History of the Clamp Suture of 
the late Dr. J. Marion Sims, 
and why it was abandoned 
by the Profession, 
Compliments of the Author. 
NATHAN BOZEMAN, M.D., 
BY 
SUHGEON TO THE WOMAN’S HOSPITAL, NEW YOKK. 
©tmeroloQtcal transactions. 
REPRINT PROM VOLUME IX 
1884. THE CLAMP SUTUEE AND THE EANGE OF 
ITS APPLICABILITY, CONSIDEEED IN 
DELATION TO THE CHEE OF 
THE INJUEIES INCIDENT TO 
PAETUEITION, WITH 
STATISTICS. 
BY NATHAN BOZEMAN, M. D., 
New York. 
It was mj intention in the outset to include in this paper 
a brief sketch of the early labors of every surgeon in the 
United States who had in any way contributed to the com- 
mon fund of our knowledge relating to the injuries incident 
to parturition. But when the material accessible for the 
purpose had been collected, it was found that, to do justice 
to all, more space would he required than the limits of an 
article to he read before this society would warrant. 
I have therefore restricted myself in the present consid- 
eration of the subject to the clamp-suture, as perfected in 
June, 1849,1 by J. Marion Sims, M. D., then of Montgomery, 
Alabama, and what was accomplished with it by him and 
other surgeons in the United States and England (the only 
two countries in which it was ever used), outside of the 
Woman’s Hospital of the State of New York. The cases 
treated by those surgeons constitute the first series. The 
cases treated individually by Dr. Sims in the Woman’s Hos- 
pital by the same method form the second series. 
The importance of the subject is sufficient to justify the 
1 American Journal of the Medical Sciences, January, 1852. 2 
THE CLAMP SUTURE. 
time and labor which I have bestowed upon it, and the sta- 
tistics collected can not fail to prove of more than ordinary 
interest to the profession, in connection with the labors of 
Dr. Sims at this time, especially to the younger members of 
the society, who may not yet have a clear understanding of 
the peculiar difficulties that surrounded the treatment of the 
lesions in question only thirty years ago. 
As one of the oldest if not the oldest operator now living 
in this country, I have to regret, as every one at all inter- 
ested in the subject must, that Dr. Sims never published the 
statistics upon which rest his claims to priority of successful 
treatment of vesico-vaginal fistule. I always hoped that he 
would publish these statistics, knowing that they would 
place in a much clearer light the precise nature of the ob- 
stacles that he had to contend against in his early labors with 
the clamp-suture, and would at the same time prove inter- 
esting and profitable to the profession at large. Indeed, so 
thoroughly was I impressed with the importance of the sub- 
ject, from all I knew about it from personal observation, and 
examination of the records of the Woman’s Hospital, that, 
notwithstanding the differences of opinion between myself 
and Dr. Sims, as to certain claims of originality in the opera- 
tion, which had existed for nearly a quarter of a century, I 
addressed him a letter in Paris urging the importance of his 
publishing these statistics, and promising him full co-opera- 
tion in all that I could do in the way of assisting him. This 
letter, a copy of which is still in my possession, was sent to 
him through a friend in Paris March 19, 1879; but the in- 
ference is that he did not regard the matter of much import- 
ance, as the communication remained unanswered. 
My reasons for addressing him upon the subject were 
fourfold: First, because we had been associated as partners 
years before, and had during that time treated jointly several 
most important cases of vesico-vaginal fistule with the clamp- 
suture, the complete details of which were in my possession; 
second, because the method of operating was peculiarly his 
own, and he had only the year before our association in prac- NATHAN BOZEMAN. 
3 
tice published his account of if,1 in which he made important 
claims of originality and success; third, because the method 
proved afterward defective in his own hands, especially in 
regard to urethro-vesico-vaginal and vesico-utero-vaginal fist- 
ules, which constitute more than one third of all the fistules 
met with in practice; and, fourth, because I had been one of 
the most strenuous advocates of the method, up to the time 
when I adopted the new principles of gradual prepara- 
tory treatment and the hutton-suture. Besides, having been 
charged by Dr. Sims with unfair criticisms upon his clamp- 
suture, I wished to modify these criticisms if he still thought 
they were, in any essential particular, unjust to him or to his 
claims.* 
1 Loc. cit. 
2 As it is not generally known by the profession precisely what relation 
existed between Dr, Sims and the writer at the period above referred to, and as 
great injustice has been done the latter by authors, both in this country and in 
Europe, growing out of the supposition that the relation was that of preceptor 
and student, which had been wantonly abused, with total disregard of honorable 
obligations and professional rights, it is proper to state in this connection the 
facts as they actually existed, since they form a part of the history of the sub- 
ject under consideration, especially with regard to Dr. Sims’s stand-point just 
after he had achieved his first complete success with his clamp-suture. The 
writer had previously been a private pupil and assistant of the late Dr. S. D. 
Gross (then Professor of Surgery in the University of Louisville, Ky.) for nearly 
three years, and had acquired from that eminent teacher a practical familiarity 
with surgical maladies generally, and with surgical methods of treating them. 
It was under these circumstances that he settled as a young practitioner in the 
city of Montgomery, Alabama, in June, 1849 (the same month that Dr. Sims 
states that he perfected his clamp-suture mode of operation), and was thrown 
in close relationship professionally with Dr. Sims. The result was that the 
writer was frequently called upon by him for assistance in his special operations 
for vesico-vaginal fistule, almost from their first acquaintance up to March, 1853, 
a period which included the date of Dr. Sims’s first paper (January, 1852). 
When Dr. Sims lost his health, from the combined ill effects of overwork 
and residence in the South, and was seriously entertaining the thought of re- 
moving with his family to a northern climate, he communicated to the writer 
his intention of settling in the city of New York, and asked him to purchase 
his house and lot in Montgomery. He urged as a reason that it was only by the 
sale of this property, for which there was little or no demand, that he could 
hope to carry out the necessary arrangements to enable him to make this pro- 
posed change of residence. The result was that the writer, on the ground of 
personal friendship, became the purchaser of his property on the terms that he 4 
THE CLAMP SUTURE. 
That there were real differences between Dr. Sims’s claims 
and myself as to originality in the treatment of vesico-vagi- 
nal fistnle, no better proof can be adduced than the publica- 
tion of the statistics of the cases treated by our respective 
modes of operating, and the fact that he abandoned in the 
Woman’s Hospital his original procedure,1 only two or three 
weeks after the publication of ray procedure.2 
(Dr. Sims) proposed. In consideration of this favor, Dr. Sims associated himself 
with the writer in practice until the completion of his arrangements to leave the 
South for New York, which took place May 27, 1853, a little less than three 
months after this copartnership was formed. 
In addition to these explanations, and in the same connection, the writer 
deems it important to state that Dr. Sims, soon after the dissolution of their 
copartnership, and when their differences with regard to certain claims of pri- 
ority had sprung up, began to deny the originality of the labors of the writer in 
relation to his button-suture, and his modification of the lever-speculum, main- 
taining that this form of suture was no better than that of his clamp-suture, 
and at best could only be regarded as a slight modification of it, and of no prac- 
tical value. As to the writer’s modification of Dr. Sims’s form of the lever-specu- 
lum, the latter objected to this as worse than useless. This he continued to do 
in various publications, not necessary to mention here (notwithstanding the fact 
of his early adoption of the writer’s principle of gradual preparatory treatment, 
and his mode of adjusting interrupted silver sutures in the vagina), up to the 
time of his death, as shown by his autobiography, edited and published by his 
son within the last few months, entitled “ The Story of My Life.” 
Here, on pages 316 and 364, are to be found references to the writer, to- 
gether with his button-suture, and his modification of the lever-speculum, first 
used in a case by him in the service of M. Robert, at the Hotel Dieu, Paris, 
November 16, 1858, and exhibited to Mr. Isaac Baker Brown and other sur- 
geons in Europe, on other similar occasions, which not only are unjust to the 
writer, and disparaging in the highest degree to his legitimate claims of 
originality, but reflect seriously upon his honor. 
It is true Dr. Sims is dead; but his words and sayings live, and enter into 
the literature of the subject under consideration, and deserve to be regarded as 
valuable, so far as they accord with principles and facts which are open to dis- 
cussion by all. These will be presented for that purpose by the writer hereafter 
in a separate paper. 
It is not the wish or intention of the writer in this communication to take 
notice of any disparaging reflections whatever, relating to his labors, by Dr. 
Sims, but simply to lay before the profession all the facts in detail appertaining 
to their respective claims of originality and priority, by which alone personal 
as well as scientific differences can be estimated and weighed. 
1 Register of the Woman's Hospital of the State of Hew York from 1855 to 1862. 
3 Louisville Review, May, 1856. NATHAN BOZEMAN. 
5 
The important questions, therefore, presented for consid- 
eration are two: First, which of the two procedures, one 
with the damp-suture, perfected by him June, 1849, without 
gradual preparatory treatment, and one with gradual pre- 
paratory treatment and the button-suture, perfected by me 
May 12, 1855, was best suited to the treatment of all classes 
of injuries incident to parturition ? And, second, what was 
the range of applicability of each procedure, from the begin- 
ning of its adoption, as measured by the standard of success ? 
The peculiarities of the clamp-suture, first described by 
Dr. Sims, together with the principles upon which this form 
of suture was based, will now be presented, with the view 
of showing the range of its applicability, and the degree of 
success which attended its employment in actual practice. 
