On 
Genital Renovation 
Kolpostenotomy and Kolpoecpetasis 
in 
Urinary and Fecal Fistules 
by 
BY 
NATHAN BOZEMAN, M. D. 
NEW YORK 
REPRINT FROM VOLUME VI. 
(Sjnmalflfltcal (EransiacttanS 
1882 GENITAL RENOVATION BY KOLPOSTENOTOMY 
AND KOLPOECPETASIS IN URINARY AND 
FECAL FISTULES. 
BY NATHAN BOZEMAN, M. D.A 
New York. 
PART I. 
Genital renovation, or genital anakainosis, as opposed 
to genital kleisis, particularly by kolpostenotomy and kol- 
poecpetasis in urinary and fecal fistules, without interfer- 
ence with the functions of the organs involved, is the title 
in extenso of the paper which I now have the honor of 
reading before this Society. 
The term genital kleisis is here used in a generic sense, 
and is intended to include all those operations employed 
to occlude or impair the vulvo-vaginal and uterine tract by 
interference with its functions. It was first proposed, I 
believe, by Dr. Anatole Le Double, of Paris, in 1876, in a 
treatise entitled, “Du kleisis genital et principalement 
de I’occlusion vaginale et vulvaire dans les fistules uro- 
genitales.” The term genital anakainosis is also used in 
a generic sense, and is intended to include all those op- 
erations employed to restore or renew the vulvo-vaginal 
and uterine tract without interference with its functions. 
This word, now used, I believe, for the first time, is formed 
from the Greek dm, again, and kouvl£w, to renew or restore, 
and has a wide signification, not only as regards lesions 
of the bladder and rectum, which involve the vagina, but 
also some of the lesions of the uterus and its appendages. 
Another word for which I am partly responsible, and which 
I propose to use in this connection, is ephelkosis, im, to, 
upon, and ZXkw, to draw, pull, drag. It is intended by this 2 
GENITAL RENOVATION. 
to describe the process or act of pulling to or drawing down 
the uterus like a drawer to make it subservient to the clos- 
ure of large defects in the vesico-vaginal and recto-vaginal 
septa. The operation itself is, therefore, called hystero- 
ephelkosis. Professor Horner, of Philadelphia, be it to the 
credit of American ingenuity, made the first systematic at- 
tempt in the Blockley Hospital to practice hysteroephel- 
kosis in a case presenting a very large vesico-utero-vaginal 
fistule, but he met with a disastrous failure.1 
The umbrella-shaped instrument which he employed in 
performing the operation was evidently of French origin, 
as its name, ephelcometre, suggests. There is still another 
word of Greek origin which I wish to introduce in connec- 
tion with the bladder, and that is stellosis, from o-re'AAw, to 
contract, fold up, to confine, restrain. When this word is 
united with the Greek work KuVns, bladder, we have cysto- 
stellosis, which is shorter than the phrase, contraction of 
the bladder, and preferable to the term atrophy of the blad- 
der, which is not applicable to the condition of the organ 
after its collapse, or folding up; a condition almost always 
found associated with large urinary fistules. As a com- 
panion word, therefore, for kolpostenosis, cicatricial narrow- 
ing of the vagina, cystostellosis seems to be called for, and 
the two words I shall have occasion to use frequently in 
this paper. Kolpoecpetasis I have already described in a 
former communication read before this Society ; and belong- 
ing to it, as part of the same procedure, we have kolposte- 
notomy, which is the surgical procedure of cutting into a 
cicatricially narrowed or distorted vagina. Kolpoecpetasis 
may be employed in simple, uncomplicated narrowing of 
the vagina from natural or morbid causes ; but in compli- 
cated narrowing or obliteration of the vagina from slough- 
ing, adhesions, cicatricial bands and bridles, tortuosities, 
distortions, etc., kolpostenotomy becomes an indispensable 
part of the procedure for gradually stretching open the 
organ, and maintaining its natural functions independently 
of those of neighboring organs, Kolpoecpetasis with kol- 
1 Am. J. M. Sc., vol. xxi., p. 109, 1837. NATHAN BOZEMAN. 
3 
postenotomy, therefore, forms a very important part of the 
treatment of urinary and fecal fistules, and this is readily 
admitted when it is remembered that kolpostenosis in some 
form or other constitutes about one half of all the cases 
met with in practice. Kolpostenosis is almost always com- 
plicated by cystostellosis to a greater or less extent. Kol- 
poecpetasis, in addition to its special sphere of usefulness 
in opening up the vagina and restoring that organ to the 
normal dimensions, fulfills a most important indication as 
regards the lost function of the bladder, namely, the obtura- 
tion or the stopping up of the fistulous opening, as does 
the lid when placed upon the mouth of a modern milk jar, 
thus forcing the bladder to take on, to a certain extent, its 
function of retaining the urine, and afterwards of dilating 
pari passu with the expansion going on in the vagina. In 
this process the urine, notwithstanding the existence of the 
fistulous communication between the bladder and vagina, is 
made mechanically to perform the part of a dilator, and the 
operation, properly speaking, is cystoecpetasis, to stretch 
open the bladder, a companion word to kolpoecpetasis. 
Some may object to the introduction of so many new 
words, but why should they, if the terms can aid us in the 
study and the rational treatment of a class of diseases so 
important as the one under consideration ? In the nomen- 
clature of diseases of the male genito-urinary organs we 
find descriptive words applied to special operations, as for 
example, urethral dilatation, urethral divulsion, internal and 
external urethrotomy, excision of the third lobe of the pros- 
tate gland. These are all words or phrases intended to 
fix the attention upon the various resources of our art for 
overcoming the obstacles which prevent the performance 
of the normal functions of the organs involved. These 
operations are all based solely on the idea of maintaining 
the genital tract intact, without hindrance or implication of 
neighboring organs, and are known to be in strict accord- 
ance with the highest aims of pathology, physiology, and 
therapeutics, 1 
In the study of diseases of the female genito-urinary or- 4 
GENITAL RENOVATION. 
gans, then, why should we not have words equally express- 
ive, and such as give a clear conception of the character 
and objects of the operations required upon them ? Is it 
because there is in the field of vaginal surgery a less com- 
prehensive nomenclature of diseases and a greater uncer- 
tainty in the employment of our resources for their cure 
than in the domain of urethral surgery, that we are forced 
to be less precise in our descriptions and use of scientific 
terms ? This would really seem to be true as shown by 
some of our advanced teachers and writers of the day se- 
riously treating the perforating lesions of the vaginal walls 
under the generic term of “ Vesico-vaginal Fistula,” and of 
giving unwarranted prominence to the expedients devised 
for the accompanying complications regardless of the sac- 
rifice of physiological functions. Some of the evils of this 
teaching and practice will be brought out in the course of 
these remarks. 
My object in calling attention to the subject of genital 
kleisis at the present time is threefold ; first, to examine 
critically this system of practice together with some of the 
published statistics of the promoters of it, especially of 
the late Professor Simon, its most earnest advocate, and 
with the view of learning more definitely its limits, its ap- 
plication in practice, and its dangers, immediate and remote ; 
second, to show how genital anakainosis or genital renova- 
tion has been brought to its present high state of perfec- 
tion, and with the view to directing the attention of the 
profession more pointedly to the range of its usefulness, 
its application in practice, and the little danger, compara- 
tively, attending its employment; and, thirdly, to present 
a comparative analysis of the results so far as the statistics 
which we have of the two methods will permit. The sta- 
tistics used in support of genital anakainosis are those ob- 
tained from my own practice, amounting to one hundred 
and twenty cases, the last fourteen of which, excepting one, 
having been treated in the Woman’s Hospital, of the State 
of New York, since my appointment as surgeon in Feb- 
ruary, 1878. NATHAN BOZEMAN. 
5 
A. GENITAL KLEISIS. 
In 1832, when Vidal (de Cassis) first proposed to obliter- 
ate the vulva for the relief of incontinence of urine in ves- 
ico-vaginal fistules, thought to be otherwise incurable by 
the best resources of our art, he believed that no fistule 
situated in the has fond of the bladder and attended with 
loss of tissue, had ever been cured. Notwithstanding the 
fact that up to 1845 no success by his method, not even in 
a single case, had been recorded, still Vidal continued to 
question the possibility of curing a fistule of large size in 
the bas fond of the bladder, and maintained his confidence 
in the utility of his genital kleisis. At this date, however, 
August Berard, an earnest follower of Vidal, made trial of 
the method in a case supposed to be suitable, and the re- 
sult was an almost complete success, the woman being able 
to retain and pass naturally a considerable quantity of 
urine ; but on the seventeenth day she was seized with 
peritonitis, and on the thirty-eighth day died. At the au- 
topsy pleuro-pneumonia, in addition to slight peritonitis, 
was found to exist. It was also discovered that the line of 
union in the vulva was complete, excepting two small points. 
Berard reported the case to the Academy of Medicine of 
Paris, on the nth of February, 1845, when a very warm 
and excited discussion ensued, which was continued through 
two succeeding seances, Dubois, Blandin, Gerdy, Moreau, 
Roux, Velpeau, and others, participating. The result was 
that not only Berard was censured for having caused the 
death of his patient, but the operative procedure itself was 
condemned as irrational and undeserving of confidence. 
After this the method fell into general disfavor. It was not 
long, however, before the principle of the method was re- 
vived by Jobert (de Lamballe), and was extended to the ob- 
literation of the mouth of the uterus for the relief of in- 
continence of urine resulting from vesico-uterine fistules, 
and to the shutting up of the cervix uteri in the bladder for 
the same purpose in vesico-utero-vaginal fistules.1 Again 
1 Traite desfistules vesico-uterine, etc., 1852, 6 
GENITAL RENOVATION. 
the principle, after the lapse of eight or ten years, found 
an advocate in Professor Gustav Simon, then residing in 
Darmstadt, Germany. He extended it to the urethral por- 
tion of the vagina in the form of transverse obliteration. 
(Quere Obliteration der Scheide.)1 
In 1856 I finished the treatment of a case of vesico-utero- 
vaginal fistule by turning the cervix uteri into, the bladder 
(hysterocystokleisis), an operation which had been com- 
menced by Dr. Sims, and left after two or three failures. 
The case was published in the “ North American Medico- 
Chirurgical Review,” for July and November, 1857. In an- 
other case, in 1859, after closing a large recto-vaginal fistule 
by uniting its borders, there remained a large urethro-utero- 
vesico-vaginal fistule, with only the lower half of the ure- 
thra intact. Coupled with the extensive perforations in the 
two walls of the vagina there was present also the compli- 
cation of kolpostenosis to the extent of scarcely allowing 
the index finger to pass. Here it was only after the em- 
ployment of kolpostenotomy and kolpoecpetasis, and after 
the recto-vaginal fistule had been closed, that I found coap- 
tation of the sides of the urinary fistule impossible, and 
thought of transverse obliteration of the vagina (kolpoklei- 
sis) below the chasm. This I did in March of the year 
named as an original procedure, not then having ever heard 
of Professor Simon or his peculiar views upon the subject. 
