Reprinted from the New YorTc Medical Journal 
for October 1, 1887. 
THE GRADUAL PREPARATORY TREATMENT OF 
THE COMPLICATIONS OF HRINARY AND FAECAL 
FISTULaE IN WOMEN, 
Including a Special Consideration of the Treatment of Pyelitis by a 
New Method, and the Prevention of the Evils of Incontinence 
of Urine by a New System ofjfrainage * 
By NATHAN BOZEMAN, M. D., New York, 
SURGEON TO THE WOMAN’S HOSPITAL OP THE STATE OP NEW YORK. 
In the course of my experience in the treatment of uri- 
nary and faecal fistulae, as I encountered new difficulties, I 
have described from time to time the cases and the means 
by which I endeavored to overcome them; but all, espe- 
cially the more recent of my results, have not been pub- 
lished. The object of the paper, of which this is an ab- 
stract, is therefore to set these latter before the profession 
and to combine them with what I have already written. 
In this way I hope to communicate in a more systematic 
manner the results of my experience and observation in this 
department of the subject of fistula, which have extended 
over a period of thirty-four years. 
The object of ray method of treatment, preparatory to 
* An abstract of a paper read before the Section in Gynaecology of 
the Ninth International Medical Congress,  THE TREATMENT OE THE COMPLICATIONS OE 
2 
the performance of the operation for the closure of a fistu- 
lous opening, is to prevent and to overcome the injurious 
effects of incontinence of urine, and to remedy the com- 
plicating injuries and diseases of all the organs involved. 
In other words, to remove as far as possible the obstacles in 
the way of the easy performance and success of the final 
operation, and to cause the diseased tissues to return to a 
state of health, so that not only will the incontinence of 
urine be cured, but the functions of all the organs be pre- 
served. 
Treatment and Prevention of the Effects of Incontinence 
of Urine.—Inflammation and ulceration of the vagina, 
vulva, and buttocks, due to the contact of ammoniacal 
urine, may be treated in the usual way by cleanliness and 
stimulating and astringent applications. Although by these 
measures the sufferings of the patient are relieved to a con- 
siderable extent when for any cause the closure of the fis- 
tula is long delayed, it is of the utmost importance that we 
should possess some form of instrument by which the urine 
may be drained away and its contact with the mucous mem 
branes, integument, and linen of the patient be avoided. 
After many experiments, I have recently devised an in- 
strument which accomplishes these results in a perfect man- 
ner, and have also been able to combine, in the same in- 
strument, drainage with the dilatation of cicatricial con- 
tractions of the vagina. The forms of the instrument 
which concern us here are intended to secure drainage 
alone, and I have called them utero-vesical and utero-vesico- 
urethral drainage supports. The former is applicable to 
most cases, to all positions of the body, and is the most con- 
venient. The latter is suited to the recumbent position and 
to cases where the perinseum is lacerated. 
These instruments can be introduced and removed by 
the patient whenever necessary and without difficulty. They URINARY AND FA] CAL FISTULA*] IN WOMEN. 
3 
are small, simple, free from angles and sharp borders, are 
readily kept clean, excite no discomfort or irritation of the 
vagina, and do not press upon the rectum or bladder, nor 
interfere with locomotion. While possessing all these quali- 
ties, they collect the urine and conduct it away with a de- 
gree of perfection that to the patient is a constant cause of 
wonder and delight. I have now five cases in which the 
different forms of the instrument are in use. In one of the 
cases there is entire destruction of the urethra. In all, the 
instrument performs its functions perfectly. 
The Treatment of the Complications of Urinary and 
Fcecal Fistulce.—Yery few cases of fistula are simple. The 
same cause, the pressure of the child’s head, which pro- 
duced the perforation of the vesical or rectal wall injures 
to a greater or less extent other parts of the vagina, and 
frequently the uterus, ureters, and urethra. These injuries 
and the distortions of the structures involved, the result of 
the contraction of the cicatricial material produced in the 
healing process, constitute the most frequent complications. 
In the worst cases, to them are added subsequent disease 
of these organs and the bladder, and fixation of the uterus, 
the consequence of puerperal cellulitis and peritonitis. 
Cicatricial Contractions and Distortions of the Vagina. 