Dr. Sims claimed for Ids procedure originality in these 
three particulars1 (quoting from his first publication on the 
subject): 
“ 1. For the discovery of a method by which the vagina can 
be thoroughly explored, and the operation easily performed. 
u2. For the introduction of a new suture apparatus, which 
lies imbedded in the tissues for an indefinite period, without 
danger of cutting its way out, as do silk ligatures. 
“3. For the invention of a self-retaining catheter, which 
can be worn with the greatest comfort by the patient during 
the whole process of treatment.” 
“ Of the Position of the Patient for the Operation.—With 
the exception of Yelpeau and Chelius, all other operators, 
even Jobert, recommended, that the patient be placed on the 
back, as in the operation of stone.” 
Dr. Sims adopted the teachings of the first two surgeons 
as to the advantages of the anterior positions, and selected as 
preferable for his purposes the hnee-elbow position. His 
mode of exposing the fistule in this position was with wrhat 
he called then “ the lever-speculum,” an instrument which 
had long been in use in Europe for the same purpose, but in 
which he made several important modifications and improve- 
1 American Journal of the Medical Sciences, January, 1852. 6 
THE CLAMP SUTURE. 
ments. In Dr. Sims’s first employment of this position of 
the patient, and of this form of speculum, there is no doubt 
that his estimate of their value related almost exclusively to 
examinations of the vagina and uterus in their normal state. 
This is shown in the following quotations: 
“An assistant on each side lays a hand in the fold be- 
tween the gluteal muscles and the thigh, the ends of the fin- 
gers extending quite to the labia majora; then by simul- 
taneously pulling the nates upward and outward, the os 
externum opens, the pelvic and abdominal viscera all gravi- 
tate toward the epigastric region, the atmosphere enters the 
vagina, and then, pressing with a weight of fourteen pounds 
to the square inch, soon stretches the canal out to its utmost 
limits, affording an easy view of the os tineas, fistula, etc. 
To facilitate the exhibition of the parts, the assistant on the 
Fig. 1. 
right side of the patient introduces into the vagina the lever- 
speculum represented in Fig. 1 [copied], and then, by lifting 
the perineum, stretching the sphincter, and raising up the NATHAN BOZEMAN. 
7 
recto-vaginal septum, it is as easy to view the whole vaginal 
canal as it is to examine the fauces, by turning a mouth 
widely open up to a strong light. This method of exhibit- 
ing the parts is not only useful in these cases, but in all af- 
fections of the os and cervix uteri requiring ocular inspec- 
tion. 
“ The most painful organic diseases, such as corroding 
ulcer, carcinoma, etc., may be thus exposed without inflicting 
the least pain, while any local treatment may be instituted 
without danger of injuring the healthy structures. By this 
method also a proper estimate, anatomically, can he had of 
the shape and capacity of the vagina ; for when there is no 
organic change, no contraction, and no rigidity of it from 
sloughs, ulcers, and cicatrices, and when the uterus is movar 
Me, this canal immediately swells out to an enormous extent, 
thus showing its great expansibility.” 
With regard to the suture apparatus perfected by Dr. 
Sims, as before stated, he says : “ The one that I use for clos- 
ing vesico-vaginal fistulas I have termed the clamp-suture, 
from its peculiar method of action. Thus, if the profession 
allow me to introduce a new suture by its most appropriate 
name, we shall then have in general use sutures named, first, 
according to their relation, the interrupted and continued; 
second, according to the method of securing them, the quilled 
and twisted; and, third, according to its method of action, 
the clamp-suture. As all sutures are but modifications one 
of another, so is the clamp a modification of the quilled.” 
(Fig. 2, copied, illustrates the apparatus applied to a 
vesico-vaginal fistule occupying the most favorable position 
for its use in the vesico-vaginal septum.) 
“ This suture is far preferable to anything before sug- 
gested for the purpose. Its introduction dates from June, 
1849, since which time I have had comparatively little 
trouble in the treatment of the great majority of cases of 
vesico-vaginal fistula. Properly applied, this suture never 
ulcerates out, having always to be removed by means of 8 
THE CLAMP SUTURE. 
scissors, hooks, and forceps. It -may be allowed to remain 
intact for six, eight, or ten days, or even longer. If removed 
too soon, the delicate cicatrix may gradually yield to the 
traction of the ascending uterus 
or to the force exerted by the 
bladder in expelling its contents 
and reproduce a small fistulous 
orifice, to be closed by a subse- 
quent and more cautious opera- 
tion. I have seen the new cicatrix 
give way from another cause, and 
perhaps it is the chief one. The 
damps, burrowing in the vaginal. 
surface., leave a deep sulcus or 
fissure on each side of the new 
cicatrix, which, when they are re- 
moved too soon, fill up hy granu- 
lation. It is a law of all granu- 
lating wounds to contract as 
they heal, and this contraction 
on each side of the new cicatrix 
£ °fUn sufficient to pull it apart. 
But if the clamps are allowed to 
Fig. 2. 
remain till their sulci are covered with mucous membrane 
then there is no danger of this accident, for these closures 
then gradually disappear, less by filling up with granulations 
than by an absorption of their elevated edges. 
“ Accidents of this sort have happened repeatedly in my 
hands, from a too early removal of the suture apparatus 
Great judgment, which experience alone can give, is neces- 
sary to determine the length of time that the sutures ought 
to remain intact, for no positive rules can be laid down that 
will answer invariably in every case. 
“I have also seen serious mischief result from leaving the 
clamps too long imbedded in the parts. Then burrowing and 
ulceration may extend entirely through the vagino-vesical 
structure, thereby substituting new fistulous openings for the NATHAN BOZEMAN. 
9 
original one. This complication is by no means incurable, 
but only prolongs the treatment and postpones ultimate suc- 
cess. 
“In two or three instances I have witnessed a still more 
serious accident from an undue pressure of the clamps, viz., 
a strangulation of the inclosed fistulous edges, which unfort- 
unately resulted in a sloughing of the tumefied parts, and a 
conseguent enlarging of the opening. In no instance, how- 
ever, has this accident rendered the case hopeless, or even 
caused me to feel any concern either for the immediate safety 
of the patient, or for ultimate success in treatment.” 
Next, with regard to the modus operandi of the self- 
retaining catheter proposed by Dr. Sims as an essential feat- 
ure of his procedure. (See Fig. 3.) Of this he says: “ When 
Fig. a 
well fitted to the case, it can be worn with much ease to the 
patient, and never turns, never slips out, it matters not 
whether she lies on the back or side. It is perfectly self-re- 
taining, being held in the bladder by an internal pressure 
against the symphysis pubis, and by external pressure on the 
outer end exerted by the labia overlapping it, and hiding it 
entirely from view.” (Italics by the writer.) 
In conclusion, Dr. Sims speaks of his labors in connection 
with his new operation, and of the circumstances under which 
he perfected it, together with his experience in its use, in 
these words: 
“ I have now completed what I have to say in a general 
way on the subject of the operation for vesico-vaginal fistula. 
It remains to detail individual cases, which will prove the 
curability of the disease, and also illustrate the varieties and 
complications to which it may be liable. The cases that oc- 
curred to me early, and which were given to me for the sake 10 
THE CLAMP SUTURE. 
of experiment, will show the difficulties that had to be oyer- 
come, the many disappointments that had to be borne, and 
the ultimate success that crowned my efforts after the per- 
fection of the mechanical contrivances, which, as it will be 
seen, was the work not of a day, and the result not of acci- 
dent, but of long, laborious, and persevering application. 
“ But this communication has already reached to such an 
extent that I must postpone the relation of my cases to a 
future opportunity.” 
It is evident from all that Dr. Sims says in the extracts 
given above, from his first paper upon the subject of vesico- 
vaginal fistule, that he never entertained the idea of apply- 
ing the clamp-suture to any other form of fistule than that 
of vesico-vaginal, involving the vesico-vaginal septum alone. 
Such a mechanism as that requiring the burrowing of the 
apparatus into the tissues, thereby becoming concealed from 
view, and having to be searched for in the tissues with a 
probe, when it did not occasion the more disastrous result of 
strangulation and sloughing of the borders of the fistule, can 
only be associated with the favoring conditions of a small 
fistula occupying a central position in the vesico-vaginal sep- 
tum, and with those of a like size and position in the recto- 
vaginal septum. 
The pressure necessary to bring about this peculiar mech- 
anism of the clamps described, could not fail in any form of 
fistule involving the junction of the trigone of the bladder 
and the urethra, and attended with loss of tissue—designated 
as a urethro-vesico-vaginal fistule—to produce the gravest 
complications. In those forms involving the junction of the 
has-fond of the bladder and the cervix uteri with loss of 
tissue—known as vesico-utero-vaginal fistules—the apparatus 
could only be applied, and that with the greatest difficulty, 
in a few exceptionally simple cases. 
Dr. Sims’s omission, in the preparation of his paper, to 
describe and illustrate these last two forms of fistule, as he 
did the one of vesico-vaginal fistule, is conclusive either that 
he had had no experience in their treatment at that time,' NATHAN BOZEMAN. 
11 
or that he recognized the fact that the clamp-suture not 
applicable to the management of such lesions the more 
probable explanation. It is unfortunate that he did not 
record his early experience touching these important points, 
as it would have given the profession the practical data 
needed for a proper understanding of the subject. Some 
two years after this paper appeared, Dr. Sims published the 
details of four cases—three simple vesico-vaginal tistules and 
one vesico-utero-vaginal fistule; but this number was too 
small to be of any practical value in determining so impor- 
tant a question as the one whether his method, as described, 
was applicable to the treatment of the two classes of lesions 
referred to. 
