, and had no occasion to have an action until a few days 
before the sutures were removed. 
Satisfied with the success of the plan, I have not resorted to 
the usual after-treatment in my subsequent cases. 
I direct the patient to lie quietly in bed for a few hours; if 
in pain to take an opiate; to have the catheter used every 
two hours for the first twelve hours; afterwards to pass her 
urine naturally ; to get up and go about as usual, and to allow 
the bowels to move when she has the desire. If there is any 
inability on her part to pass water, then the catheter should 
be resorted to, as may be indicated. 
The author of the article on vesico-vaginal fistula, in 
Holmes’ Surgery, says that “ we may fairly rank the operative 
cure of these distressing conditions as a finished achievement.” 
I can now repeat that, with the abandonment of the annoying, 
wearisome, and not always safe, after-treatment, the operation 
for the relief of these fistulae is a “ finished achievement.” 98 
REPORT ON TENNESSEE SURGERY. 
The patient being in good condition, the only requisite, I 
think, for complete success in the operation for vesico-vaginal 
or vesico-uterine fistula, is the proper removal of the mucous 
membrane and submucous tissue around the fistula, with co- 
aptation and maintenance of the abraded borders from eight to 
fourteen days. 
The Removal of the Sutures.—On the tenth or twelfth day 
after the operation, the sutures should be removed by placing 
the patient in the same position as for the operation, introduc- 
ing Sims’ speculum, and grasping the end of one of the wires 
with the twisting forceps, drawing it down gently until the 
loop can be reached and the nearest side clipped, when traction 
will remove the suture. One after the other is thus removed, 
especial care being taken that no violence is done to the new 
adhesions.