General thickening and rigidity of the vaginal walls and 
narrowing of the vagina by the presence of cicatricial bands 
and adhesions render the exposure of the fistula difficult, 
and tend to prevent the easy approximation of its borders. 
The operation for closing the opening is thus made diffi- 
cult, and, owing to great tension, the sutures cut and it 
fails. 
The means by which I overcome these difficulties are, 
mainly, division of the cicatrioial material and gradual dila- 
tation of the vagina. In cases in which the vagina is very 
much contracted my method consists first in the section of 4 
THE TREATMENT OF THE COMPLICATIONS OF 
all the prominent bands and adhesions, and afterward in 
the dilatation of the vagina with hard and soft instru- 
ments. 
When it is necessary to give ether, the patient is placed 
in the knee-chest position and secured by means of an appa- 
ratus which I have had constructed for the purpose. In the 
ordinary treatment of the case this is unnecessary. I place 
the patient simply in the supported knee-elbow position. 
The parts are exposed to view by means of my dilating 
speculum and perineal elevator, and the bands, which are 
at the same time rendered tense and prominent by these 
instruments, are divided while on the stretch by means of 
sharp and probe-pointed bistouries and the peculiar knife 
which I show you. 
The subsequent dilatation of the contractions of the 
vagina is produced by hard and soft dilators. On account 
of differences in form and in the manner in which they are 
used, 1 have divided them into two classes—the vulvo-vaginal 
and intra-vaginal. 
The hard dilators which I show you are made to com- 
bine drainage with dilatation. The vulvo-vaginal can be 
distinguished from the intra-vaginal by their greater length, 
and the beak-like extremity, which rests on the perinaeum. 
The intra-vaginal instruments are worn altogether inside of 
the vulva, and rest upon the posterior surface of the arch 
of the pubes and the perinaeum. A set of the vulvo-vaginal 
dilators consists of five sizes, ranging from thirty to fifty 
millimetres in diameter, and a set of the intra-vaginal of 
eight sizes, ranging between thirty and sixty-five millime- 
tres. 
The soft dilators are made of coarse sponge, torn in 
pieces, and covered with oil silk, and may be of any size up 
to seventy millimetres in diameter, or larger if necessary. 
The difference between the vulvo-vaginal and the intra-vagi- URINARY AND FyECAL FISTULA IN WOMEN. 
nal forms of these soft instruments is, that the former are 
made longer than the latter, but never so large, the sizes be- 
ing graded like the hard instruments. I have been unable 
to combine drainage with dilatation when the sponge in- 
struments are used, but, if they are frequently removed, and 
the urine which they absorb squeezed out, the vagina and 
vulva may be kept comparatively dry. 
Although only a very imperfect sort of drainage, which 
I have called sponge absorption, can be obtained with sponge 
dilators, they are superior in many respects to the hard in- 
struments. A much larger dilator can be introduced, and, 
being soft, it causes less pain. In virtue of its elasticity, 
the sponge accommodates itself to the shape of the vagina 
when the organ is irregularly contracted, and, by the imbi- 
bition of urine, increases in size after introduction. 
Time, patience, and perseverance are all that are neces- 
sary to produce, by the gradual division of opposing cica- 
tricial bands and the systematic use of these dilating instru- 
ments, a distension of the vagina nearly equal to that caused 
by the child’s head at the time when the injury was done. 
As the dilatation proceeds, the exact nature of the lesions 
present becomes more evident, and the form and the rela- 
tions of the fistula to the surrounding structures are more 
distinctly exposed to view ; the cervix uteri, which was per- 
haps altogether hidden, becomes visible and the anterior and 
posterior culs-de-sac are restored ; the vaginal walls are re- 
laxed and the uterus made movable; the mucous membrane 
of the vagina loses its fiery red hue and assumes a natural 
pink color; the inflammatory thickening of the vaginal walls 
melts away beneath the pressure, and the borders of the 
fistula lose their leather-like hardness, become smooth and 
soft, and may be more easily approximated. 
Fixation of the Uterus.—When there is great loss of 
tissue at the fistulous opening and the uterus is fixed, the 6 
THE TREATMENT OF THE COMPLICATIONS OF 
remnants of the septum can never be sufficiently stretched 
to bridge the interval. The uterus must he rendered mova- 
ble, so that the cervix can he drawn down and made subser- 
vient to the closure of the opening. 