That Dr. Sims in his early experience had the opportu- 
nity of observing the lesion of urethro-vesico-vaginal fistule, 
as well as that of vesico-utero vaginal fistule, there can be no 
doubt. This opinion is based on the well-known fact that 
the proportion of the class of vesico-vaginal fistules, with 
which he was familiar, bears a more or less definite relation, 
not only to the class of vesico-utero-vaginal fistules (a case of 
which he reported, as stated), but to all other classes of fist- 
ules and injuries incident to parturition. Therefore it is 
reasonable to infer that his field of observation and study, 
when he wrote his paper on the application of the clamp- 
suture to the treatment of the simple class of vesico-vaginal 
fistules, was sufficiently wide to include as well the propor- 
tional numbers, at least, of the classes of urethro-vesico-vagi- 
nal and vesico-utero-vaginal fistules; and that his failure to 
point out their special treatment by his new mode of operat- 
ing arose from a consciousness of the inapplicability of the 
method to these lesions, rather than from the want of oppor- 
tunity for trial. 
I would state here that my conclusions, with regard to 
the inapplicability of the clamp-suture to the successful treat- 
ment of urethro-vesico-vaginal fistules, were based on person- 
al observations of some of Dr. Sims’s own patients, during 
the early period of his employment of the method. 12 
THE CLAMP SUTURE. 
The same may be said to have been true of my conclu- 
sions as to the class of vesico-utero-vaginal fistules, though 
the inapplicability of the apparatus here existed in a less 
marked degree; there being a small proportion of these cases, 
unattended with loss of tissue in the has-fond of the bladder 
and cervix uteri, that really could be cured with it by a judi- 
cious adaptation. 
I would also state, from my personal observation of Dr. 
Sims’s general practice with the clamp-suture, that it was 
almost wholly inapplicable to that large proportion of cases 
belonging to all the classes of fistules and injuries, urinary, 
fecal, and perineal, complicated with plastic exudations about 
the vagina and uterus, with cicatricial contractions, bands, and 
bridles of the vagina, with immobility of the borders of the 
co-existing fistule or fistules, and with fixation of the uterus. 
It is a remarkable fact that Dr. Sims, in his first paper, 
on the treatment of vesico-vaginal fistule, made no mention 
of cicatricial contractions of the vagina as complications of 
the affection, thus showing that he either regarded them as 
insurmountable by any sort of treatment, or that he believed 
his clamp-suture was inapplicable under such circumstances. 
It is only through his followers that attention was first di- 
rected to this most important matter. 
Again, Dr. Sims was almost wholly mistaken in the esti- 
mate he placed on the value of his self-retaining catheter. 
Subsequent experience with it in the hands of other surgeons 
proved that it was troublesome to manage, caused cystitis, 
endangered the success of the method as a whole, proved in- 
applicable in a large proportion of cases, and, taken all in all, 
was far inferior to the male (English) elastic catheter, when 
any catheter at all was required. 
Therefore, from all that has been said up to this point in 
the discussion of the subject, it may be fairly stated that Dr. 
Sims’s attention was almost exclusively directed to the treat- 
ment, with his clamp-suture, of that simple class of fistules 
alone known as vesico-vaginal, when the lesion was situated 
at or near the center of the vesico-vaginal septum, as his Fig. NATHAN BOZEMAN 
13 
2 illustrates on a preceding page. Here tlie adjustment of 
the apparatus was easy, and the clamps could always burrow 
smoothly and uniformly into the tissues, as insisted upon by 
him, provided there were no cicatricial contractions or modu- 
lar masses occupying the borders of the fistule. In trans- 
versely oval fistules ■ thus favorably situated, with diameters 
not exceeding an inch or an inch and a quarter, it was possi- 
ble to secure with it and his self-retaining catheter a fair 
degree of success. The proof of this limited adaptation of 
the clamp-suture is found not only in Dr. Sims’s own indi- 
vidual practice, but in that of nearly all of his followers, in- 
cluding (in the chronological order of cases treated by them) 
the names of Sims and Bozeman, then of Montgomery, Ala., 
jointly, and Bozeman individually; Baker Brown, Mussey, 
Thomas, Pope, Buck, Williams, Mettauer, Ash, Kollock, 
Wragg, and Finnell. 
It is important to state here that all the eases reported, 
treated and not treated, by the above-named surgeons, be- 
longed to the three classes of vesico-vaginal, urethro-vesico- 
vaginal, and vesico-utero-vaginal fistules, with the exception 
of a recto-vaginal fistule which was operated upon and cured 
by Dr. R. D. Mussey, of Cincinnati, Ohio. 
In order now to point out particularly the peculiarities 
and relations of these three important lesions, and show the 
precise mechanism of the clamp-suture, with the limitations 
of its successful application in the several classes named, it 
will be necessary to refer to the two original illustrations, 
Figs. 4 and 5. 
The two figures both represent fistules at the center of 
the vesico-vaginal septum, the most common form and situa- 
tion of the class of vesico-vaginal fistules, which are both 
shown to be closed by a transverse application of the clamp- 
suture similar to that illustrated by Dr. Sims (Fig. 2), but on 
a reduced scale. Below the seat of these two fistules thus 
closed with the clamp-suture are seen, at the junction of the 
trigone of the bladder with the urethra, two fistules unclosed, 
which belong to the class of urethro-vesico-vaginal fistules— 14 
THE CLAMP SUTURE. 
one a longitudinal slit (Fig. 4), unattended with loss of tissue 
in either structure implicated, and the other (Fig. 5) a trans- 
versely oval opening, attended with loss of tissue in both 
structures. These are the simplest forms of this class of 
Fig. 4. 
Fig. 5. 
fistules. In the first, the relative positions of the clamps, in 
longitudinal outline, show the possibility of easily closing 
the fistule; but, in the second, the actual longitudinal posi- 
tions of the clamps, with wires and perforated shot in readi- 
ness, show the impossibility of it, because the form of the 
lesion, and the slight elasticity of the structures below within 
the pubic arch, oppose the required mechanism of the clamps. 
Here, then, parallel approximation could not be effected, or 
their uniform burrowing into the tissues take place, without 
serious damage to the structures on account of the underly- 
ing pubic bones. For the application to the latter form of 
fistules, therefore, the only other alternative would be to 
change the positions of the two clamps to the sides of the NATHAN BOZEMAN. 
15 
fistule and place them in a transverse relationship, as shown 
by the lower clamp on the closed vesico-vaginal fistule, and 
the clamp in dotted outline standing across the urethra. By 
such a mechanism of the clamps, coaptation of the borders 
of the fistule would be possible j not, however, by equal ap- 
proximation of both borders, for the reasons before stated, 
but by stretching the tissues of the superior border of the 
fistule, in which alone any elasticity resides. As to the other 
requisite of the mechanism of the clamps always insisted 
upon by Dr. Sims—the burrowing into the underlying tissues 
—it is easy to see what the effect of the lower one would be 
upon the urethra compressed against the pubic arch. It 
would simply be cut in two and a urethro-vaginal fistule 
would be the result. With this explanation of the mechan- 
ism of the clamp-suture in a possible and impossible applica- 
tion of it, in the forms of the class of urethro-vesico-vaginal 
fistule illustrated, there will be no difficulty in imagining the 
increase of the defectiveness and dangers of the method, 
from the gradual augmentation of the size of the fistule, 
whether in one or more directions. Such a loss of tissue, it 
must not be forgotten, is liable to extend both longitudinally 
and transversely, sometimes involving the greater part or the 
whole of the urethra, on the one hand, and, on the other, the 
vesico-vaginal septum, together with a part or the whole of 
the infra-vaginal portion of the cervix uteri. 
Let us next direct our attention beyond the seat of the 
two fistules, closed to the junction of the has-fond of the 
bladder with the cervix uteri. Here are seen, also, two un- 
closed fistules which belong to the class of vesico-utero-vagi- 
nal fistules. One (Fig. 5) a longitudinal slit, unattended 
with loss of tissue in either structure implicated, and the 
other (Fig. 4) a transversely oval opening, attended with 
loss of tissue only in the bas-fond of the bladder. These 
are likewise the simplest forms of this class of fistules. In 
the first, the relative positions of the clamps in longitudinal 
outline, with their upper ends resting against the sides of 
the anterior lip of the cervix uteri, show the possibility of 16 
THE CLAMP SUTURE. 
easily closing the fistule, but, in the second, the actual lon- 
gitudinal positions of the clamps and sutures show the im- 
possibility of it, because the form of the lesion, the slight 
transverse elasticity of the structures, and the position of the 
somewhat solid anterior lip of the cervix uteri between the 
upper ends of the clamps, all oppose the one essential ele- 
ment of the mechanism—to wit, their parallel approximation. 
The uniform burrowing of the clamps—the other requisite— 
however, is possible here, but not without serious danger to 
other important anatomical structures, notably the ureters. 
In this form of the lesion, therefore, the only other alterna- 
tive would be to introduce the same three sutures antero- 
posteriorly, making the middle one traverse the anterior lip 
of the cervix uteri in the median line, and the other two in 
the borders of the fistule proper on either side of the cervix. 
This being done, and the upper clamp placed on the upper 
ends of the wires, across the cervix uteri, and the lower one 
on the lower ends of the wires, in relation with the upper 
clamp on the closed fistule, the next thing called for would 
be the required adjustment of the apparatus, as illustrated 
by its application to the vesico-vaginal fistule below. What 
would be the mechanism of the apparatus, from such an ap- 
plication of it, in such a relationship of the parts? The 
obvious and injurious result would be the undue pressure 
of the clamp placed across the cervix uteri, supported only 
at its middle, and mounted on a plane far above that of its 
fellow of the opposite side. The natural consequences of 
such an unphilosophical application of the apparatus would 
be to cause ulceration and the cutting across of the cervix 
uteri, followed by hemorrhage and possibly cellulitis and 
septic peritonitis, with permanent injury to the cervical canal, 
should the patient be so fortunate as to escape with her life. 