The result was a complete closure at the first operation.2 
In 1856, just before or about the time Dr. Sims adopted the 
interrupted silver suture as a new method, he performed 
obliteration of the vagina in two cases of vesico-utero-vagi- 
nal fistules (kolpokleisis), but in these cases the urethral 
portion of the vagina was intact, a condition of the parts 
which even at that early day was regarded by me as contra- 
indicating such a line of practice.3 The credit, however, 
was due to Professor Simon for having first made the ap- 
plication of the principle. His first patient, Margaretha 
1 Deutsche Klinik, Fall viii., August 15, 1856. 
2 New Orleans M. andS. J"., January, iB6O. 
8 Cases IV. and V., Silver Satures in Surgery, 1858. NATHAN BOZEMAN 
7 
Hubert, was operated upon in May, 1855, in the presence 
of Drs. Orth, Eigenbrodt, and Hegar.1 The occasion of the 
operation was a vesico-utero-vaginal fistule, complicated just 
below by a kolpostenosis, the latter lesion opposing access 
to the former for treatment. The operation consisted in 
paring off the sides of the stenosis and uniting the front 
and posterior sides with double rows of silk sutures, a plan 
which Professor Simon only a short time before had per- 
fected. After the fourth trial the opening was reduced to 
a point so small that the patient could retain a large part 
of her urine and pass it in the natural way. 
From this success Professor Simon was led to conclude 
that the procedure was a great improvement on the method 
of Vidal. After this it became an established operation with 
him, and was soon adopted by other German surgeons. 
Among them were Roser, Wernher, Wilms, Ulrich, Bar- 
deleben, Wagner, Esmarch, Spiegelberg, and Hegar. In 
1867, Professor Simon states in his book on “ Plastic Sur- 
gery,” that he had obtained up to that date, twenty-eight 
successful closures of the vagina. Then, having so high an 
appreciation of the method, he called it kolpokleisis, and 
divided it into two forms ; to wit: transverse and oblique 
kolpokleisis. His indications for the procedure in these 
two forms were eight, namely : (a) Great loss of substance, 
making it impossible to bring the sides of the fistule to- 
gether ; (b) Inaccessibility of the fistule; (c) Loss of the 
infra-vaginal cervix uteri and danger to the peritoneum ; 
(d) Hemorrhage into the bladder, if severe, after operation ; 
(e) Incarceration of the cervix uteri in the bladder; (/) 
Atresia of the vagina above the fistule; (g) Atresia of the 
urethra with one fistule above and one below ; (h) Uretero- 
vaginal, and uretero-uterine fistules ? 
This brings us to a study of the statistics of Professor 
Simon, statistics as completed and published by him in his 
letter addressed to me in the “Deutsche Klinik,” 1868, 
which gives the best reflex of his practice to be found any- 
where in his writings. He published this communication 
1 Deutsche Klinik, Fall viii., August 15, 1856. 8 
GENITAL RENOVATION. 
under peculiar circumstances, to wit; In defense of his 
claim of priority of the operation of kolpokleisis, and this, 
too, at the time when the procedure had been received with 
the highest favor in Germany. It may be inferred, there- 
fore, that no case or fact relating to the substantiation of 
his claim to the originality of the operation was omitted in 
order to make his tabular statement complete. From his 
English translation I make the following extract, which in- 
cludes his statistics in full from 1853 to the autumn of 1868, 
a period of fifteen years. 
“My results, in toto, are consequently the following : Of one 
hundred and eighteen fistules which existed in one hundred and 
five patients, one hundred and four fistules which existed in 
ninety-two patients were completely cured ; five fistules which 
existed in five patients were closed except small openings ; three 
fistules which existed in two patients, as incurable, dismissed ; 
six patients died. 
“ Thus in comparing the results of 1859 by the old imperfect 
method, with those attained after that year by means of the im- 
proved one, the proportion is considerably in favor of the latter. 
While previous to 1859, °f twenty-two fistules only fourteen 
= 64 per cent.) were cured and two patients (= 9 per cent.) 
died, after that period, of ninety-six fistules which existed in 
eighty-three patients, eighty-nine (= 92! per cent.) fistules in sev- 
enty-seven patients were cured and only four patients per 
cent.) died. 
“With what safety the cures are effected by my simplified 
method the following report of my latest operations may serve 
to inform you, besides my works of 1862 and 1868, in which the 
results are given in detail. During six months’ residence at 
Heidelberg (from May to October, 1868) we have operated, in the 
hospital, on fourteen fistules in fourteen patients. I have per- 
formed twelve and my assistants Messrs. Heine and Hotz 
each one. Three of the fistules were very small; they had re- 
mained after previous operations at Rostock; the other eleven 
were new cases, but six of them had been operated upon already 
once or several times by other surgeons. Several of them were 
of considerable size; in five cases twelve sutures were required in 
order to close them, in one even fifteen. Moreover, different com- NA THAN BOZEMAN. 
9 
plications existed, which made it necessary three times to embrace 
the posterior lip of the os uteri in the suture ■ once to overlap an 
existing atresia of the urethra; once to remove one ; twice to per- 
form kolpokleisis, and once to make a transplantation of a flap 
from the vulva. Yet, notwithstanding these troublesome circum- 
stances, all fourteen patients were cured by seventeen operations. 
Of these eleven required only one operation; three had to be 
operated on twice each among them were two small fistules 
which had remained from previous operations.” 
From a glance at these figures, one in search of informa- 
tion regarding the operation of kolpokleisis and the results 
attending its use, will be sadly disappointed at finding no 
distinction made between the cures effected by it, and those 
secured by direct operation, namely: “By uniting the bor- 
ders of the defect.” I confess that I examined and was 
disappointed, since just here is to be found the measure of 
differences between the results of practice by Professor 
Simon and myself, and of the value to be attached to the 
one and to the other. But nevertheless, it is possible to 
supply this defect in Professor Simon’s figures from state- 
ments made in his work on “ Plastic Surgery,” 1 published 
in the same year and only a few weeks prior to the date of 
his tabular statement. Here it is seen that during the pe- 
riod of thirteen years, commencing with Margaretha Hu- 
bert (1855), and ending at the date of the work above 
quoted, he had had twenty-eight cases in all treated by 
kolpokleisis alone. Add to these the six cases out of the 
fourteen patients treated at Heidelberg from May to Octo- 
ber, 1868, and the total number will be thirty-four cases. 
Of the cases, therefore, submitted to direct operations by 
uniting the borders of the defect and preserving the func- 
tions of the organs involved, there are fifty-eight, and of 
those submitted to indirect operations (kolpokleisis) by di- 
visional closure and impairment of the genital tract without 
regard to existing lesions or normal functions there were 
thirty-four; being in the proportion of fifty-eight to thirty- 
four. 
1 Beitrage surplustischen Chirurgie, Prag, 1868, vol. ii., pp. 217 and 
218. GENITAL RENO VA TION. 
With this discrimination, therefore, in the character of 
the ninety-two cures claimed out of one hundred and five 
cases by Professor Simon, his figures, rearranged, stand as 
follows : 
Fifty-eight cases were cured by uniting the borders of the fis- 
tule or direct operations with preservation of the vagina, 52.23 
per cent. 
Thirty-four cases were treated and ameliorated by kolpokleisis 
or indirect operations with sacrifice of the vagina, 32.38 per 
cent. 
In five cases the fistules were closed except small openings, 
4.76 per cent. 
In two cases the patients were dismissed as incurable, 1.90 per 
cent. 
In six cases the patients died, 5.71 per cent. 
As to the number of operations required to complete the 
cures and ameliorations by kolpokleisis in these one hundred 
and five cases there is no clue, except in the fourteen cases 
treated at Heidelberg, which were sufficiently satisfactory 
as to repetitions. Only eight cases out of the fourteen, 
however, were real cures, 57.15 per cent., six of the number 
being simply ameliorations, 42.85 per cent. These figures 
as to real cures are almost the same as those in Professor 
Simon’s original table and go far to corroborate the relative 
proportion above given ; as to the ameliorations, the propor- 
tion is considerably above that in his table. It may be said 
that the bridging over of an obliterated urethra in one of 
these fourteen cases was not kolpokleisis. This is true to 
some extent, but it is equally true that the operation was 
an expedient and the result was not a cure, since it left an 
obstruction to the flow of urine, and the patient afterwards 
was exposed to the formation of stone in the bladder. The 
turning of the cervix uteri into the bladder, it may be said, 
also, was not kolpokleisis, since the operation left the pa- 
tient with a large part of the genital tract intact; but it 
must be remembered that this result was obtained at the 
expense of fecundity and of the habit of ever afterwards 
menstruating by the urethra, a condition of things which NATHAN BOZEMAN. 
11 
does not comport with a high degree of excellence in the 
operative procedure or of skill in employing it. The best, 
therefore, that can be said for those results is that they 
were ameliorations and only deserve to be so classified. 
The same remarks apply with equa] force to the four amel- 
iorations thus secured by Dr. Sims and myself from 1856 
to 1859, as before mentioned. 
Let us here see what had been the experience of other 
surgeons with genital kleisis up to about the time that Pro- 
fessor Simon published his statistics. Dr. Sims, in a letter 
dated August 4, 1864, addressed to Dr. Jose E. Monteros,1 
and published by the latter, stated that up to that time he 
had had under his observation three hundred and twelve 
cases of urinary fistules in women, two hundred and sixty of 
which he had cured, 80.01 per cent. Out of this number 
of cures there were twelve cases in which the cervix uteri 
was turned into the bladder with urethral menstruation, 
(hysterocystokleisis) with which his two cases of kolpoklei- 
sis previously referred to made fourteen cases, a percentage 
of 4.48. As to the precise number of cases treated by Dr. 
Sims from 1856 to 1864 by kolpokleisis and hysterokleisis, 
the period during which the greater number of his cases 
occurred, he leaves us in ignorance, but judging from the 
fact that he so early resorted to both of the latter proced- 
ures in his practice, the presumption is that the number of 
kolpokleidic and hysterokleidic cures was equal to, if not 
greater than, that obtained by shutting up the cervix uteri 
in the bladder, amounting in all to at least thirty cases, 
9.62 per cent. ; at all events this is about the average per- 
centage of genital kleisis by his method, as we shall pres- 
ently see. It is well known that Dr. Sims had had compar- 
atively little success previous to the adoption of his present 
method of operating, June 24, 1856; and were it not that 
the seemingly large number of his cases (three hundred and 
twelve) is so fully authenticated by Dr. Monteros, I should 
be disposed to think there was some mistake, judging from 
1 Essai sur le traitement des fistules genito-urinaires chez la femme. 
1864. 12 
GENITAL RENOVATION. 
the experience of other surgeons with equal opportunities 
for observation during the same period. Dr. Sims not hav- 
ing reported in detail over a score or two of these cases, it 
is of course impossible to verify his exact percentage of 
genital kleisis by reference to individual cases. 