The fixation of the uterus may be overcome by upward 
pressure, made with the dilators already described, and by 
a sort of passive motion of the uterus, which is secured by 
traction, frequently repeated, with a hook fastened in the 
cervix. 
The practical use of these measures is sufficient to dem- 
onstrate their efficiency, but, in order to render the results 
obtained by them clear to all, I made an experiment, while 
in Vienna, in a case of fistula in which there was immobili- 
ty of the borders, due to fixation of the uterus. The results 
of this experiment have been reported by Bandl.* At the 
beginning of the treatment the edges of the opening could 
not be approximated by any amount of force. After sec- 
tion of the band and dilatation of the vagina continued for 
four days, they could be brought together imperfectly by 
the exercise of two thousand eight hundred grammes of 
traction, measured by a scale. After the continuance of the 
treatment for seventeen days longer, one hundred and twen- 
ty grammes were sufficient for this purpose, and the opera- 
tion for the closure of the fistula had become easy. 
The advantages secured by the use of these preparatory 
measures are also well illustrated in certain more special 
forms of fistula. By the aid of my button suture and these 
preparatory measures, with the modifications which I have 
described fully in my paper, I have been able to treat suc- 
cessfully vesico-utero-vaginal fistulas with incarceration of 
the cervix uteri in the bladder,.restoring the cervix to its 
natural position in the vagina and closing the vesical open- 
ing without the formation of a pouch in the bladder; I have 
* “ Wiener medizinische Wochenschrift,” Nos. 49-52, 1875. URINARY AND FAECAL FISTULAS IN WOMEN. 
been able to reach and to close vesico-utero-cervical frstulae, 
attended with loss of tissue, even when the opening was 
situated above the vaginal junction, and have met with the 
same success with recto-utero-vaginal fistula}, with incarcera- 
tion of the cervix in the rectum. All these conditions have 
been and are still considered without remedy, except by 
kolpokleisis, occlusion of the os uteri, or by the perpetu- 
ation of the incarceration of the cervix in the bladder or 
rectum. 
Cystitis, Contraction, and Prolapse of the Bladder are 
frequent complications, and must be treated. The principal 
cause of cystitis is the retention in the bladder of stagnant 
pools of urine in pouches of the raucous membrane, or as 
the result of imperfect drainage of the urine through the 
fistulous opening. The sacculation of the vesical mucous 
membrane at the base of the bladder is due to the distor- 
tion of the anterior wall of the vagina by cicatricial bands. 
The treatment of cystitis consists, therefore, in the frequent 
irrigation of the interior of the bladder and the obliteration 
of the folds of the mucous membrane by dilatation of the 
vagina. 
Atrophy or contraction of the bladder is best treated by 
obturation of the fistulous opening by means of an oil-silk 
sponge dilator placed in the vagina. A sufficient quantity 
of urine is thus retained in the bladder to gradually distend 
its walls, A prolapsed bladder should be reduced in the 
supported knee-chest position, the abrasions of the mucous 
membrane touched with nitrate of silver, and the reproduc- 
tion of the condition prevented by filling the vagina with 
one of the forms of dilators already described. 
Injuries of the Ureters.—One of the ureters may be 
opened by a slough which does not penetrate the whole 
thickness of the septum. By an injury of this kind a ure- 
tero-vaginal fistula is produced. One or both of the ureters 8 
THE TREATMENT OF THE COMPLICATIONS OF 
may also form a part of the border of a vesico-vaginal fis- 
tula. In the first form of injury the ureter must be turned 
into the bladder before the fistula is closed, thus convert- 
ing it into a vesico-uretero-vaginal fistula. In all cases, 
when the ureters are involved, unless they are slit up on their 
vesical surfaces, their orifices are liable to be obstructed by 
the sutures or to be occluded by the apposition of the bor- 
ders of the fistula. This little operation is best done, as a 
preparatory measure, long enough before closure of the fis- 
tula to allow healing to occur. Stenosis and eversion of the 
orifices of the ureters frequently occur in these cases, and it 
is therefore important to ascertain, before closing a fistulous 
opening, whether these conditions exist. When such a con- 
dition is present, the lower part of the ureter should be di- 
vided and the incision should extend through the vesical 
mucous membrane, and be followed by dilatation with sounds 
if necessary. 