Still another grave consequence would be the almost certain 
burrowing of the lower clamp into the vesico-vaginal septum, 
and the opening of the bladder in its tract, simply, or by the 
strangulation and sloughing of the included structures arising 
from stress of the ascending uterus, thus cutting short the NATHAN BOZEMAN 
17 
prospect of permanent closure of the original fistule even by 
repetition of the procedure, should the patient be so fortu- 
nate as to escape with her life the disasters incident to a first 
trial. 
Next imagine the augmentation of the size of the fistule 
by a more extended implication of a part or the whole of the 
infra-yaginal portion of the cervix uteri, and a part or the 
whole of the vesico-vaginal septum down to the urethra, even 
to the extent of destroying a part of the canal, all different 
phases or grades of implications that are constantly met with 
m practice, as I have often personally seen, and think of ex- 
pending the application of this form of suture by lengthening 
the clamps to suit the diversified grades of lesion indicated. 
Tor the human mind to conceive a greater absurdity would 
seem clearly impossible. 
How practical surgeons, in their experience with the clamp- 
suture, gradually approached the border-line of its efficiency 
and inefficiency, tried all sorts of expedients to accomplish 
cures which were impossible on account of the violation of 
natural laws involved in them, and invented all sorts of apolo- 
gies for their disastrous failures, are interesting points of 
study. I propose, in my examination and analysis of the 
facts relating to the treatment of the several classes of lesions 
to which attention has been called, to present the views of 
each surgeon referred to, in his own words, so far as may be 
found practicable. 
This brings us now to an examination, according to classi- 
fication, of the peculiarities of fistules treated with the clamp- 
suture in the United States and England, during the period 
of sixteen years extending from 1845 to December, 1861, 
when the last operation with it, of which there is any ac- 
count, was performed, by Dr. T. C. Finnell, of New York. 
In this period are comprised all the fistules and injuries 
incident to parturition, and the results of their treatment 
with the clamp-suture, reported by Dr. Sims and the differ- 
ent surgeons before enumerated. The number of cases con- 
stituting the first series was thirty-eight, and they presented 18 
THE CLAMP SUTURE. 
forty-three fistules and injuries belonging to six classes— 
twenty-four vesico-vaginal fistules, seven urethro-vesico-vagi- 
nal fistules, six vesico-utero-vaginal fistules, two urethro-vagi- 
nal fistules, two recto-vaginal fistules, and two lacerations of 
the perineum. 
The cases admitted into the Woman’s Hospital of the 
State of Hew York, and treated individually by Dr. Sims 
with the clamp-suture, from May, 1855, to May, 1856, when 
he abandoned this form of suture, are comprised, as before 
stated, in the second series. The number also amounted to 
thirty-seven, in which there were forty-two fistules and inju- 
ries belonging to five classes—seventeen vesico-vaginal fist- 
ules, seven urethro-vesico-vaginal fistules, eight vesico-utero- 
vaginal fistules, five recto-vaginal fistules, and five lacerations 
of the perineum. The number of cases in this second series, 
and the classification of the same in one year, are thus shown 
to be, by an extraordinary coincidence, almost precisely the 
same as those given in the first series, the treatment of which 
extended through a period of sixteen years, and, what is no 
less remarkable, the results of treatment in this second series 
vary but little from those of the first, as will hereafter be 
shown. 
There is no evidence to be found, in connection with this 
second series of cases in the Woman’s Hospital, that Dr, T. 
A. Emmet, the successor in 1862 of Dr. Sims, ever performed 
an operation with the clamp-suture, but his labors during the 
period named, beginning with the opening of the hospital, 
May 1,1855, and showing his faithful record of the histories 
and peculiarities of the eases of this series, are not without 
great practical value in a statistical point of view. For this 
record, Dr. Emmet is certainly entitled to the highest credit 
from the profession, and I for my part heartily acknowledge 
this deep sense of obligation to him, since without it the in- 
dividual efforts of Dr. Sims in this institution at that period, 
supported as they were by the resources of the great State of 
New York, ans encouraged by the sympathies and sacrifices 
of a few noble women, would have been entirely lost to sci- NATHAN BOZEMAN. 
19 
ence, whatever may now be thought of their philosophy or 
usefulness. 
First Series, 
Cases I-lll.—First Three Vesico-vaginal Fistules cured 
with the Clamp-Suture—Lesions situated at or near the Center 
of the Vesico-vaginal Septum—No Complications present— 
Forty Operations performed, mostly experimental, before the 
Method was perfected and the Cures completed. 
Class of Vesico-vaginal Fistules. 
Anacha, Lucy, and Betsy, all colored, were the first three 
women treated by Dr. Sims, in Montgomery, Ala., from 1845 
to June, 1849, with his various modifications of the old quill- 
suture, and, finally, with his perfected clamp-suture. They 
were all completely cured eventually ; the three having under- 
gone from first to last no less than forty operations in all. 
From the best information that can be gathered from the vari- 
ous published sources extant, regarding the peculiarities of 
these cases, the writer is led to conclude that the fistules in the 
outset were all of small size and favorably situated, at or about 
the center of the vesico-vaginal septum, in vaginas otherwise 
normal. These three cases are of peculiar historical interest, 
from the great number of operations they underwent, and the 
gratifying results that were finally realized. It is to be re- 
gretted that Dr. Sims never made a detailed report of them. 
Case IV.— Vesico-vaginal Fistule—Lesion Small, situated 
near the Center of the Vesico-vaginal Septum—No Complica- 
tions present—One Operation with the Clamp-Suture—Self- 
retaining Catheter caused Inflammation of Urethra, and had 
to he removed on the Fourth Day— Clamps removed on Ninth 
Day, and found burrowed into the Tissues, almost out of Sight 
—First Operation Successful. 
Ann McKee,1 colored, aged sixteen, came under Dr. Sims’s 
care in the autumn of 1849, and presented a transversely oval 
fistule situated just below the center of the vesico-vaginal sep- 
tum, as shown by Fig. 6, copied from his original illustration. 
Dr. Sims operated upon the case October 25, 1849, with his 
1 See Case I, New York Med, Gazette, vol. v, January, 1854. 20 
THE CLAMP SUTURE. 
clamp-suture, using three points of silver wire, and, in the 
after-treatment, his self-retaining catheter. 
He states that on the fourth day the urethra became much 
inflamed and swollen, when the catheter had to he removed 
entirely and the patient allowed to 
pass the urine naturally. An exami- 
nation on the seventh day showed 
the clamps to he completely hidden 
in the tissues from burrowing, only 
the projecting ends of the wires and 
perforated shot being visible (italics 
by the writer). The apparatus was 
removed on the ninth day. Of the 
condition of the cicatrix on the 
eleventh day Dr. Sims says : “ The 
sulci on each side of it made by the 
clamps were filled up by granula- 
tions, while the cicatrix, which two 
days ago was so compact as scarcely 
to be visible, is now considerably 
widened, thinned, and depressed be- 
low the vaginal surface, and evi- 
dently seems to be on the point of 
giving way ” (italics his). He after- 
ward remarks : “ This was the first 
Pig. 6. 
case I had cured by a single, operation, and I felt great satis- 
faction at the result, particularly as it was obtained under such 
unfavorable circumstances.” 
Case V. Vesico-vaginal Fistule—Situation same as in 
Preceding Case, but Size Larger—No Complications present— 
Patient very large, and coicld not bear the Knee-Elbow Posi- 
tion— Operation with Clamp-Suture performed on the Left 
Side—Clamps removed on the Sixth Pay, and found burrowed 
out of Sight in the Substance of the Bladder—Cicatrization of 
the Sulci thus produced nearly caused Reproduction of the Fist- 
ule—First Operation successful. 
Mrs. A. F.,1 aged forty, quite stout, and weighing nearly 
two hundred pounds, applied to Dr. Sims for treatment. He 
1 See Case 11, op. cit. NATHAN BOZEMAN. 
21 
says: “ Fistula was considerably larger than the one first de- 
scribed, but occupied precisely the same relative position with 
regard to other parts.” He operated with the clamp-suture on 
November 12, 1849, when three points of suture were used. 
Owing to the inability of the patient to bear the knee-elbow 
position, Dr. Sims placed her on the left side for the operation, 
of which he thus speaks ; 
“ Placed on her left side, with the thighs well flexed on the 
abdomen, the nates forcibly pulled upward and backward, the 
lever-speculum was introduced and the parts brought into view, 
which was accomplished more easily than I anticipated, but 
did not show the fistula so well as when the proper position on 
the knees is resorted to. However, I managed to get through 
with the different stages of the operation with tolerable 
ease. ... 
“On the sixth day the clamps were removed. They were 
buried in the substance of the bladder, and entirely hidden 
from view, the leaden knots alone being visible. The fistula 
seemed to be accurately and perfectly closed; the line of 
union being scarcely perceptible [italicized by the writer]. . . . 
“It [the cicatrix] underwent precisely the same changes as 
noticed in the former case, only to a greater degree: viz,, a 
stretching, thinning, and depression, which gradually disap- 
peared, the cicatrix then becoming smooth and regular [itali- 
cized by him]. 