Mr. Isaac Baker Brown, a partial adherent of the Sims 
method, in the third edition of his work, entitled, “ Surgi- 
cal Diseases of Women, 1866,” reports in detail eighty-nine 
cases of vesico-vaginal fistule, in its various forms. Of this 
number six were treated by genital kleisis : one by obliter- 
ating the os uteri fora vesico-uterine fistule (hysterokleisis), 
three by uniting the posterior lip of the cervix with the an- 
terior border of the fistule (hysterocystokleisis), and two by 
obliteration of the vulva and orifice of the vagina (episio- 
kolpokleisis). Mr. Brown’s recourse to genital kleisis, 
therefore, in his eighty-nine recorded cases, amounted to 
6.74 per cent. 
Dr. T. A. Emmet, a strict adherent of the Sims method, 
in his book entitled, “ Vesico-Vaginal Fistula, 1868,” re- 
ports in detail seventy-five selected cases. Of this number 
there were seven cases treated by genital kleisis : one by 
obliteration of the os uteri for a vesico-uterine fistule (hys- 
terokleisis), five by uniting the posterior lip of the cervix 
uteri with the anterior border of the fistule (hysterocysto- 
kleisis), and one by uniting the walls of the vagina (kolpo- 
kleisis). Dr. Emmet’s percentage is 9.33 per cent. 
It will be seen, therefore, from an average of the per- 
centage of resorts to genital kleisis by the above three sur- 
geons, that it differs widely from that of Professor Simon, 
being 23.82 per cent. less. The explanation of this differ- 
ence will appear further on. As to the death rate of these 
three surgeons, there is nothing to show that it exceeded 
four per cent., which speaks well in this particular for 
their method of operating. That of Professor Simon was 
5.71 per cent, as we have seen, which is not large, particu- 
larly when compared with the mortality of his followers, 
especially with kolpokleisis, which alone, in the hands of 
some, reached twenty-five per cent. The latter figure may NATHAN BOZEMAN. 
13 
seem high as compared with that of Professor Simon, but 
I doubt very much, judging from what I saw and learned 
of the operation of kolpokleisis in Europe, whether it is 
much, if at all, above the average. Of the four cases I 
there saw operated upon, two died, making fifty per cent. 
In four fifths of the cases in which kolpokleisis has been 
performed, I venture to say that kolpostenosis, in some form 
or another, existed. In cases with this complication, ac- 
cording to my experience, the tendency is in a large pro- 
portion of them to alkalinity of the urine. Under such 
circumstances phlegmonous inflammation is exceedingly 
liable to follow any operation of genital kleisis, especially 
where there is much exposure of raw surfaces to the action 
of such urine, shut up as it is in the vagina, and conse- 
quently the danger of the pelvic peritoneum becoming in- 
volved is greatly increased. This undoubtedly is the expla- 
nation of the high mortality indicated. 
As to the frequency of the indications laid down by 
Professor Simon for kolpokleisis and the acceptance of 
them by surgeons generally in Europe, I am satisfied from 
what I saw there during a visit of nearly three years (from 
July, 1874, to April, 1877), that they are strictly adhered 
to. Of twenty-one cases which I was called upon to exam- 
ine for an opinion, eight in Germany, five in Austria, and 
eight in France, eighteen of the number either showed 
kolpokleisis already commenced or bore acknowledged con- 
demnations of the procedure as a dernier ressort. 
Again, as to the objections and dangers of kolpokleisis. 
It was a careful study of the remote causes of death after 
this operation that first led me in 1868 to investigate and 
oppose it, and that the grounds of my opposition were well 
taken additional facts have since abundantly proved. I 
had seen already as far back as 1859, after performing my 
first and only kolpokleisis, a case of large recto-vaginal fis- 
tule with a thick, hard, and unyielding kolpostenosis, com- 
plicated with pregnancy at six months, which to my mind 
foreshadowed imminent danger. The vaginal tract was 
reduced to the size of the index finger. It was only by 14 
preparatory treatment (kolpostenotomy and kolpoecpetatis) 
that I was enabled to save this woman from further inju- 
ries and to preserve the life of her child, the latter object 
being regarded by the parties concerned as of the greatest 
importance. I intentionally brought on labor at the sev- 
enth month after the preparatory treatment had been fairly 
completed, and by only a few incisions, when the child’s 
head had descended to the point of stenosis, and the timely 
use of the forceps, I effected a safe delivery of the mother, 
and saved the child, which afterwards throve and did well. 
The kolpostenosis in this case was no less a remote cause 
of danger to the life of this woman than if it had been ne- 
phritis or pyonephrosis, remote causes of death after kolpo- 
kleisis. Another case of almost complete spontaneous kol- 
pokleisis came under my observation in the spring of 1870. 
It was the result of a protracted labor. There existed here 
a recto-vaginal and a urethro-vesico-vaginal fistule. The 
kolpokleisis in the urethral portion of the vagina, in corre- 
sponding relationship to the two fistules, was complete with 
the exception of a point only large enough to admit a 
very small surgeon’s probe. In this blind process of na- 
ture both fistules were inclosed, and continence secured of 
both feces and urine. This was the first case to open my 
eyes in a practical way as to the remote results or causes 
of death, from direct interference with normal functions. 
This woman had labored under these several lesions for 
five or six years, but the spontaneous closure of the vagina 
did not reach its stage of causing complete continence of 
urine and feces until six or eight months before my advice 
was sought. 
GENITAL RENOVATION. 
Now Nature’s work and the result, as regarded the con- 
tinence of feces and urine, were just as satisfactory, so 
far as they went, as possibly could have been secured by 
the surgeon, and yet before they were fully completed some 
of the remote results had already developed. When the 
woman applied for treatment her condition was such as to 
augur a speedy termination by death. Indeed it was only 
by the most timely interference of undoing her spontane- ous kolpokleisis and restoring the genital tract that her life 
was saved. After kolpostenotomy and kolpoecpetasis both 
fistules were cured by uniting the borders of the defect, 
thus proving in this instance the work of art to be superior 
to that of Nature. This patient remains perfectly well, 
now after eleven years. 
NA THAN BOZEMAN. 
15 
Here then were found the remote causes of death as the 
result of the spontaneous operations of Nature alone; but 
were no less important, as bearing upon the subject, 
than if the kolpokleisis had been effected by the hand of 
the surgeon, and in consequence the remote causes had 
been developed in the usual way. 
Furthermore, seeing now in my case of kolpokleisis ef- 
fected eleven years prior to this, that the beneficial results of 
the operation had considerably diminished as regarded the 
continence of urine, and were likely soon to be lost entirely, 
I naturally concluded that the legitimate evils of the expe- 
dient were in progress and would soon develop into the 
remote causes of death as in the preceding case. In this 
train of thought I then addressed a letter (1870) to Profes- 
sor Wernher, of Giessen, Germany, one of the earliest pro- 
moters of kolpokleisis after Professor Simon’s adoption of 
the principle, and perhaps the earliest to record a success 
by it; he replied promptly to the effect that only a few 
months before receiving my letter his patient had died, and 
at the autopsy he found a calculus the size of a pigeon’s 
egg in the vagina just above the cicatricial diaphragm. 
Such were the data upon which my first investigations 
with regard to kolpokleisis were based, and which led me 
to the conviction that the operation was exceedingly dan- 
gerous as regarded its remote consequences, and was alto- 
gether too indiscriminately employed everywhere in Amer- 
ica as well as in Europe. This belief I then set forth in 
my paper upon the subject.1 
Soon after this, and in the same line of investigation, my 
attention was called to the objections and dangers of the 
Sims’ method of operating for urinary fistules, which I had 
1 Am. Jour. Med. Sciences, July, 1870. GENITAL RENOVATION. 
long suspected but of which I had not before had positive 
proof. I conceived that the dangers arose from certain er- 
roneous principles of practice ; first, the rendering of cica- 
tricial bands or distortions of the vagina available for fold- 
ing or turning the borders of the fistule, like shelves, into 
the neighboring organs without regard to structure or func- 
tions ; and second, in the absence of kolpostenosis from the 
plaiting or folding in of one or the other of the vaginal walls 
with corresponding projections into neighboring organs 
without regard to the passage of urine or feces. These 
principles of practice I will designate under the term sec- 
tional kolpokleisis, in contradistinction to Professor Simon’s 
divisional kolpokleisis, Of the first form of sectional kol- 
pokleisis referred to, the objections and dangers are mani- 
fested in the occurrences of cystitis and stone formations 
in the vesical pockets or shelves, as occurs generally after 
divisional kolpokleisis. Numerous examples of the above 
sequences could be cited from high authorities, but the 
liability to such complications is so self-evident from the 
peculiar mechanism thus induced in the interior of the 
bladder as not to be called for here. As to the second form 
of sectional kolpokleisis mentioned, however, it is not so 
frequently met with and deserves here a more extended no- 
tice. I cannot do better, therefore, than cite the following 
case presenting a small and uncomplicated urethro-vesico- 
vaginal fistule. 
I was requested to see Mrs. S. in consultation with Dr. 
S. W. Dana of this city on the nth of November, 1870, 
only a few months after my first paper condemning divis- 
ional kolpokleisis had appeared. The doctor himself called 
late at night to ask me to see this patient, believed to be 
laboring under uremic poisoning. He stated that she had 
been operated upon in one of our hospitals for a urinary 
fistule by a distinguished gynecologist of whom there could 
be no doubt as to skill, six months previously, and that a 
catheter to draw off the urine had been used daily ever 
since, as he had been informed. The patient had been 
under his care only three or four weeks, but during this NATHAN BOZEMAN 
time he had been compelled to use the catheter daily. For 
the past two days he said the quantity of urine had so di- 
minished and the condition of the patient had become so 
alarming that he feared a speedy termination of the case 
from the cause above mentioned. 
Suffice it to say, I found the patient suffering from cystitis 
and cystostellosis attended with the most violent tenesmus. 
There was also stillicidium of urine. The introduction of 
a catheter showed little or no urine in the bladder, but 
the use of the instrument revealed the existence of a soft 
yielding substance in the neck of the organ. The patient 
stated that her suffering began soon after she was operated 
upon for the closure of the fistule in her bladder, and that 
she had been pronounced cured. She was told at the time 
of her dismissal from the hospital that it would be neces- 
sary to have the urine drawn off with an instrument every 
day for two or three weeks. She said the introduction of 
the instrument had gradually become more and more pain- 
ful until she could no longer endure it. 
After learning this history of the case I suggested the ad- 
ministration of morphine to the extent of allaying pain and 
procuring sleep, promising to call the next day to determine 
the situation of the urinary fistule which I knew existed at 
some point in the genito-uterine tract. My examination, in 
which I was assisted by Dr. Dana, showed a great shorten- 
ing of the anterior wall of the vagina and a cicatricial line 
about two inches in length running directly across the root 
of the urethra, all the result, as I then thought, of the clos- 
ure of a large urethro-vesico-vaginal fistule. The precise 
relationship, however, of this condition of the parts in the 
vagina with the soft, yielding body in the neck of the blad- 
der, I could not at first comprehend or explain ; it was 
something I had never encountered before, after any of 
my operations in this region. Next turning my attention 
to the presence of urine in the vagina, I began to search 
for the fistulous opening, but I utterly failed to find it here. 