Pyelitis.—The causes which lead to the development of 
pyelitis, as a complication of fistula, are cystitis and ob- 
struction of the ureter or ureters. The principal symptoms 
which I have observed to be present in this disease are more 
or less constant pain in the lumbar region, attacks of renal 
colic, nausea and vomiting, anaemia, emaciation, and the 
cachexia of chronic suppuration. At times the course of 
the disease is varied by the occurrence of severe rigors, 
accompanied and followed by great pyrexia. Pus and blood 
may be seen to exude from the orifice of the ureter, which 
is exposed to view by the fistulous opening. 
I have recently devised a new method of treatment for 
this disease, and have used it in two cases, both of which 
are now cured. It consists essentially in dilating the ureter 
and washing out the pelvis of the kidney by means of a 
catheter. In my first case, which I have reported at length 
in ray paper, the pyelitis involved the pelvis of the left kid- URINARY AND FJECAL FISTULA IN WOMEN. 
9 
ney, and occurred as a complication of a large urethro- 
vesico-utero-vaginal fistula implicating both ureters and 
the greater part of the septum. It was occasioned by 
the obstruction of the orifice of the ureter, due to the con- 
traction of the cicatricial border of the fistula of which it 
formed a part. The patient was suffering from frequent 
paroxysms of renal colic, rigors were occurring at short in- 
tervals, and her temperature was constantly elevated, ranging 
between 102° and 105°. Pus could be seen exuding in con- 
siderable quantities from the left ureter. The patient was 
emaciated and her complexion was pale and sallow. She 
wa3 evidently rapidly dying from exhaustion, induced by the 
fever and the pain. The condition of the patient continued 
to grow worse and the case more hopeless until December 
26th of last year, when I passed a small olive-tipped cathe- 
ter through the ureter into the pelvis of the kidney. Car- 
bolized water was then injected with a syringe, and a small 
quantity of foetid pus washed out. The catheter was al- 
lowed to remain in place twenty-four hours without causing 
any evil consequences, and the irrigation of the pelvis of 
the kidney repeated at frequent intervals. Afterward the 
douching was repeated daily, the catheter being introduced 
and removed without difficulty. The condition of the pa- 
tient improved after this treatment was begun with remark- 
able rapidity, the temperature became normal in twenty- 
four hours, and the pus gradually diminished in quantity, 
and at the end of six weeks entirely disappeared. The pa- 
tient has since gained about thirty pounds in weight, her 
general health has become good, and the fistulous opening 
is now ready for operation. 
In the course of the treatment of this case I made sev- 
eral interesting observations on the relative secreting capaci- 
ties of the two kidneys, the details of which I have not time 
to tell you in this abstract. I also caused to be constructed 10 
THE TREATMENT OF THE COMPLICATIONS OF 
the flexible steel renal sound which I show you. It is in- 
tended for purposes of diagnosis rather than of treatment, 
but was of service in this case in dislodging the detritus 
from the pelvis of the kidney. 
Encouraged by ray success in this case, I conceived the 
idea of extending this method of treatment to cases of pye- 
litis when no fistulous opening existed. Fortunately, I soon 
had an opportunity. Mrs. B, came under ray care. She 
gave a history of symptoms similar to those already de- 
scribed. Hsematuria formed a marked feature of tbe case, 
and had continued for three years and a half. The pelvis 
of the right kidney was suspected, from the location of the 
pain, to be the seat of the disease. In order to expose tbe 
right ureter, an opening was made in the bladder at the 
point where it pierces the vesical mucous membrane. 
The name which I suggest for this new operation is 
kolpo-uretero-cystotomy; it is appropriate because it corre- 
sponds with the established nomenclature, and serves to dis- 
tinguish the operation from kolpo-cystotomy done for cysti- 
tis, and kolpo-ureterotomy, which may be done in future. 
When the orifice of the ureter was thus exposed, blood 
was seen exuding from it. The ureter having been made 
accessible, the subsequent treatment was the same as in the 
previous case, and the result equally fortunate. The dis- 
charge disappeared in a few weeks. The use of my utero- 
vesical support prevented all inconvenience from inconti- 
nence of urine, and made the patient so comfortable that 
haste in closing the opening was considered unnecessary. 
She was therefore sent home to Charleston, and instructed 
to return for this purpose when she was stronger and fully 
restored to health. 