“ It follows, then, that three or four days is not long enough 
for the suture apparatus to remain, because the fistula has al- 
ways been reproduced after its removal ; and that seven or 
eight days is not sufficient, because there is great danger of the 
same accident. My large experience has demonstrated the 
fact that about twelve days is the proper length of time for 
the clamp-suture to remain in the tissues. It is evidently 
unsafe to remove it sooner, and it may remain till the fif- 
teenth day with impunity, but a longer time is altogether 
unnecessary.” 
Case Yl,—Vesico-vaginal Fistule—Situation near Center 
of Vesico-vaginal Septum—Size very Small, and Direction 
through the Tissues Valvular—No Complications present— 
First Operation with Clamp-Suture successful. THE CLAMP SUTURE. 
Mrs. H.1 applied to Dr. Sims for the treatment of a small 
fistule situated in the upper part of the trigone of the bladder, 
as seen in the accompanying illustration, Fig. 7, and thus de- 
scribed by him : “ The fistulous opening was just above the 
neck of the bladder, a little to the right of the mesial line, and 
altogether favorable for a successful operation. It ran diag- 
Fig. 7. 
onally through the walls of the bladder, thus forming a sort 
of sinuous canal of a valvular character.” Dr. Sims operated 
upon the case February 2, 1853, using two points of suture 
with his clamps, and completed the cure at a single operation. 
Suture apparatus removed on the thirteenth day. (Illustration 
copied.) 
Case VII.— Vesico-vaginal Fistule without Loss of Tissue, 
being the Result of Vesico-vaginal Lithotomy—Direction of 
Incision longitudinal—Situation in Trigone of Bladder—Cal- 
culus, Size of a Partridge1 s Egg—Easily seized and removed— 
Vagina naturally Small, hut otherwise Normal—Eight or ten 
Operations with the Clamp-Suture—Conversion of the Original 
Incision into a Round Opening, the Size of the Index-Finger, 
and the Establishment of a Urethro-vesieo-vaginal Fistule with 
Complete Obliteration at the Same Point of the Urethral Canal, 
and Extensive Cicatricial Surfaces around both Fistules, all 
Results of the repeated cutting away of the Tissues and slough- 
ing out of the Suture Apparatus—Patient discharged incurable. 
1 New York Medical Times, May, 1854, and American Journal of the Medi- 
cal Sciences, vol. xxviii, p. 283, July, 1854. NATHAN BOZEMAN. 
Lavinia Boudurant, colored, aged thirteen, applied to Dr. 
Sims for treatment, on account of a calculus in the bladder, in the 
spring of 1850. The incision made for the removal of the stone 
was in the median line, and extended upward from a point near 
the junction of the urethra with the trigone of the bladder. It 
was about three quarters of an inch in length, and consequently 
extended slightly into the bas-fond of the bladder. The calcu- 
lus was seized with forceps and removed through this opening. 
As soon as the bladder was cleansed of blood, Dr. Sims made a 
longitudinal application of his clamp-suture, the position of the 
clamps being the same as shown by dotted lines in the diagram, 
Fig. 4, illustrating a urethro-vesico-vaginal fistule unattended 
with loss of tissue. The result of this application of the clamps 
proved a total failure. I was present and assisted in the op- 
eration. During the next eighteen months or two years, the 
patient underwent, without success, eight or ten similar opera- 
tions, in many of which I also assisted. The final result was 
the conversion of the original straight incision in the trigone 
of the bladder into a transversely oval vesico-vaginal fistule, 
from the repeated paring away of 
the tissues, and the ulcerating out 
of the suture apparatus. There 
was established also an addition- 
al complication from the same 
causes, a urethro-vesico-vaginal 
fistule about half an inch from 
the lower border of the existing 
vesico-vaginal one, and a com- 
plete obliteration of the urethral 
canal at the seat of the accidental 
opening. Over the obliterated 
portion of the urethra, and around 
the borders of each fistule, were 
to be seen extensive surfaces of a 
Fig. 8. 
cicatricial or modular tissue, resulting also from the repeated 
cutting out of the clamps, as shown by the wavy lines in the 
accompanying illustration (Fig. 8). The relation of the two 
fistules, as well as the obliterated point of the urethra between 
them, are also shown. 24 
THE CLAMP SUTURE. 
No report of this case was ever made by Dr. Sims. 
Some six or seven years after this patient was discharged 
by Dr. Sims, she applied to me for further treatment (Janu- 
ary 18, 1858), when both of her fistules, together with the 
stricture of the urethra, as above described, were completely 
cured at two operations by gradual preparatory treatment, and 
the button-suture, as will be more fully described hereafter, 
in the consideration of the class of urethro-vesico-vaginal 
fistules. 
Case YIII,— Vesico-vaginal Fistule—Situation of the Le- 
sion below the Center of the Vesico-vaginal Septum—Trans- 
versely Oval and of Medium Size—No Complications present 
—Ten or more Operations with the Clamp-Suture—Closure of 
the Fistule in the Middle, leaving two Angular Openings—Pa- 
tient abandoned for a Time uncured. 
Delia, colored, aged twenty-three, Dr. Sims’s own servant. 
She began to receive treatment from Dr. Sims in the spring of 
1850, and this was continued from that time up to March, 1853. 
Now becoming associated with Dr. Sims as partner, I had the 
opportunity of seeing the exact stage of advancement in the 
treatment of the case. Having also been present and assisted 
in some of the many operations previously performed by Dr. 
Sims, I had become thoroughly acquainted with the difficulties 
pertaining to the case. The fistule originally occupied a low 
and very accessible position in the vesico-vaginal septum, and 
extended transversely, but further to the right of the median 
line than to the left. It was in the outset oval in outline, and 
measured perhaps an inch and a quarter in its longest diameter. 
During the period the patient was under Dr. Sims’s treatment, 
she underwent ten or more operations, according to her own 
account. Dr. Sims stated to me, regarding the previous history 
of his treatment, that by his first two or three operations he 
succeeded in closing the fistule in the middle and narrowing it 
down to two small angular openings, which had since defied all 
efforts to complete the cure. 
On or about May 20, 1853, Dr. Sims performed his last 
operation, which was a double one, and consisted in applying 
a pair of clamps to each remaining fistule. He left the after- 
treatment to me, this being only a few days before his own de- NATHAN BOZEMAN. 
25 
parture from Montgomery for New York, The result of the 
operation was a total failure, both pairs of clamps cutting out. 
No report of the case was ever made by Dr. Sims. The 
woman remained in this condition until the autumn of 1855, 
when she applied to me for further treatment. Both fistules 
were completely closed, each at a single operation, by means 
of the button-suture. The case will be referred to again and 
illustrated in another connection. 
Case IX.— Vesico-vaginal Fistule—Size Small, and Situa- 
tion near the Cervix Uteri, and to the left of the Median Line— 
Cicatricial Contraction of the Left Wall of the Vagina with 
Distortion of the Organ opposite the same Point—Complica- 
tions not treated—Three Operations with the Clamp-Suture for 
Closure of Fistule—All failed from the early cutting out of the 
Left Clamp—Dr. Sims’s Lever-Speculum found to he too short 
to expose the Fistule—Lmportant Modification of this Instru- 
ment—Patient first discharged uncured, and finally considered 
incurable, by the Clamp-Suture. 
Julia McDuffie, colored, aged twenty. She first came 
under observation early in March, 1853, and was treated jointly 
by Dr. Sims and myself, this being the first new case in our 
practice after we became associated as partners. The fistule 
was about the size of a No. 6 catheter, and was situated near 
the cervix uteri, about midway between the median line and 
left lateral wall of the vagina. Between it and the wall of the 
vagina, the parts showed the effects of direct injury, which had 
resulted in slight contraction of the canal at this point, to- 
gether with a thickening and elevation of the corresponding 
border of the fistule to a plane above that of its fellow of the 
opposite side. 
Owing to the distortion of the vagina at this point, and 
the shortness of the lever-speculum as improved by Dr. Sims, 
great difficulty attended the effort of displaying the fistule in 
the knee-elbow position. The anterior wall of the vagina, be- 
ing thus drawn toward the posterior, and restrained in its 
movements, could not drop to the usual position when the 
speculum was introduced and air admitted into the organ, as 
always insisted upon by Dr. Sims as an important principle. 
Gravitation of the pelvic and abdominal viscera took place as 26 
THE CLAMP SUTURE. 
usual, but the anterior wall of the vagina remained in its more 
or less restrained relationship with the posterior, thus prevent- 
ing exposure of the fistule, as before stated. Nevertheless, on 
or about March 15, 1853, Dr. Sims performed his operation 
with the clamp-suture. I held the speculum, and of course saw 
the complication present, and realized fully the disadvantages 
of the short blade of the speculum for displaying the fistule. 
The nearness of the opening to the anterior lip of the cervix 
uteri precluded the possibility of making a transverse adjust- 
ment of the apparatus, even had the parts been in a normal 
state. Under such circumstances a longitudinal application 
became the only alternative, and this necessitated the placing 
of the left clamp upon the hardened and unyielding border 
of the fistule described, and of the right, upon the soft and 
elastic one. 
Two points of suture were used. Fig. 9 illustrates the 
closure of the fistule and the apparatus in position, together 
with the cicatricial contraction 
and distortion of the vagina on 
the left side. 
The left clamp, as shown, rest- 
ed on a plane higher than its fel- 
low of the opposite side, and, 
instead of sinking into the tissues 
to reach an easy, even point of ad- 
justment, it caused ulceration, and 
cut its way down, in the course of 
the after-treatment,to the required 
level, with consequent strangula- 
Fig. 9. 
tion and sloughing of the included structures ; thus resulting 
in an increase in the size of the original opening. 