After wiping dry the os uteri and placing a piece of old 
or worn linen over it (my linen test) the source was, soon 18 
GENITAL RENOVATION. 
proven by the merest point of moisture on the linen. The 
escape was from the cervical canal. Dilatation of the os 
uteri with a sponge tent and the application again of the 
linen test showed precisely the point of communication in 
the canal with the bladder. In this way was demonstrated 
not only the existence of a vesico-utero-cervical fistule, which 
had escaped the observation of the gynecologist referred to, 
but the mechanism of the course of the urine from the blad- 
der into the vagina and the error of supposing uremic ab- 
sorption which had been entertained by the physician in 
attendance. 
The course of treatment adopted was to lay open the an- 
terior lip of the cervix uteri from the fistulous sinus down 
to the bladder and vesico-vaginal septum, pare off the bot- 
tom of the sinus and then close the parts a procedure 
devised by me in 1856 for fistules of this class. The result 
was a total failure owing to the complication of cystitis and 
cystostellosis, the extent of which I did not fully appreciate 
before. 
Seeing now that the disease of the bladder was the ob- 
jective point of rational treatment, and believing that this 
was referrible to some peculiar mode of closing the little 
urethro-vesico-vaginal fistule by the surgeon previously in 
charge of the case, I determined to open up his cicatrix and 
learn definitely of what the soft, yielding body in the neck 
of the bladder consisted, and if possible remove it. The 
considerations that influenced me at this juncture to adopt 
this course were : First, the patient had no power to pass 
urine voluntarily ; Second, the painfulness of introducing 
the catheter and the daily increasing vesical tenesmus ; and 
Thirdly, fears of speedy exhaustion and death. The opera- 
tion was performed in the presence of Drs. Frank H. Ham- 
ilton, Samuel T. Hubbard, T. C. Finnell, J. F. Chauveau, 
and several other physicians, all of whom concurred in the 
opinion that the operation was urgently demanded under 
the circumstances. The first step consisted in piercing 
the cicatrix just where it crossed the urethra and then slit, 
ting it up right and left in its entire extent about two 
inches —as stated. When this was done, very much to the NATHAN BOZEMAN. 
19 
astonishment of all present the two sides of the divided 
parts separated and spread out, presenting a raw surface 
over an inch in width, and a small fistulous opening in the 
centre of the sulcus formed, large enough to admit an ordi- 
nary probe. A catheter was now introduced which showed 
the complete disappearance of the obstacle previously en- 
countered in the neck of the bladder. The second step of 
the operation consisted in enlarging the small fistule up- 
wards to the size of a half dollar, the object of this being 
to put the bladder at perfect rest and to insure an unin- 
terrupted outflow of the urine and the muco-purulent secre- 
tions. The result was that the patient was promptly re- 
lieved of all her urgent and threatening symptoms and 
placed in a position to be cured. It was nearly eight 
months, however, before the bladder got into a normal con- 
dition and the artificial fistulous opening could be closed. 
This was effected at a single operation with the button su- 
ture, and soon afterward the vesico-utero-cervical fistule 
was shut up by the same method and all in accordance 
with the highest aims of genital anakainosis. The patient, 
after a year’s treatment, was discharged cured and remains 
so to this day, now over ten years. 
Another case illustrating the objections and dangers of 
the Sims’ method by folding or turning different structures 
into neighboring organs without regard to functions, came 
under my observation in August, 1871. It formed the sub- 
ject of a communication by me to be found in the Trans- 
actions of this Society for 1879. Here the disease was a 
recto-utero-vaginal fistule, and the complication suggesting 
the expedient, a kolpostenosis stretching across the poste- 
rior wall of the vagina just beneath the fistule. The sur- 
geon who preceded me, one of the most eminent of New 
York in this department, not deeming it possible to remove 
the stenosed obstruction, decided to make it available for 
bridging over the chasm in the recto-vaginal wall by uniting 
its apex with the anterior lip of the cervix uteri (hystero- 
proctokleisis), thus turning the menstrual flow through the 
rectum and enforcing sterility. It is true the operative 20 
procedure failed by the cutting out of the silver wire sutures 
as shown by one of the latter which I found five years and 
a half afterwards hanging in the summit of the stenosed 
point, but this is of no consequence ; it is not the failure 
I criticise, but the practice. As to the unjustifiability of 
the procedure, it is only necessary now to say that through 
the judicious employment of kolpostenotomy and kolpoec- 
petasis the opposing obstacle was overcome, the borders of 
the fistule reached and united, and the patient discharged 
cured on the principle of genital anakainosis. No stronger 
proof of the brilliancy of the result could be adduced than 
the fact that the woman afterwards conceived and bore a 
child at seven months. The mishap of premature labor was 
caused, some two years after her cure, by an exceptionally 
severe voyage from the West Indies to New York. 
GENITAL RENOVATION. 
It was under those circumstances, and with those impres- 
sions concerning the objections and dangers of genital 
kleisis in the several forms here particularly referred to, 
that I visited Europe in 1874, intending to renew my in- 
vestigations there upon the subject, my hospital advantages 
at home not being adequate. After meeting with several 
eminent surgeons and gynecologists in Germany, among 
them Professors Esmarch, Bardeleben, Martin, and Crede, 
and conversing with them upon the subject, I received a 
very kind and liberal proposition from the late Professor 
Simon to visit Heidelberg, and take part with him in the 
operations required in a considerable number of cases of 
vesico-vaginal fistule, which he then had in the hospital of 
the university, in order to test the relative advantages of 
our respective modes of operation in these cases. I ac- 
cepted Professor Simon’s proposition about the Ist of Oc- 
tober, and began work in a most practical way, alternating 
with him in operations as the cases presented. 
Among the first cases I saw in the hospital after I ar- 
rived in Heidelberg was one of pregnancy occurring after 
an almost complete kolpokleisis about half an inch behind 
the meatus urinarius. Mr. Spencer Wells happened to be 
present on the occasion. The little remaining opening NATHAN BOZEMAN. 
21 
could only be seen by the closest search. Through this 
little filiform tract the spermatozoa entered and traversed 
the whole length of the vagina to the cavity of the uterus, 
the former at the time being the recipient of all the urine 
through a urethro-vesico-vaginal fistule. Pregnancy was 
the result, and the woman presented herself at about the 
fourth or fifth month of gestation for medical advice. Pro- 
fessor Simon having already thoroughly investigated the 
case requested an opinion from Mr, Wells and myself re- 
spectively as to what was best to be done for the woman 
under the circumstances. Mr. Wells expressed his belief 
that it was best to permit the pregnancy to progress to full 
term, and then when the child’s head had put the cicatricial 
diaphragm or kolpokleidic closure on the stretch to lay the 
parts open by incision, thus allowing the completion of 
labor. He stated that he had had a similar case himself 
after one of his kolpokleidic operations, and he recom- 
mended this course of procedure, which turned out well. 
In theory I regarded this opinion of Mr. Wells correct as 
far as it related to his own case, knowing, as he did un- 
doubtedly, that the vagina above the seat of his kolpokleidic 
closure was free from stenosis as a complication of the co- 
existing fistule, but I knew perfectly well, from the light 
thrown upon the case before us by the investigations, that 
kolpostenosis was the complication of the fistule, which had 
in the first place led to the uncompleted kolpokleisis now 
existing, and that to wait for the child’s head to pass this 
stenosed point of the vagina, and put the kolpokleidic dia- 
phragm below on the stretch, according to the opinion of 
Mr. Wells, would be to expose the woman unnecessarily to 
further injuries, and perhaps to the loss of her life, as well 
as that of her child. From the experience I had had in 
the case of pregnancy, associated with a recto-vaginal fis- 
tule and kolpostenosis, before referred to, I gave an opinion 
directly opposite to that of Mr. Wells, which was based on 
the belief that the proper course under the circumstances 
was to undo at once the kolpokleidic closure, overcome the 
kolpostenosis, and thus prepare the vagina for the incoming 22 
GENITAL RENOVATION 
head of the child at premature or full birth, as might after- 
wards be determined by the adaptability of the restored 
vagina. 
Suffice it to say, Professor Simon concurred in the 
opinion of Mr. Wells, and sent the woman home with in- 
structions to the family physician how to proceed when 
the labor should set in. The result was, as Professor Si- 
mon afterward informed me, that the physician in charge 
failed to carry out the instructions or found it impossible 
to do so, and the woman sustained terrible injuries in ad- 
dition to those she already had. So serious and extensive 
were these complications now, he further said, that no hope 
was left for her relief, not even from a second kolpokleisis. 
Now, whether the physician in charge of the case was to 
blame for the misfortune of this poor woman, or could have 
done any better under the circumstances, I very much 
question. The cause of the trouble and accident no doubt 
was the preexisting kolpostenosis, as I believed at the time 
of giving my opinion, and the only thing to have been 
done under the circumstances was just what I suggested, 
to wit, the reestablishment of the vaginal tract by kolpo- 
stenotomy and kolpoecpetasis as a preparatory step for labor. 
So thoroughly satisfied am I of the safety and judicious- 
ness of this course that I have no hesitation in recom- 
mending it as the best to be pursued in all cases where 
there is the slightest doubt as to the existence of kolposte- 
nosis. 
Another case of medico-legal interest I saw in the ser- 
vice of Professor Simon, where kolpokleisis had been per- 
formed by a distinguished German surgeon. The patient 
was a young woman from Russia. She had sustained a 
urethro-vesico-vaginal fistule of small size, which was com- 
plicated by a hard and resisting stenosis situated just be- 
low. The surgeon on finding it impossible to overcome 
this kolpostenosis, reach the fistule, and unite the bord- 
ers of the defect, concluded to leave the latter untouched 
and make a kolpokleidic closure within the stenosed point. 
The obliteration was complete, and the woman was sent NATHAN BOZEMAN 
23 
home as cured. The result proving unsatisfactory, the poor 
woman was a second time sent off to Germany, now to 
consult Professor Simon, the author of kolpokleisis, as to. 
the judiciousness of the work of the previous surgeon. 
Professor Simon instituted an exploration of the bladder by 
his method of urethral dilatation, and discovered that the 
fistule was only large enough to admit the index finger. 
He at once concluded to undo the kolpokleidic closure by 
incisions and reestablish the continuity of the vaginal tract, 
thus bringing to light the covered up stenosis and fistulous 
opening. This all occurred only a week or so before my 
arrival in Heidelberg. With this case began practically the 
application of the principles underlying the operative pro- 
cedures of Professor Simon and myself respectively. These 
points have been already sufficiently dwelt upon in another 
place, and will be passed over here. 
Another case in the hospital at Heidelberg, illustrating 
in a striking degree some of the remote causes of death, was 
next brought to my notice. Here a urethro-vesico-vaginal 
fistule of medium size existed, with kolpostenosis just below 
it, reduced to the calibre of admitting the index finger. 