She wrote me on August 12th the following report of 
her condition : “ The drainage works perfectly. There is 
no escape of urine, except sometimes a little while lying URINARY AND FJ3CAL FISTULJE IN WOMEN. 
down. Ido not suffer from any irritation whatever. The 
instrument keeps the uterus in position. I have not suf- 
fered any pain in the kidneys. I feel better than I have 
for years., I have just been weighed, so will acquaint you 
with the numbers—one hundred and nine pounds, having 
gained nineteen pounds in three months (that is, since the 
operation). I am able to attend church services. I can 
either ride or walk. Neither gives me any uneasiness. My 
friends look at me, and speak of my improvement with 
astonishment.” 
All the complications of gravity of urinary and faecal 
fistulae having now been studied, what I have already said 
may be, in conclusion, enforced by a brief summary of cer- 
tain important facts and principles, and an enumeration of 
the results that I believe may be secured by the employ- 
ment of the methods of treatment which I have described. 
1. The importance of the complications has not been 
duly appreciated. They form in many cases the principal 
difficulty in the way of the successful performance of the 
operation for the closure of the fistulous opening. In other 
cases, when the fistula is cured but the complications left 
without treatment, they lead sooner or later to suffering or 
to the death of the patient. The greatest care should, 
therefore, be taken to discover and remove them. 
2. Kolpokleisis, occlusion of the os uteri, and incarcera- 
tion of the cervix in the bladder or rectum, are unjustifiable 
operations. They destroy the functions of the genital 
organs, and lead to cystitis, the formation of renal and vesi- 
cal calculi, pyelitis, and other grave diseases. Moreover, 
they are unnecessary operations. By means of the gradual 
preparatory treatment of the complication, and by the aid 
of my button suture and dilating speculum I have been 
able to overcome all the difficulties which have been de- 
scribed as indications for their performance. 12 
the treatment of the complications of 
3. The association of intra-vaginal drainage with dilata- 
tion of the vagina is a great improvement. The inconven- 
ience and evil effects of incontinence of urine are thereby 
lessened, and the duration of the treatment is shortened hy 
the more rapid healing of the incisions and the formation 
of less cicatricial material in the reparative process. 
4. We now possess a means of palliating the suffering 
due to incontinence of urine in the small percentage of 
cases of fistula which are incurable by any method even 
the dangerous one of kolpokleisis. I believe some form of 
drainage instrument may be adapted to every case, and 
these patients may be thus restored to the enjoyment of 
life and the performance of its duties. 
5. The possession of a system of drainage will widen 
the scope of the operation of kolpo-cystotomy done for 
cystitis by removing the evils of incontinence of urine, now 
the chief objection to its performance. 
6. Finally, I believe the operation which I have called 
kolpo-uretero-cystotomy, followed by the exploration and 
treatment of the diseases of the ureter and pelvis of the 
kidney, has a brilliant future of usefulness before it. In 
the treatment of pyelitis, renal calculi, and obstruction of 
the ureters, it will restrict within narrow limits the opera- 
tions of nephrotomy and nephrectomy. 
Discussion. 
Dr. Grajxy Hewitt, of London, thought the operation de- 
scribed in the paper promised to be of much value, and would 
probably lead to important changes in our methods of treating 
cystitis and affections of the kidney. The ingenuity the author 
had brought to bear in getting rid of contractions and adhesions 
by constant pressure was remarkable, but the new operation for 
the treatment of pyelitis was most original and appeared to 
promise great results. Hitherto extirpation of the kidney had 
seemed to be the only treatment available in certain cases. URINARY AND FA3CAL FISTUIAE IN WOMEN. 
13 
Conservative surgery here stepped in, and in Dr. Bozeman’s 
snake-like sound we seemed to have a very important assistance 
in carrying out a conservative treatment in appropriate cases. 
Dr. A. Hewson, of Philadelphia, had effected much good in 
the class of cases referred to by Dr. Bozeman by dilating the 
vagina for twenty minutes daily with air-pressure. He had 
applied gases—carbon dioxide and hydrogen sulphide—directly 
to the location of the morbid parts through such instruments, 
keeping up the application of these gases for at least twenty 
minutes daily, the yielding and dissipating being apparent in the 
relief and comfort after the first application.