Under the same difficulties with regard to exposure of the 
fistule, I performed the same operation June 1, 1853, and with 
precisely the same unfortunate result. 
In both of these operations, the patient showed great suf- 
fering, and in her struggles became quite exhausted at times. 
Finally, not being able to maintain the knee-elbow position, 
she sank into that of the knee-face, in which the procedure 
was completed, as usual under such circumstances. NATHAN BOZEMAX. 
The general health of the patient suffered very much from 
these operations, and she was consequently sent home with no 
encouragement whatever to expect an ultimate cure. 
No report by Dr. Sims of this case, or his operation, was 
ever made. Nearly two years afterward, however, the patient 
returned to me for further treatment. I will speak of the sub- 
sequent operations and final result in another connection. 
Having observed the defectiveness of Dr. Sims’s form of 
tbe lever-speculum, as employed in these two operations, it 
occurred to me that the instrument might be greatly im- 
proved for the treatment of all cases having the complica- 
tion above described. In June, 1853, I submitted my plan 
of modification of the instrument to a jeweler,1 upon whom 
I was dependent at that time for all such impromptu work. 
The result was the embodiment of all my proposed altera- 
tions, which proved most satisfactory. The accompanying 
cuts show the original forms of the two instruments—Fig. 
10 Sims’s, and Fig. 11 Bozeman’s. 
The objects of these alterations in the form of Dr. Sims’s 
speculum, without regard to aid from atmospheric pressure, 
and believed to be called for in this case, were threefold: 
1. To increase the length of the blade of the instrument 
from two inches and a half, as described by Dr. Sims, to 
about four inches, so as to make it extend the whole length 
of the posterior wall of the vagina, thus making it pass into 
or beyond the point of cicatricial contraction. 
2. To make the heel of the blade narrower, and the distal 
extremity wider, so as to insure greater elevation of the peri- 
neum, and consequently more forcible expansion of the cica- 
tricially contracted portion of the vagina, necessary for ex- 
posure of the co-existing fistule. 
3. To place the handle of the instrument at such an angle 
to the blade, 75°, that it could be easily held in the right 
hand of the assistant, with the forearm resting over the sa- 
crum of the patient, thus giving the required adaptation of 
1 John Bates, of Montgomery, Ala. 28 
THE CLAMP SUTURE. 
the blade to the entire rectal wall of the vagina without 
fatigue of the arm, as from the elevated and awkward angle 
of the elbow requisite in the use of Dr. Sims’s form of the 
instrument. To show that all of these alterations were philo- 
Fig. 10. 
Fig. 11. 
sophical, and the objects of them fully attained,! will only state 
the fact that my pattern of the instrument, as above shown, 
superseded in my hands entirely that of Dr. Sims, which was 
intended originally for the simple purpose of elevating the 
perineum and securing the admission of air, thought by him 
to be sufficient for the distension of the vagina. 
Case X.— Fesico-vaginal Fistule—Situation supposed to 
have been favorable in the Vesico-vaginal Septum—Impor- 
tant Modification of the Clamp-Suture—First Operation with 
it successful. NATHAN BOZEMAN. 
29 
Dr. Mussey, in his report1 of the first successful operation 
for recto-vaginal fistule, by an important modification of the 
clamp-suture, April 20,1853, incidentally refers to an unreported 
case of vesico-vaginal fistule operated upon by a surgeon in 
Ohio, who had also modified the clamp-suture in a somewhat 
similar manner to that proposed by himself. 'He says : “ Dr. 
Thomas, in the eastern part of Ohio, now of Pittsburgh, Pa., 
who treated a case of vesico-vaginal fistula with entire success, 
placed his stitches in the clamp-suture about the fifth of an 
inch apart. The wire which I employed in the recto-vaginal 
fistula was not far from twice the diameter of a horse-hair.” 
This case of recto-vaginal fistule will be introduced in its ap- 
propriate place in the consideration of this class. Although 
the situation, size, and form of the fistule in Dr. Thomas’s case 
were not stated by Dr. Mussey, the inference may be fairly 
made, from the success of the operation, that the lesion occupied 
the usual position at or near the center of the vesico-vaginal 
septum. 
Cases XI-Xlll.—Three Vesico-vaginal Fistules—First one 
of Medium Size, and situated near the Center of the Vesico- 
vaginal Septum—No Complications present on the Anterior 
Wall of the Vagina, hut upon the Posterior existed a few 
Cicatricial Bands—Complication not treated—First Opera- 
tion with Clamp-Suture successful—Self-retaining Catheter 
caused Cystitis, and its Use had to he discontinued—Fistules 
in Second and Third Cases large, hut supposed to have been 
favorably situated in the Vesico-vaginal Septum— Crave 
Cicatricial Contractions of the Vagina present— Complica- 
tions not treated— Operated upon hy Heated Wire and Ordi- 
nary Suture, and hy the Methods of Hayward, Johert, and Sims, 
hut all failed—Both Cases discharged as incurable. 
Mary Porch, aged thirty, came under the care of Dr. Charles 
A. Pope,2 of St. Louis, in the autumn of 1853, presenting a fist- 
ule at the center of the vesico-vaginal septum, with a transverse 
diameter of an inch and a quarter. There were slight cicatri- 
cial contractions upon the posterior vaginal wall, and calcare- 
ous incrustations and excoriations of the external parts were 
1 American Journal of the Medical Sciences, vol. xxvii, Oct., 1853. 
2 St. Louis Med. and Surg. Jour., vol. xii, p. 401, Aug., 1854. 30 
THE CLAMP SUTURE. 
also present. On December 3d, Dr. Pope proceeded to operate 
with the clamp-suture, and was entirely successful at the first 
trial. He states that the self-retaining catheter of Dr. Sims, 
in the after-treatment, caused cystitis, and its use had to he dis- 
continued. He concludes his report of the case with an allu- 
sion to two other cases, treated by the same method, but prov- 
ing unsuccessful on account of the complication of cicatricial 
contractions of the vagina. As showing the gravity of such 
complications, and how they were regarded by Dr. Sims at 
this stage of his experience with the clamp-suture, the writer 
will quote Dr. Pope’s own words. He says : 
“ I have tried various modes of relief in these distressing 
cases of vesico-vaginal fistulse, as the heated wire, the ordinary 
suture with freshened edges, Hayward’s as well as Jobert’s 
methods, and in three instances Sims’s operation. Partial bene- 
fit occurred in almost every case. The two former instances, in 
which I failed by Sims’s operation, were not favorable cases, 
owing to their great size and the accompanying coarctations of 
the vagina. In describing one of these cases to Dr Sims him- 
self, whom I had the pleasure of meeting at the American Med- 
ical Association, held in Richmond, Va. {lB5 f), he stated that he 
would not have undertaken an operation for its relief [ltalics 
by the writer.] Cures of vesico-vaginal fistula have doubtlessly 
been effected by other means, but the success in my last case 
was so easily and completely attained that I must confess ray 
decided preference for the operation adopted. Too much 
praise can not be awarded Dr. Sims for his persevering and in- 
genious efforts in this department.” 
Case XIY.— Vesico-vaginal Fistule—Situation near the 
Center of the Septum, and Size Small—No Complications 
present—Lithotomy Position, and Anesthesia used in the 
Operation—Jacobson)s Lithotrite applied to expose the Fist- 
ule— Operation for Closure of the Same by an important 
Modification of the Clamp-Suture—Employment of Silver 
Wire and Flat Clamps instead of Round Ones, and of Two 
Interrupted Silver Wires, each secured independently with 
Perforated Shot—First Use of Interrupted Silver - Wire Su- 
tures secured in this Way—Anterior Clamp burrowed into the 
Tissues, leaving an ulcerated Groove—Fistule completely closed. NATHAN BOZEMAN. 
31 
Mary Harty, aged twenty-eight, came under the care of 
Dr. Gurdon Buck,1 in the New York Hospital, July 4, 1854. 
The fistule was situated just below the center of the vesico- 
vaginal septum, and was of the size of the index-finger. Dr. 
Buck operated on this case on July 13, 1854, placing the 
patient in the lithotomy position, and using an anesthetic. Of 
the procedure adopted, which was an important modification 
of Dr. Sims’s method, he says ; 
‘‘A Jacobson’s lithotrite answered a most useful purpose 
in bringing within reach the fistulous opening, and keeping the 
surrounding vesico-vaginal wall on the stretch, thus very much 
facilitating the subsequent steps of the operation. This instru- 
ment resembles in form an ordinary catheter with a short curve. 
The curve, when the instrument is opened, is converted into 
a pointed hook, or noose. It was introduced closed per ure- 
thram into the bladder and then opened. By elevating the han- 
dle of the instrument toward the abdomen, the loop was de- 
pressed against the base of the bladder, forcing it downward 
into the vagina, and forward toward the vulva. The fistule 
being thus brought within reach, its edges are pared away, so 
as to render the longest diameter of the opening transverse.” 
The fistule having been thus exposed, and its edges pared, 
Dr. Buck introduced six silver sutures, and then secured them 
with “ a narrow, flat strip of lead, called a clamp,” and perfo- 
rated shot. Only the four middle wires were secured with the 
damps and shot. The two end ones were fastened independently 
by simply running down on each one of them a perforated shot, 
and compressing it. The clamps and sutures were removed on 
the fourteenth day, and closure of the fistule found complete. 
The anterior clamp had burrowed into the tissues some, leaving 
in its site an ulcerated groove. (Italics by the writer.) 
The particulars in which Dr. Buck departed from Dr. Sims’s 
procedure may be summed up as follows : 
1. The patient was placed in the lithotomy position, instead 
of the knee-elbow. 