The woman, five or six years before, had been submitted to 
kolpokleidic closure by an eminent surgeon for the reason 
that the fistule could not be reached so as to unite its bor- 
ders. The result was complete, and the woman returned 
to her family, with continence of urine restored. After a 
few years she began to have pain in the region of the blad- 
der and kidneys, and finally diminishing power to retain her 
urine. These troubles gradually progressed from bad to 
worse until all control of the urine was lost, when she ap- 
plied to Professor Simon for relief. We examined the case 
together, and found that the continuity of the vaginal tract 
had been reestablished by the formation of a calculus in the 
vesico-vaginal pouch, which had cut through the cicatricial 
diaphragm below, thus making an outlet for itself. Profes- 
sor Simon asked me what I would do under the circum- 
stances. I stated that I would first overcome the obstacle, 
the kolpostenosis, and then close the fistule, if the patient’s 24 
GENITAL RENOVATION. 
general health, then very much shattered, could be im- 
proved. He replied that he did not believe that those ends 
could be accomplished according to the plan I proposed. 
After waiting a few weeks he performed kolpokleisis on the 
site of the first operation. The result was that the patient 
died on the fifth day from uremic poisoning. The autopsy 
revealed nephritis of one kidney and pyonephrosis of the 
other, with a long calculus, the size of the thumb, project- 
ing from the left ureter into the bladder. 
Suffice it to say there was found in this autopsy all of 
the worst evils I had ever predicted of kolpokleisis, and 
from this, and what I had previously learned from my in 
vestigations upon the subject, I now determined to con- 
demn the operation in toto. 
Next, I will refer to a case illustrating the immediate 
cause of death, which came before me in Vienna a few 
months after I left Heidelberg. Here the fistule was ves- 
ico-vaginal, of small size, situated just above the root of the 
urethra, but the complication was kolpostenosis beyond 
this point, not, however, in a marked degree. The sur- 
geon, not believing it possible to overcome the latter and 
close the fistule by uniting its borders, resolved to perform 
kolpokleisis, the usual method employed there under such 
circumstances. I was invited to be present, and saw the 
operation performed with the greatest care and skill. The 
result was that phlegmonous inflammation developed in a 
day or two in the locality of the sutures, owing to the in- 
filtration of the surrounding connective tissue by alkaline 
urine. From this pelvic peritonitis followed, and on the 
fourth day the patient died. The autopsy confirmed what 
has just been said of the morbid processes, and showed the 
immediate cause of death which is to be expected in a 
large proportion of cases after this operation. 
A few days after the unfortunate termination of the above 
case, Professor Billroth, in a conversation with me upon 
the result, remarked that he had had a patient die in the 
same way after kolpokleisis. When I visited Paris a few 
months later, a distinguished surgeon of Lille, whom I met, NA THAN BOZEMAN. 
25 
told me he had had a similar misfortune. There were 
other eminent surgeons with whom I conversed upon this 
subject, but only a very few seemed willing to admit the 
objections and dangers of the operation which I insisted 
upon. So firm was the hold of the procedure upon popular 
favor, and so decided were the convictions of its value as 
a dernier res sort, that only the few who had lost cases by 
it could be found willing to discuss the feasibility of any 
other plan of dealing with the difficulties thought to be 
insurmountable. 
In order to show the confidence of French surgeons in 
genital kleisis as a principle, and the kind of pretext for 
its employment, it is only necessary to refer to the action 
of the Academy of Medicine of Paris, at its seance, March 
16, 1875, on a memoir presented by Dr. F. J. Herrgott, of 
Nancy, a candidate for membership, entitled, “De I’Ob- 
literation du vagin comme moyen de guerison de I’incon- 
tinence d’urine dans les grandes pertes de substance de la 
vessie.” This memoir is a resume of what had been ac- 
complished by genital kleisis from the time of its adoption 
by Vidal, in 1832, up to that date, including me among the 
authors then recommending and endorsing the practice, 
when I had only performed hysterocystokleisis and kol- 
pokleisis each once nearly twenty years before, and had 
for five years condemned the practice as unjustifiable! 
Dr. Herrgott, in support of his views and practice, pre- 
sented an epitome of four cases, the history of the fourth 
and details of the three operations required being in full 
as follows : 
“ Case VI. Great loss of substance in the anterior wall of 
the vagina ; cicatricial closure of the vagina, excepting two holes ; 
occlusion of these by suture ; peritonitis ; death the second day. 
(October, 1864.) 
“ Case XL Great loss of substance ; vagina closed by a 
cicatricial septum, excepting an opening admitting two fingers ; 
a first operation reduced the extent of the opening; after a sec- 
ond operation there remained a little hole, which was closed by 
a third operation. (March, 1872.) 26 
“ Case XII. Anterior wall of the vagina totally destroyed ; 
hernia of the vesical mucous membrane in the vagina; first oper- 
ation complete failure; second operation (in two sections), con- 
siderable reduction of the fistule ; third operation, cure; men- 
struation by the urethra. (May, 1872.) 
GENITAL RENOVATION. 
“ Case XV. Fistule vesico-utero-vaginal, measuring in length 
six centimeters ; cicatricial deformity of the neck ; vesical her- 
nia in the vagina ; first operation united the right portion ; sec- 
ond operation united the left portion ; there remained a little 
opening in the centre which was closed by a third operation. 
(Case reported by Dr. Marchal, chief of the clinical service of 
accouchement.) ” 
This fourth case was operated upon in 1874, and the 
history shows that the fistulous opening only occupied the 
bas fond of the bladder, with cicatricial bands in the pos- 
terior cul-de-sac. The urethra was intact, the coexisting 
kolpostenosis was undoubtedly the indication for kolpoklei- 
sis. 
The report of the committee, consisting of MM. Hirtz, 
Verneuil, Giraldes, upon the memoir, was made to the 
Academy on the date mentioned, and, after it was read 
by M. Giraldes, the following resolutions were offered and 
passed : 
“ 1. To authorize the insertion entire of the fourth case in the 
memoir of the author, in the body of this report. 
“2. To thank Professor Herrgott for his interesting case. 
“3, To send his memoir to the Committee of National Cor- 
respondents, to be added to the scientific papers of this candi- 
date.” 
In the discussion that followed the reading of the above 
report, M. Verneuil expressed his preference for occlusion 
of the vulva, according to Vidal’s method, over kolpokleisis, 
for the singular reason that it was much more difficult to 
carry out the latter, and that when the operation high up 
in the vagina did succeed, the aims of the surgeon were 
liable to be soon thwarted by the marital relation. This 
had happened once in his practice, and the circumstance, 
he thought, ought to be taken into account in the estimate NA THAN BOZEMAN. 
of the two methods. In another case he unluckily opened 
Douglas’ pouch and let out several coils of intestine, which, 
however, were returned and the opening stitched up with- 
out further harm. He said that this was exceedingly liable 
to occur in cases where there were cicatricial bridles in 
the locality referred to, and the operation here had to be 
carried out. He further stated that the success of kolpo- 
kleisis in his hands had been three closures out of four, and 
that almost always several repetitions of operations were 
required. Dr, Herrgott’s success, he remarked, had 
amounted to about this, and as Dr. Herrgott’s unsuccessful 
case was one of death it may therefore be inferred from 
the experience of Professor Verneuil that the ratio given 
by him was one death out of four, thus making the mortal- 
ity of the operation in his hands also twenty-five per cent. 
In 1876, about a year after this action of the Academy of 
Medicine, of Paris, by which it placed itself almost in direct 
opposition to the course taken by it on the 1 ith of February, 
1845, with regard to Vidal’s method, M. Le Double, doubt- 
less encouraged by this change in opinion of the members of 
the Academy, published his book on Genital Kleisis. He 
presented me with a copy of it, and I have found it to be full 
of valuable information upon the class of operations com- 
prised under this most appropriate title. It is exceedingly 
questionable, however, whether his division of episiokleisis 
rests on well-authenticated cases of occlusion of the vulva. 
I have never seen the closure complete, the result being a 
mere episiostenosis, and of but little benefit to the patient. 
Professor Simon was also of the same opinion. The result 
in the only case I ever saw had been achieved at great sac- 
rifice of time and labor by a distinguished surgeon of New 
Orleans for a large vesico-utero-vagihal fistule and lacera- 
tion of the urethra ; later the case came under my care, 
when I overcame the episiostenosis, and cured the fistule 
and cleft urethra by three direct operations, thus putting the 
treatment on a legitimate basis. The first of these opera- 
tions I performed on the 15th of February, 1857.1 The 
1 Case XI.— North Am. Med.-Chir. Review, July and Nov. 1857. 28 
GENITAL RENOVATION. 
vesico-utero-vaginal fistule was almost the counterpart of 
the fourth one described by Dr. Herrgott at length in his 
memoir, above referred to. 
The case of Dr. Schuppert, of New Orleans, to which M. 
Le Double refers in support of his classification, and which 
was operated upon in 1861, does not appear to have been 
one of episiokleisis. Dr. S. states that two centimeters of 
the urethra remained and a narrow stenosis existed above. 
To have secured the result he claims in the case, the denu- 
dation must have been carried to a point beyond the ure- 
thral orifice, and was, therefore, partly in the vulva and 
partly in the vagina, constituting, properly speaking, an 
episiokolpokleisis ; in fact, Dr. Schuppert himself designates 
the operation as one of episioelytrorrhaphy.1 The case of 
Professor Simon, the report of which he ascribes to me, 
was not one of obliteration of the vulva at all. The kolpo- 
stenosis in this case was seated near the root of the ure- 
thra and the obliterating operation was at this point, thus 
constituting kolpokleisis in the urethral portion of the va- 
gina. 
Next let us examine the classification of the different 
forms of genital kleises. That of Professor Simon was for 
a long time regarded as the most complete ever given. Just 
before Professor Simon’s death, however, Dr. Herrgott, in 
his memoir to the Academy of Medicine of Paris, upon the 
obliterating operations of the vulva as well as of the vagina, 
led the way to an extension of the old classifications. To 
this latter circumstance I attribute the adoption by M. Le 
Double of the title of “ Genital Kleisis ” for his treatises 
on the subject, he intending to include under it all the 
classes of obliterating operations on the vulvo-vaginal and 
uterine tract.2 As a matter of scientific interest bearing 
upon genital kleises at the date of which I am speaking, 
especially in France, I here present M. Le Double’s classi- 
fication. This will show at a glance what has been pro- 
posed and attempted to be carried out by all promoters 
of the practice : 
1 A Treatise on Vesico-vaginal Fistula, 1866. 2 Op. cit. NATHAN BOZEMAN. 
29 
Hysterokleisis. With Cicatricial Diaphragm incomplete (Dieffenbach). 
ist. By turning the 
neck of the uterus 
into the bladder, 
ad. By turning the 
neck of the uterus 
into the rectum. 
3d. By embracing 
the two walls of 
Of the Arch of 
the Vagina. 
Transverse. 
the vagina. 
Of the body of the vagina. 
Of the urethral portion of the vagina. 
At the entrance of the vagina imme- 
diately behind the vulvar ring 
(Vidal). 
Kolpokleisis. 
( With Cicatricial Dia- 
) phragm complete. 
Vertical. 
f Neck of the uterus outside of the oc- 
j elusion. 
j Neck of the uterus behind the occlu- 
[ sion. 
Oblique. 
f With rectal diverticulum. 