3. Jacobson’s lithotrite was used for displaying the fistule, 
instead of the lever-speculum. 
2. An anesthetic was used. 
1 New York Journal of Medicine, vol. iv, October, 1854. 
24 THE CLAMP SUTURE. 
4. A greater number of sutures were used, and the two end 
ones were secured independently of the clamps, as interrupted 
sutures, by compressing on them perforated shot. 
5, Narrow, flat clamps were used, instead of small, round 
ones, preferred by Dr. Sims to facilitate their burrowing into 
the tissues. 
Case XY.— Yesico-vaginal Fistule—Situation at or near 
the Center of the Septum, and of a Size to admit Two Fingers 
with Longest Diameter transverse—No Complications present— 
Two Operations with the Clamp-Suture—ln Second Operation 
the Apparatus found burrowed into the Tissues—Closure of 
Fistule successful. 
Mrs. R. came under the care of Dr. A. Y. Williams,1 of New 
York, in the autumn of 1854, presenting a fistule near the cen- 
ter of the vesico-yaginal septum, in a vagina otherwise nor- 
mal. It was large enough to admit two fingers. Dr. Williams 
performed the operation, “ as recommended by Dr. Sims,” Octo- 
ber 14, 1854. Everything progressed well until the fifth day, 
when the escape of urine per vaginam was discovered. Now, 
“on examination it was found ulceration had taken place at 
one end of the damps, probably from their having been applied 
too firmly. It may here be remarked that the proper applica- 
tion of the clamps is one of the nicest points of the operation: 
if applied too loosely, urine will escape; if too tight, they will 
ulcerate. It is difficult to state the degree of pressure neces- 
sary / it is a matter for the exercise of judgment on the 
part of the operator. It perhaps may do to suggest that, if 
the clean edges of the cut surfaces are brought into exact 
coaptation it will answer, as the swelling, of the parts will 
then keep them well together. The condition of the clamps 
was always exactly as stated by Dr. Sims, and need not here 
be repeated.” 
The clamps were removed on the eleventh day, when the 
fistule was found to be reduced to the size of one finger, the 
operation having practically failed. 
Dr. Williams performed a second operation, using the same 
form of suture, in December, 1854. He removed the apparatus 
this time on the fourteenth day, finding it 11 lying seemingly 
1 New York Medical Times, vol. iv, p. 189, March, 1855. NATHAN BOZEMAN. 
33 
enclosed in a new mucous surface ” ; but the result was a com- 
plete closure of the fistule. (Italics by the writer.) 
Case XVI.— Vesico-vaginal Fistule—Situation at or near 
the Center of the Septum, and Size half an inch in Diameter 
—No Complications present— One Operation with the Clamp- 
Suture—ln the After-treatment, the Perforations in the Self- 
retaining Catheter became closed by Projections into them 
of the Mucous Goat of the Bladder—Closure of the Fistule 
successful. 
A colored woman, aged twenty-three, was placed under the 
care of Dr. W. C. Ashe,1 of Demopolis, Ala., in the spring of 
1855. No statement of the seat or form of the fistule is made, 
but it is said to have been half an inch in diameter. From the 
meager report of the details of the case, and the promptness 
with which it was cured with the clamp-suture at a single op- 
eration, it is safe to say that the fistule occupied a favorable 
position for the burrowing of the clamps, at or near the center 
of the vesico-vaginal septum. The after-treatment was con- 
ducted by Dr. Ruffin, who had trouble with the self-retaining 
catheter, as may be inferred from the following statement: 
“ He found that granulations would shoot rapidly into the fora- 
mina of the catheter so as to render its removal indispensable 
to the free discharge of urine.” 
The operation was performed in March, 1855, and the pa- 
tient discharged cured. 
Case XVII. Three Fistules, one Vesico-vaginal, one 
Urethro-vesico-vaginal, and one Urethro-vaginal—Situation 
of Vesico-vaginal Fistule near the Center of the Septum— 
Direction Longitudinal and of a Size to admit Point of Index- 
Finger— Cicatricial Contraction of the Vagina to the same 
estimated Size of the Fistule—Alkaline Urine and Extensive 
Excoriations of the Internal and External Genital Parts— 
First Successful Employment jointly of Bozeman?s Improved 
Lever-Speculum, of his Supported Knee- Chest Position, and 
of his Gradual Preparatory Treatment— Very close Relation- 
ship of the Vesico-vaginal and the Urethro-vesico-vaginal Fist- 
ule— Only possible to close one Opening at a Time with the 
Clamp-Suture—Operated first upon the Former—Result, a 
1 New Orleans Medical and Surgical Journal, vol. xii, July, 1855. 34 
THE CLAMP SUTURE. 
Complete Failure from the sloughing out of the Apparatus— 
Causes of the Disaster, Hardness of the Tissues, and Poisonous 
Effects of the Urine upon the Denuded Edges of the Fistule, 
flowing into the Vagina through the Neighboring Fistule— 
Case now considered incurable unless Protection against the 
Evil Effects of the Urine could in some Way be Secured—ln- 
vention of the Dutton-Suture made for this Purpose, about a 
Month afterward. 
Matilda Stamper,1 colored, aged twenty-one, came under 
my care in Montgomery, Ala., February 9, 1855. Description 
at the time of admission as follows : “ Found the vagina very 
much contracted by indurated bands extending across it. One 
just below the cervix uteri occasioned such narrowing of the 
canal that the point of the index-finger could scarcely be passed 
through it. On the posterior side of the organ the induration 
and contraction were greatest, giving rise to considerable short- 
ening of the canal, and drawing in the labium pudendi of the 
right side. Communicating with the urethra, very near the 
meatus, there was a small opening; further back, just across 
the beginning or root of the urethra, was situated another, 
about three quarters of an inch in length and, of course, com- 
municating with the bladder. About half an inch above this 
last, and to the extreme right, was situated still another open- 
ing about the same size. These two last, one having its long- 
est diameter transverse, and the other longitudinal, represented 
two sides of a square. 
“In attempting now to pass a catheter through the urethra 
into the bladder, I found great difficulty, owing to distortion 
at its neck, caused by the anterior border of the fistule, situated 
thus, being drawn up to the pubic bones. 
(See Fig. 12, two thirds size [knee-chest position], intro- 
duced here to show the contraction and distortion of the vagi- 
nal tract, and the situations of the three classes of fistules 
indicated. The dotted lines, seen running across the vesico- 
vaginal septum at C, point to the upper and lower extremities 
of the vesico-vaginal fistule situated to the right side, half an 
inch from the median section. B stands in the breach of the 
1 See Case XYI, Hew Orleans Med. and Surg. Jour., January, March, and 
May, 1860. NATHAN BOZEMAN. 
35 
urethro-vesico-vaginal fistule, formed at the expense of both 
the trigone of the bladder and the root of the urethra, the end 
of the latter being obliterated and drawn out of line with the 
corresponding border of the fistule, and fixed behind the pubic 
bones. A indicates the break between the vagina and urethra 
just behind the meatus urinarius. B illustrates the point of 
Pig. 12. 
greatest contraction and distortion of the vaginal tract, it not 
admitting there the point of the index-finger.) 
“Having considered now the case in all its bearings, I 
determined to make an application of Hr. Sims’s ‘clamp-sut- 
ure,’ this being the one I was at that time employing. Before 
proceeding to the operation, however, the question arose in 
my mind as to the possibility of closing both of the vesical 
openings at once by two sets of clamps, this appearing to me 
to be the preferable course. Upon a minute examination now 
of the parts, with reference to the practicability of such a pro- 
cedure, I was convinced that it could not be done, owing to the 
narrowness of the intervening tissue, upon which both sets of 36 
THE CLAMP SUTURE. 
clamps would have to rest. Thus applied, one of each set of 
clamps would necessarily cross the other. Seeing this diffi- 
culty, therefore, I determined upon the only other alternative, 
which was to close one opening at a time. The upper one (the 
vesico-vaginal fistule) I selected for my first operation, think- 
ing by this to avoid\ to some extent, the irritating effect of the 
urine passing through the lower opening. As a preparatory 
measure now for this operation, I had to make deep incisions 
in the contracting hands of the vagina, and then dilate the 
organ hy the use of tents. This took up considerable time, and 
was the cause of much suffering to the patient, owing to the 
excessive irritability of the parts.” 
Fig. 13 illustrates the kind of tent or dilator which, after 
Pig. 13. 
much experimentation and several failures, was finally adopted,, 
with the necessary incisions, as the proper mode of gradual 
preparatory treatment. 
It would be interesting here to point out the special advan- 
tages of this kind of sponge-dilator over that made of hard 
material (which could not be borne by this patient), but space 
does not permit. Suffice it to say, this bag of oil-silk, here 
represented two thirds size,, is filled with torn pieces of coarse 
sponge, every piece being compressed separately, so as to give 
the whole the required firmness for easy introduction. This 
form of dilator is also far better and more manageable than 
the ordinary compressed sponge-tents shielded in the same NATHAN BOZEMAN. 
manner, because, in the use of it, the exact amount of pressure 
needed can always be determined beforehand, a most impor- 
tant precaution. This is the size used in the case, the diame- 
ter being about an inch and three quarters (about forty-four 
millimetres). This was the limit of the dilatation reached in 
the case, after a little more than six weeks of persevering effort. 
But even with this limit of expansion of the vagina, there still 
remained a considerable degree of hardness and stiffness of the 
vaginal walls—a leathery condition, so to speak, with more or 
less persistent resiliency. My improved lever-speculum, used 
for displaying the cicatricial and contracted points in the vagi- 
na, was found to be very much restricted in its applicability. 