(Cicatricial Diaphragm complete and 
obturation of the meatus urinarius.) 
Without rectal diverticulum. 
(Cicatricial Diaphragm complete or in- 
complete. 
( Primitive or pathological. 
( Secondary or surgical, 
f With preservation of a part of the 
I length of the urethra or of all the 
| meatus urinarius. 
-J (Cicatricial Diaphragm complete.) 
With the destruction of all the inferior 
j wall of the urethra and the meatus. 
[(Cicatricial Diaphragm incomplete.) 
Episiokleisis. 
For all practical purposes it would seem that the above 
classification of M. Le Double is sufficiently comprehen- 
sive and well arranged. But large as it is it does not des- 
ignate clearly and precisely the several forms of kleisis in- 
volving the cervix uteri and the bladder and rectum ; and 
as to the plaiting and folding of the borders of the fistule 
and the bridging over of atresias of the urethra, he does 
not include these in his scheme at all. With the view, there- 
fore, of making prominent the procedures of thrusting the 
cervix uteri into the bladder and rectum, and of adding the 
folding and doubling of the separate walls of the vagina, 
regardless of the homogeneity of structures and the har- 
mony of functions, I propose a new classification based on 
the divisional abridgment of the vulvo-vaginal and uterine 
tract and the sectional abridgment of the vaginal walls 
anteriorly and posteriorly. This accords better, it is be- 
lieved, with the teachings sought to be enforced both as 
regards the permanent sacrifice and alteration of organs 
and of functions. The scheme is here presented in tabular 
form: 30 
GENITAL RENOVATION. 
Divisional Abridgment. 
GENITAL KLEISIS. 
A. Hysterokleisis. 
Sectional Abridgment, Anteriorly. 
1. Hysterocystokleisis. 
2. Kolpocystokleisis. 
3. Kolpourethrokleisis. 
4. Kolpourethrocystokleisis. 
Sectional Abridgment, Posteriorly. 
1. Hysteroproctokleisis. 
2. Kolpoproctokleisis. 
B. Kolpokleisis. 
a. Transverse. 
In urethral portion, body and arch of the vagina. 
i. Oblique. 
In body and arch of the vagina. 
C. Episiokolpokleisis. 
D. Episiourethrokleisis. 
With rectal diverticulum. 
B. Episiovulvokleisis. 
With rectal diverticulum. 
Such are my views upon the classification of genital 
kleisis, but from what I have previously said regarding the 
objections to this practice and its dangers it will not be 
inferred that I indorse and recommend this large class of 
operative procedures. On the contrary, I condemn them 
all except one, and that is the divisional form of episiokol- 
pokleisis. Here all the vesico-vaginal septum and the upper 
half of the urethra are supposed to be destroyed, and hys- 
teroephelkosis and the button suture are found insufficient 
to close the chasm. Under such circumstances obliteration 
of the vaginal orifice (all other conditions favoring it) might 
be undertaken with fair prospect of securing continence of 
urine in the recumbent, if not in the erect posture, but 
even this operation is scarcely warranted from the benefits 
really conferred. As to the two other forms of episioure- 
throkleisis and episiovulvokleisis with rectal diverticulum 
and anal outlet, I think they should never be thought of as NATHAN BOZEMAN. 
31 
surgical resources. Here, in addition to the above-de- 
scribed lesions, the lower half of the urethra is also par- 
tially or completely destroyed. It is far better for the poor 
woman to remain in her already deplorable state than to 
undergo either of the last-named operations, at the cost, 
perhaps, of many repetitions to secure success, and then 
ever afterwards to maintain a communication between the 
bladder and vagina on the one hand and the rectum and 
the vagina on the other, with the anus as a common outlet 
for all three organs. 
With regard to kolpokleisis, the view that I take of it 
in any of its forms is that if there is tissue enough remain- 
ing for the operation there is enough remaining also for 
the coaptation of the borders of the fistule, and why then 
resort to the expedient ? As to hysterokleisis, there is no 
necessity for it, since exposure of the vesico-uterine fistule 
by splitting the anterior lip of the cervix uteri and the 
cure of the same are entirely feasible with preservation of 
the normal uterine outlet. 
Concerning the sectional forms of genital kleisis with 
distortion and shortening of the vulvo-vaginal tract, it is 
only a question of patience and perseverance with kolposte- 
notomy and kolpoecpetasis in order to entirely avoid these 
expedients and maintain intact the vulvo-vaginal contour. 
I know it will be said that my picture of genital kleisis 
is overdrawn, being based mainly upon my individual ex- 
perience and observation. Granting this to be true, it is of 
but little consequence as affecting the many facts which I 
have endeavored, in these remarks, to place before the reader. 
My percentage of genital kleisis out of one hundred and 
twenty cases is only 1.66 per cent, the smallest that has 
ever been recorded by any operator of equal experience, 
and from this fact alone I assume to speak authoritatively 
upon the points above presented. In this connection I 
will tabulate the percentage of genital kleisis by the four 
other prominent surgeons to whose labors I have previously 
referred, in order to place their results side by side with 
my own, which may be stated thus : 32 
Simon, 34 cases treated by genital kleisis out of 105 presented, 32.38 
per cent. 
GENITAL RENOVATION 
Sims, 30 cases by genital kleisis out of 312 presented, 9.62 per cent. 
Emmet, 7 cases by genital kleisis out of 75 presented, 9.33 per cent. 
Baker Brown, 6 cases treated by genital kleisis out of 89 presented, 
6.74 per cent. 
Bozeman, 2 cases treated by genital kleisis out of 120 presented, x.66 
per cent. 
These figures as regards the practice of Mr. Brown, Dr. 
Emmet, and the writer are correct, having been taken from 
the records. As to Dr. Sims’, they are believed to be ap- 
proximately, if not positively, correct; the proof is that 
they tally almost exactly with those of Dr. Emmet, his strict 
follower. Professor Simon’s are correct only as relates to 
his occlusion of the vulvo-vaginal tract and the turning of 
the cervix uteri into the bladder. The proportion of his 
cases in which the mouth of the uterus was obliterated 
does not enter into the account, but out of his one hundred 
and five cases it could not have been less than four, which 
would make his proportion of genital kleisis as 38 to 105, 
or 36.19 per cent., instead of 32.38 per cent., as tabulated. 
This, however, is of but little consequence, since his differ- 
ence of percentage is already so much greater than either 
of the other four surgeons cited as to give the appearance 
of the grossest error in calculation. 
The question may now be asked, What is the explanation 
of these differences of percentage in the results from gen- 
ital kleisis ? The writer, the first advocate of kolposte- 
notomy and kolpoecpetasis combined, insists that these 
procedures are the true measures of the differences above 
shown. Kolpostenotomy alone, as a means of immediate 
preparatory treatment for exposing concealed fistules in 
the vulvo-vaginal tract, and making them accessible to the 
use of instruments, was understood for a very long time 
before kolpoecpetasis was successfully applied under the 
form of gradual preparatory treatment, and hence the be- 
ginning of a new era by the combination made of the two 
procedures. As results of the combination follow cysto- 
ecpetasis and hysteroephelkosis, as described in the outset of these remarks. The button suture, although criticised 
and even pronounced hurtful by some who are ignorant of 
its true principles of action, has contributed largely in 
the combination indicated to restrict genital kleisis to the 
narrowest limits in the practice of the writer. Professor 
Simon, accredited with the other extreme percentage of 
genital kleisis, understood thoroughly the value of kolpo- 
stenotomy as a means of immediate exposure of the fistule 
concealed in the vulvo-vaginal tract in simple cases ; but 
he had no conception or appreciation whatever of the value 
of the combination with it of kolpoecpetasis as a means of 
gradual and certain exposure in the graver cases. This the 
writer found to be the weak point in his mode of operating, 
which mainly accounts for his high percentage of genital 
kleisis, and for the great mortality, especially from kolpo- 
kleisis, in the hands of many of his followers. As to the 
percentages of genital kleisis in the hands of the other 
three surgeons named, they fall under the same general 
criticism, though in a far less degree, and the differences 
in their results point unerringly to failure or inability on 
their part to combine and carry out to the legitimate end 
the fundamental principles above indicated. The histories 
and analyses of their cases, as far as reported, go to sustain 
this statement. 
NATHAN BOZEMAN 
33 
As further support of all that has been said condemna- 
tory of genital kleisis, and of the possibility of avoiding the 
practice entirely, the writer proposes to introduce here 
an epitome of his last fourteen cases of urinary fistules, 
treated in the Woman’s Hospital, twelve of the number 
having been complicated with kolpostenosis, and a large 
proportion of them answering to Professor Simon’s indica- 
tions for kolpokleisis. These cases admit of the following 
classification: 
One urethrovaginal fistule. 
Two urethro-vesico-vaginal fistules. 
Three vesico-vaginal fistules. 
Six vesico-utero-vaginal fistules. 
One vesico-utero-cervical fistule. 
One urethro-utero-vesico-vaginal fistule. 34 
GENITAL RENOVATION 
Number. 
Name and Residence. 
c3 
60 
< 
| Children. 
Injured. 
Admitted. 
Disease. 
Complications. 
I Previous Operations by 
1 Sims’ Method. 
Preparatory 
Operations. 
I 
C. B. 
New 
York 
City. 
38 
4 
Jan. 
187s. 
Mar. 26, 
1878. 
1 Vesico- 
utero-vaginal 
fistule. 
Incarceration of 
cervix uteri in blad- 
der. Kolposteno- 
sis and cystostello- 
sis. 
2 
Kolpostenotomy 
and kolpoecpeta- 
sis carried from 
45 to 65 mm., 
with cystoecpeta- 
sis. 
2 
J. c. 
Wood- 
stock, 
N. Y. 
26 
1 
May, 
1876. 
Oct. 23, 
1878. 
1 Vesico- 
utero-vaginal 
fistule. 
Kolpostenosis. 
Sinus in the ante- 
rior lip of the cervix 
uteri. 
2 
Kolpostenotomy 
and kolpoecpeta- 
sis carried from 
40 to 60 mm. 
3 
L. C. 
Corn- 
wall, N. 
Y. 
2S 
0 
Nov. 14, 
1878. 
1 Vesico- 
vaginal fis- 
tule the re- 
sult of kol- 
pocystotomy. 
Uterus ante-flexed. 
Hysteria and apho- 
nia, overdistention 
and paralyzation of 
urethra. 
— 
None required. 
4 
C. B. 
East 
Spring- 
field, N. 
Y. 
33 
- 
Aug. 25, 
1878. 
Dec. 2t, 
1878. 
1 Vesico- 
utero-vaginal 
fistule. 
Kolpostenosis 
slight. 
- 
Kolpostenotomy 
and kolpoecpeta- 
sis carried to full 
size of vagina. 
5 
K. B. 
New 
York 
City. 
22 
1 
Mar. 19, 
1878. 
Feb 27, 
1879. 
1 Vesico- 
vaginal fis- 
tule. 
Kolpostenosis; a 
remaining silver 
wire the nucleus of 
a calculus and fol- 
lowed by vaginitis. 
I 
Removal of cal- 
culus. Kolpo- 
stenotomy and 
kolpoecpetasis 
carried from 45 
to 60 mm. 
6 
J. N. 
New 
York 
City. 
33 
6 
Sept. 6, 
1879. 
Oct. 13, 
1879. 
1 Vesico-ute- 
ro-cervical 
fistule. 
Kolpostenosis. Fis- 
tulous opening in 
cervical canal. 
- 
Kolpostenotomy 
and kolpoecpeta- 
sis carried to 70 
mm. NATHAN BOZEMAN 
35 
Finishing Operations by 
Bozeman’s Method. 
Results. 
Relationship of the Sex- 
ual Organs and of their 
Functions. 
Discharged. 
Remarks. 
Im- 
proved. 
Restored. 
June 24, 
1879. 
Uterus retroflexed. Neck lacerated and incarcerated in the 
bladder. Fistule of small size. Uterus disengaged from 
bladder and almost completely restored to its normal re- 
lationship. Having about completed the preparatory 
operations, the patient, becoming discouraged, placed her- 
self in the hands of another surgeon, who performed two 
finishing operations. Result thought to be successful, 
but the patient afterwards informed me that as soon as she 
got up and began to walk about the urine ran off through 
the vagina just as it had previously done. Patient there- 
fore remained uncured. 
I 
Cured. 
Preserved. 
Mar. 24, 
1879. 
Fistule large enough to admit the point of the index finger, 
lay to the right of the median line and involved the cervix 
uteri. From the left angle a sinus extended upwards 
through the anterior lip of the cervix uteri, and opened 
into the cervical canal, constituting a vagino-utero-ceryi- 
ca! fistule. Vagina shortened and distorted by cicatricial 
bands, which rendered the anterior border of the fistule 
immovable. Sinus in the cervix uteri laid open and fol- 
lowed up by the usual treatment. Elastic catheter only 
used at intervals in the after treatment. 
I 
Cured. 
Preserved. 
April 13, 
1879. 
Patient had been under the treatment of half a dozen or 
more physicians during several years for anteflexion of the 
uterus, hysteria, retention of urine, and cystitis, and had 
undergone urethral dilatation, and finally kolpocystotomy. 
After closing the fistulous opening incontinence of urine 
was found to exist owing to the patulous condition of the 
urethra. On the 4th of April, 1879, I laid the whole ure- 
thral tract open, intending to let the parts rest a few 
months, and then, after reducing the calibre of the canal 
to its proper size, to close it over an elastic catheter. 
The patient did not return to me for the finishing opera- 
rion required, but placed herself in the hands of another 
surgeon. The procedure on the urethra here referred to, 
the first step of which I performed, was original with me 
and would have been completed at one operation had not 
my plan of treatment been thus interrupted. As it turned 
out, eleven operations had to be performed by the surgeon 
who succeeded me, running, as I understand it, through a 
period of nearly two years. 
1 
Cured. 
Preserved. 
Feb. 24, 
1879. 
Cervix uteri almost completely cut off from view by a broad 
and annular cicatricial band. Fistulous opening readily ad- 
mitted two fingers after preparatory operations — was 
bordered above by the anterior lip of the cervix uteri and 
rested below within the band of nodular tissue mentioned. 
Catheter only used at intervals of two to four hours. 
I 
Cured. 
Preserved. 
April 22, 
1879. 
This patient had previously been operated upon by the 
Sims’ method, by an eminent gynecologist, but the result 
was a total failure. The fistule I found situated in the 
trigone of the bladder to the right of the median line, and 
about large enough to admit the index finger. Across the 
anterior wall of the vagina, just below the fistule, there 
was found stretched a thick unyielding band of cicatricial 
tissue, and from this border of the fistule hung a twisted 
wire loop, remaining from the operation mentioned. This 
loop serving as a nucleus, a calculus die size of a pigeon’s 
egg had formed in the vagina and this, in its turn with al- 
kaline urine, had caused the violent vaginitis found coex- 
isting. Catheter only used at stated intervals. 
2 
Cured. 
Preserved. 
April 8, 
1880 
Vagina considerably contracted in the upper third. Uterine 
orifice of fistule situated in the cervical canal one cm. 
from internal uterine orifice, and large enough to admit 
into the bladder an English No. 10 catheter. After kol- 
poecpetasis was completed the cervical canal was dilated, 
and bilateral hysterotomy was performed. The divisions 
were carried to the vaginal junction, and then all the an- 36 
GENITAL RENOVATION. 
[ Number. 
Name and Residence. 
| Children. 
Injured. 
Admitted. 
Disease. 
Complications. 
Previous Operations by 
Sims’ Method. 
Preparatory 
Operations. 
7 
M. S. 
Port 
Chester, 
N. Y. 
34 
2 
March, 
1880. 
May ix, 
1880. 
i Urethro- 
vesico-vagi- 
nal fistule. 
Kolpostenosis, con- 
gestion of the vagi- 
na, and plastic ex- 
udations in the sur- 
rounding connec- 
tive tissue. Partial 
immobility of the 
uterus. 
- 
Kolpostenotomy 
and kolpoecpeta- 
sis carried from 
40 to 60 mm. 
8 
S.J. 
Cayuta, 
N.Y. 
37 
- 
1870. 
Sept. 16, 
x88o. 
1 Urethro- 
vaginal fis- 
tule. 
Prolapsus uteri and 
vaginal hyperesthe- 
sia. 
- 
Kolpoecpetasis 
alone carried to 
the limit of 65 
mm. 
9 
A. F. 
New 
York 
City. 
35 
1 
July 2i, 
1880. 
Sept. 16, 
1880. 
1 Vesico- 
utero-vaginal 
fistule. 
Kolpostenosis. 
fartial fixation of 
uterus. 
— 
Kolpostenotomy 
and kolpoecpeta- 
sis earned from 
40 to ss mm. 
io 
J.S. 
Staten 
Island, 
N. Y. 
19 
I 
Aug., 
1880. 
Sept. 27, 
18S0. 
1 Urethro- 
vesico-vagi- 
nal fistule. 
Kolpostenosis of 
annular form just 
below the fistule. 
- 
Kolpostenotomy 
and kolpoecpeta- 
sis carried from 
20 to 50 mm. 
XI 
A. L. C. 
Albion, 
Wis. 
4i 
4 
Oct., 
rS??. 
Oct. 1, 
1880. 
1 Urethro- 
utero-vesico- 
vaginal fis- 
tule. 
Kolpostenosis 
seemingly insur- 
mountable. Root 
of the urethra in- 
volved in it. 
Marked cystostello- 
sis. 
2 
Kolpostenotomy 
and kolpoecpeta- 
sis carried from 
40 to 65 mm., 
with correspond- 
ing cystoecpeta- 
sis. NATHAN BOZEMAN. 
37 
I Finishing Operations by 
I Bozeman’s Method. 
Results. 
Relationship of the Sex- 
ual Organs and of their 
Functions. 
Discharged. 
Remarks. 
Cured. 
terior lip below the fistule, including the vesico-vaginal 
attachment, was excised, thus converting the original small 
fistule into a large vesico-utero-vaginal fistule. This be- 
ing only a preliminary step, the kolpoecpetasis was contin- 
ued up to the point indicated. As a preparatory step to 
the finishing operation the internal uterine orifice was 
again dilated, and the stump of the anterior lip of the cer- 
vix uteri united to the opposing border of the vesico-vagi- 
nal septum, thus leaving the cervical canal, though short- 
ened two thirds of its length, in its normal relationship 
with the vaginal tract. After removal of the suture appa- 
ratus only a small suture hole remained, which had to be 
closed at a second operation. Catheter only used at 
stated intervals. 
I 
Preserved. 
June 28, 
1880. 
The fistule occupied the trigone, and part of the has fond of 
the bladder. Vagina narrowed by cicatricial bands, and 
plastic exudations in the surrounding connective tissue. 
Cicatricial bands were situated below and above the fis- 
tule. Calibre reduced to about forty mm. By kolposte- 
notomy and kolpoecpetasis calibre of vagina increased in 
fifteen days to sixty mm. Fistule now large enough to 
admit three fingers. Operation for closure of the fistule 
attended with considerable hemorrhage. Hot water used 
to control it, but it was not entirely arrested until the 
sutures were introduced and adjusted. Hemorrhage 
probably due to the unusual shortness of the preparatory 
stage of treatment. Catheter used at stated intervals. 
2 
Cured. 
Preserved. 
Dec. 12, 
1880. 
Fistule situated at about the middle of the urethra, and was 
of a longitudinal shape. Here dilatation was employed 
to restore the organs to their proper relationship, and to 
overcome the morbid sensibility of the vaginal tract. My 
assistant, Dr. Janvrin, performed the finishing operation, 
using my suture. Success was only partial. Second 
operation by myself. Elastic catheter after first few days 
used at stated intervals. 
2 
Cured. 
Preserved. 
Dec. 16, 
1880. 
Fistule occupied the has fond of the bladder, the anterior 
lip of the cervix uteri forming its upper border. Plastic 
exudations in the connective tissue surrounding the latter, 
the cause of the fixation noted. Fistule'after dilating 
operations admitted easily two fingers. When the suture 
apparatus was removed on the seventh day there remained 
an opening about the size of a pin’s head, at a point cor- 
responding to the entrance of the right ureter into the 
bladder, which constituted a vesico-uretero-vaginal fistule. 
A slight operation six weeks afterwards completed the 
cure. Catheter used at stated intervals. 
Z 
Cured. 
Preserved. 
T)ec. 13, 
1880. 
Fistule occupied the trigone of the bladder, involving below 
the root of the urethra. The stenosis of an annular form 
was situated just below the fistule and held within its 
firm grasp the anterior border of the latter. Fistule closed 
with four sutures and button to suit the requirements of 
the pubic arch. Complete distention of the borders of 
the fistule was thus maintained within the range of the 
annular contraction during the reparative stage. Conti- 
nence of urine restored. Patient required after the cure 
to wear an intra-vaginal dilator for a month or two in or- 
der to guard against recontraction and consequent par- 
alyzation of the sphincter vesica; muscle. Elastic cathe- 
ter worn permanently for three or four days only. 
3 
Cured. 
Preserved. 
May, 
1881. 
Fistule occupied the trigone and has Jond of the bladder 
and implicated the root of the urethra below and the an- 
terior lip of the cervix uteri above. Outside of the fistu- 
lous opening the mucous membrane on both walls of the 
vagina had been extensively implicated in the sloughing 
which followed the injury. From these pathological con- 
ditions resulted the marked kolpostenosis or hard unyield- 38 
GENITAL RENOVATION 
Number. 
Name and Residence. 
Age. 
Children. 
Injured. 
Admitted. 
Disease. 
Complications. 
Previous Operations by 
Sims’ Method. 
Preparatory 
Operations. 
12 
M. S. 
New 
York 
City. 
Dec. 22, 
1880. 
1 Vesico-_ 
utero-vaginal 
fistule. 
Kolpostenosis. 
I 
Kolpostenotomy 
and kolpoecpeta- 
sis carried from 
4S to 60 mm. 
13 
M. C. 
New 
York 
City. 
40 
i 
Sept, s, 
1876. 
Feb. 14, 
1881 
t Vesico- 
vaginal fis- 
tule. 
Kolpostenosis in- 
volving whole cali- 
bre of the vagina. 
Laceration of peri- 
neum. 
- 
Kolpostenotomy 
and kolpoecpeta- 
sls carried from 
40 to 60 mm. 
14 
A. M. 
Brook- 
lyn,N.Y. 
32 
9 
April, 
1880. 
Mar. 14, 
1881. 
1 Vesico- 
utero-vaginal 
fistule. 
Partial incarcera- 
tion of the cervix 
uteri. Marked kol- 
postenosis, cysto- 
stellosis,_ and en- 
dometritis. Lacer- 
ation of perineum. 
I 
Kolpostenotomy 
and kolpoecpeta- 
sis carried from 
40 to 60 ram., with 
cystoecpetasis. NA THAN BOZEMAU. 
39 
Finishing Operations by 
Bozeman’s Method. 
Results. 
Relationship of the Sex 
ual Organs and of their 
Functions. 
Discharged. 
Remarks. 
Cured. 
Preserved. 
Feb. 19, 
1881. 
ing band involving the anterior border of the fistule. The 
urethra was about an inch long, and this, with the corre- 
sponding portion of the vaginal wall, was drawn upwards, 
as a result of the cicatrization and the contracting band 
referred to. The stump of the cervix uteri was drawn 
downwards by the same morbid forces. The space inter- 
vening constituted the fistulous opening only large enough 
to admit the index finger into the bladder. The anterior 
border of the opening stood on a plane far above that of 
posterior, and was wholly without elasticity, having the 
feeling of cartilage. The preparatory operations resulted 
in not only opening up the vaginal tract, but in the dila- 
tation of the bladder to two thirds of its natural size. 
First operation for closure of the fistule completely suc- 
cessful, but the cicatrix after two days gave way at the left 
extremity. Second operation was supplemented by a bi- 
lateral division of the cervix uteri, but still, owing to the 
great retraction of the parts, the right angle failed to close, 
thus leaving about the middle of the first line of union a 
small opening. Third operation with bilateral cervical di- 
vision resulted in complete closure, except a small suture 
hole which fortunately healed itself after a few days, leav- 
ing the patient with power to retain and pass urine at inter- 
vals of two or three hours. Catheter used at stated inter- 
vals. The two previous operations had been performed 
by one of the most eminent gynecologists of the West. • 
1 
Fistule occupied the has fond of the bladder, and had for 
its posterior border the anterior lip of the cervix uteri. 
After preparatory operations the fistule was almost large 
enough to admit two fingers. Operation for closure of the 
fistule was performed by my assistant, Dr. Janvrin. Cath- 
eter used at stated intervals. Result, complete cure. 
This case had previously been operated upon by the Sims’ 
method, without success, by an eminent gynecologist of 
the city. 
Fistule occupied the vesical trigone, and only admitted a 
No. 6 catheter. Incisions required superficial, and mainly 
upon the posterior wall. Fistule closed under my direc- 
tion, by Dr. G. F. Chambers, member of the house staff. 
The laceration of the perineum, which extended nearly 
through the sphincter ani muscle, I afterwards completely 
closed at a single operation with my modification of the 
quill suture. 
i* 
Cured. 
Preserved. 
May 16, 
1881. 
I 
( 
Cured. 
Preserved. 
May 9, 
1881. 
Fistule occupied the has fond of the bladder and admitted 
the index finger. The partial incarceration of cervix uteri 
in the bladder "resulted from injury at the time of labor to 
the side of the cervix. The body of the uterus falling 
backwards forced the anterior lip of the cervix partially 
through the newly formed fistule, and in this forced rela- 
tionship the two adhered, leaving the pathologico-physio- 
logical condition indicated. After completion of the pre- 
paratory operations, and attention to the endometritis, 
the finishing operation was undertaken. This consisted 
in enlarging the fistule at each angle and thus freeing the 
anterior lip of the cervix uteri from its confined position 
in the bladder. Then the sutures were so introduced and 
the button so formed, that the lip of the cervix involved 
was lifted up to a plane with the anterior border of the 
fistule. The patient after the operation had considerable 
vesical tenesmus, but this was controlled with the free use 
of opium. Catheter used at stated intervals. The cure 
was complete. The operation for the laceration of the 
perineum was deferred to another time. This case had 
previously been operated upon by a distinguished gynecol- 
ogist of a neighboring city, according to Sims’ method. 40 
GENITAL RENOVATION 
TABULAR STATEMENT OF RESULTS. 
For 14 fistules which existed in 14 patients there were 18 opera- 
tions performed. 
Thirteen fistules which existed in 13 patients were cured with preser- 
vation of vagina. 
One fistule which existed in 1 patient left after preparatory work. 
Percentage of cures and of operations for each cure and each fistu- 
lous closure ; 
There were 13 cures out of 14 cases .... 92.85 per cent. 
Operations for each cure 1.38 per cent. 
Operations for each fistulous closure .... 1.38 per cent. 
Now, the difficulties encountered in the above cases will 
not be questioned, it is presumed, when it is stated that six 
of the number had resisted nine previous operations by the 
Sims’ method in the hands of four of the most eminent 
gynecologists of our country, and that in twelve of the cases 
kolpostenosis ranging all the way from seventy to twenty 
millimeters was found to exist. In addition to this there 
were two cases of incarceration of the cervix uteri in the 
bladder which had to be disengaged, and one in which the 
whole vesico-vaginal septum with a little of the anterior lip 
of the cervix uteri above and a little of the root of the ure- 
thra below had been destroyed. Besides this, in a fourth 
case a large vesico-utero-cervical fistule was presented, and 
the lower part of the cervix uteri had to be taken out with 
a part of the vesico-vaginal septum, which constituted a 
new procedure; and yet in all of these cases complete 
genital anakainosis was accomplished, and the women dis- 
charged cured, in the enjoyment of all their normal func- 
tions. Six at least of these fourteen cases answered to the 
indications laid down by Professor Simon for kolpokleisis. 
This percentage of success by genital anakainosis, 92.85 
per cent., is the highest ever reached by me before, and is 
probably the highest ever reached by any surgeon in such 
a series of cases. 
Three of these cases were operated upon by Drs. Janvrin 
and Chambers, two of them being cured at the first trial. 
Neither of these gentlemen had ever performed my opera- NATHAN BOZEMAN 
41 
tion before, and as regards the latter gentleman, a member 
of the house staff, it was his first effort by any method. Yet 
their results, two successes in three cases, would do credit 
to the most experienced and skillful operator. Thus is 
proven the perfect simplicity and success of my procedure, 
and that any one, the merest tyro in medicine, can, by 
means of kolpostenotomy and kolpoecpetasis carried to the 
point of completion, reach the highest aims of conserva- 
tism. Of the value of kolpostenotomy and kolpoecpetasis 
as preparatory measures towards rendering all cases sim- 
ple and successful, as above shown, I will here quote the 
opinion of Dr. Ludwig Bandl, of Vienna, after observation of 
my practice in the General Hospital of that city : 
“ Eine grosse Sicherheit fur den Erfolg liegt meines Erachtens 
in der vorbereitenden Behandlung die Bozeman als einer der 
Ersten geiibt hat (die Anfange dieser methodischen Dilatation 
sind schon in Bozeman’s erster Schrift vom Jahre 1856 enthalten) 
und von der auch Emmet der beriihmte Chirurg des New Yorker 
Frauen-Hospitals, der wohl hunderte von geheilten Fisteln auf- 
zuweisen hat, mit Recht sagt, dass von derselben das Geheim- 
niss des Erfolges abhange, und dass die best ausgefiihrte Op- 
eration fehlschlagen konne, wenn sie verabsaumt wiirde; er 
erweitert mit dem von Sims gebrauchten Glasdilatator metho- 
disch die Vagina. Bozeman selbst legt ihr eine grosse Bedeu- 
tung bei under sagte often: ‘ Nicht das Operiren, sondern das 
Prapariren sei oft schwer.’ ” 1 
Professor Simon, in his last paper on our competitive op- 
erations in Heidelberg, and on my operations in Vienna, 
1 A great guaranty for success lies, in my opinion, in the preparatory 
treatment, which Bozeman was one of the first to practice (the be- 
ginning of this methodical dilatation is mentioned in Bozeman’s first 
paper published as far back as the year 1856) and of which Emmet 
also, the celebrated surgeon of the New York Woman’s Hospital, who 
can show hundreds of healed fistules, says with truth that the secret 
of success depends upon it, and that the best performed operation may 
miscarry if this treatment be omitted; he enlarges the vagina method- 
ically with the glass dilatator used by Sims. Bozeman himself attaches 
the greatest importance to the preparatory treatment, and often said, 
“It is not the operation but the preparation which is difficult.” 
Wiener med. Wochenschrift, 49-52, 1875. 42 
GENITAL RENOVATION. 
published in August, 1876, just before his death, also says 
of this procedure : 
“ Ich selbst habe fur mich aus dem Concours, besonders aber 
aus der Beschreibung der Wiener Falle, den Gewinn gezogen, 
dass ich die allmalige'Vorbereitungskur hoher schatze als friiher, 
indem ich sie ungeiibteren Kollegen sehr dringend empfehlen zu 
miissen glaube.”1 
It is also seen in a large proportion of the above tabu- 
lated cases that the after-treatment was conducted with- 
out the permanent use of a catheter, in accordance with the 
principle of practice laid down by Professor Simon. This 
speaks well for the correctness of the principle in a gen- 
eral way ; but there were cases, especially where the ure- 
thra was involved, in which my old practice was strictly 
adhered to, namely, the permanent use of an elastic cath- 
eter. 
Here the elastic catheter, the form of instrument best 
adapted, is used, not so much on account of the hurtfulness 
of the urine, as for the purpose of assisting the sutures in 
holding the broken ends of the urethra together; but not- 
withstanding this reserve in the adoption of the principle 
set forth by Professor Simon, I accord to him full credit 
for his important modification of the old practice, even if 
for no other consideration than to save the patient from un- 
necessary discomfort and the surgeon from useless trouble 
and annoyance. The adoption, therefore, of this principle 
of practice, whether completely or partially, destroys utterly 
that of the heavy metallic or sigmoid catheter so strongly 
insisted upon by Dr. Sims in his so-called “ Clamp Suture 
Method,” and goes far to prove that by his new interrupted 
silver-suture method one of the causes, at least, of the nine 
failures accredited to his four followers in this series of 
1 I have profited much by the competitive operations, but especially 
from the report of the Vienna cases, placing a higher value on the grad- 
ual preparatory treatment than formerly, and I feel bound to recom- 
mend it most urgently to my less expert colleagues.— Wiener med. 
Wochenschrift, 27-32, 1876. cases was referable to the hurtfulness of this clumsy and 
very objectionable instrument. 
NATHAN BOZEMAN. 
This brings us to the consideration of genital anakai- 
nosis, the second part of my paper, which will be presented 
in a subsequent communication. 
296 Fifth Avenue.