Owing to the implication of the rectal wall, the incisions here 
had to be made without the instrument. For making the re- 
quired incisions, the employment of a properly adapted bivalve 
or dilating speculum for putting on the stretch cicatricially 
contracted bands would, no doubt, have contributed to a much 
higher degree of expansion of the vagina, and, consequently, a 
much more satisfactory display of all the fistules, than were 
attainable in the way described, but there was no such instru- 
ment in use at that time. 
It is also important to mention here the fact that, during 
the stage of preparatory treatment, the patient bore badly the 
fatigue of the knee-dhow position, she having to change all the 
while from this to the very objectionable knee-face position, 
according to her fatigue or the severity of her sufferings. To 
obviate this unsteadiness of the patient, and insure greater 
safety and certainty in making the incisions, I resorted to the 
expedient, adopted in other cases for a year or so before, of 
placing her body in a horizontal position and supporting it 
there upon pillows, piled up one upon another, under the chest 
and head—the most comfortable and useful of all the anterior 
positions. By this plan, and a sufficient number of assistants 
to hold her upon the pillows, it was found quite possible to 
make her comfortable, and to secure the advantages of an anes- 
thetic with safety. But, from the softness of the pillows, and 
their readiness to become disarranged attending the excitement 
of the anesthetic and the resistance of the patient, a bench of 
suitable height, surmounted by a firm cushion, was finally sub- 38 
THE CLAMP SUTURE. 
stituted for the former. This arrangement turned out to be a 
great improvement upon the pillows as a chest and head sup- 
port, and afterward was always employed when an anesthetic 
was required. It finally became the sustaining part of what I 
described a few years later as my supporting and fixing appa- 
ratus for the Tcnee-chest position without assistants. Attention 
will hereafter be directed specially to the superior advantages 
of this last improvement for overcoming the previously recog- 
nized necessity of kolpokleisis and for the performance of all 
operations upon the anterior wall of the vagina, and to a very 
large extent for those upon the posterior wall as well. 
Fig. 14 shows the patient in this position, held by assistants 
upon the cushioned bench, ready for the anesthetic and the 
operation for closure of the vesico-vaginal fistule, after com- 
pleting the gradual preparatory treatment. 
Fig. 14. 
Present as assistants at this operation were Dr. W, C, Jack- 
son, and two students of medicine, Mr. Hannon and Mr. Tarver, 
all of Montgomery, Ala. 
Here follows a description of the operation and result: 
“ Operation, March 23, 1855.—Everything being as favor- 
able as could be expected under the circumstances, the operation 
above indicated was performed. Owing to the great induration 
and contraction of the parts, I encountered no little difficulty NATHAN BOZEMAN. 
39 
in going through with the different stages. Three sutures were 
required to close the opening after its edges were thoroughly 
pared. These being introduced transversely, of course the 
clamps had to be applied longitudinally, and thus secured. 
The edges of the opening came together well enough, but they 
were not accurately adapted to each other, owing to a greater 
thickness of one than the other, and the consequent elevation of 
the corresponding clamp above its fellow. 
“ With this condition of things the patient was put to bed, 
and a catheter (English elastic) introduced into the bladder to 
convey off as much of the urine as possible. Very little of it, 
however, passed through the instrument; it continued its old 
course through the vagi- 
na. The clamps were al- 
lowed to remain the usual 
length of time. When I 
came to remove them, I 
had no need of scissors. 
The whole concern had 
sloughed out and lay loose 
in the fistulous opening, 
now greatly enlarged.” 
Fig. 15 shows the an- 
terior wall of the vagina 
expanded to the limit in- 
dicated by the dilator, and 
the different sizes of the 
three fistules, together 
with their relative posi- 
tions in the different 
structures implicated. 
The pair of clamps ap- 
plied to the fistule, de- 
scribed as located in the 
vesico-vaginal septum (a 
far more eligible situation 
for their use than that of 
either of the other two lesions), are here shown detached entire- 
ly from the borders of the fistule, and incrusted with calcareous 
Fig. 15. 40 
THE CLAMP SUTURE. 
deposits from the urine, as found on the twelfth day after the 
operation. The shaded surfaces around the opening indicate 
the extent of the ulceration and cutting of the tissues by the 
apparatus. In addition to all this, there was a general elytritis 
superinduced by the increased acridity of the urine, arising 
from the operation and the cutting out of the suture appa- 
ratus. 
“ The result of this operation thoroughly satisfied me that 
I should never be able to close successively the fistulous open- 
ings in this case. The whole failure I attributed to the poison- 
ous effect of the urine upon the denuded edges of the fistule, 
and the raw surfaces caused by the imbedding of the clamps. 
So well was I convinced of this fact, that I should have dis- 
charged the patient without ever making another trial, had not 
the idea fortunately occurred to me of protection to the ap- 
proximated edges of one fistule from the irritating effect of 
the urine passing through the other. From this thought, 
scarcely need I say, the principle of the hutton-suture—a new 
application of the interrupted form of suture—originated, and 
was put into practice. 
“ Although the principle of protection was suggested in the 
combinations above stated, by the peculiarity of this case, yet 
the first trial of it was not made here.” 
The patient, after this operation, returned home to recuper- 
ate her health, and was not regularly treated again for about 
eighteen months. The case will be referred to again, and the 
final result stated, in the class of urethro-vesico-vaginal fistules, 
to be considered farther on. 
Suffice it to say, it was not until after I had performed 
two other operations with the clamp-suture, in two different 
cases (the first successfully in a yesico-utero-vaginal fistule, 
and the second unsuccessfully in a vesico-vaginal fistule), that 
the principle of this new form of suture, which I accidental- 
ly discovered in the process of buttoning my vest, came to 
be applied. The first trial of it was made after this same 
second operation, it being a third failure with the clamp- 
suture in the case. Consequently, the introduction of the 
case, or rather the conclusion of its history, since it has al- NATHAN BOZEMAN. 
41 
ready been related in part (Case IX of the series, Julia Mc- 
Duffie), properly belongs here. To this will be added three 
other cases, two not belonging to the series (they never hav- 
ing been operated upon with the clamp-suture), and one, Case 
Till of the series, Delia, previously operated upon unsuc- 
cessfully by Dr. Sims. 
The object I had in view in presenting at such length the 
foregoing history and treatment of Matilda Stamper was to 
show that, after adopting my modification of Dr. Sims’s form 
of the lever-speculum, my supported knee-chest position, and, 
finally, my system of gradual preparatory treatment, all im- 
portant principles with which to extend the usefulness of the 
clamp-suture, but which, in this case, utterly failed in their 
object, on account of the defectiveness of tbis form of suture, 
there was a sequence of incidents, from first to last, impor- 
tant to note, as showing the pressing necessity, at this junc- 
ture, of the invention of the button interrupted suture. By 
its adoption and successful application in the cases of Julia 
McDuffie and Kitty Johnston, the two first cases in which it 
was employed, not only was the great value of these general 
principles demonstrated conclusively, but the philosophy of 
the suture itself was put to the severest test as to the range 
of its usefulness, which it would be difficult to overestimate, 
even at the present time. 
The sequence of the several improved stages of treatment 
thus far discussed, and the dates of their adoption, may be 
summed up as follows: 
1. The modification of Dr. Sims’s form of the lever- 
speculum, in June, 1853. 
2. The utilization of the supported knee-chest position, in 
the spring of 1854. 
3. The adoption and first successful application of the 
principle of gradual preparatory treatment for cicatricial con- 
tractions of the vagina as complications of vesico-vaginal fist- 
ules, in February, 1855. 
4. The invention and first employment of the button 
interrupted suture, embodying the new principle of shield- 42 
THE CLAMP SUTURE. 
ing the denuded edges of the fistule from all extraneous in- 
fluences, and of a special mode of adjusting all interrupted 
metallic sutures in the vagina without the intervention of the 
fingers, May 12, 1855. 
5. The utilization of the uterus, by pulling it down and 
making it subservient, without incisions, to the reparation of 
all fistules attended with loss of tissue, August 23, 1855. 
The following are extracts taken from the published re- 
ports of the four cases above referred to, presenting seven 
fistules in two classes, five vesico-vaginal and one vesico-utero 
vaginal (two of them presenting grave complications), and 
all closed by the button-suture procedure at seven operations: 
A.—Vesico-vaginal Fistule—Small Size—Situation in the 
Septum near Cervix Uteri and Left Lateral Wall of Vagina 
Cicatricial Hardness and Thickness of Left Border of Fist- 
ule— Distortion of Vaginal Tract at Same Point—Three 
Operations with Clamp-Suture unsuccessful— Used jointly ih 
Third Operation Bozeman's Improved Lever-Speculum, and 
his Supported Knee- Chest Position for Anesthesia— Good Ex- 
posure of Fistule—Result: Total Failure as in the Two Pre- 
ceding Operations—lnapplicability of Clamp-Suture to such 
an Abnormal State of the Structures proved—Some Two Weeks 
afterward Button Interrupted Suture invented—Applied now 
for the First Time under precisely the Same Circumstances as 
attended the Third Operation with Clamp-Suture—Result: 
Complete Cure without the Slightest Irritation of the Structures 
involved—Invention of Suture Adjuster and Demonstration of 
its Practical Utility at Same Time—This Instrument Indispen- 
sable for the Successful Use of all Wire Sutures in the Vagina 
without the Intervention of the Fingers—Applicability of the 
New Procedure to such an Abnormal State of the Structures 
proved beyond Question. 
Julia McDuffie, colored, aged twenty-one, readmitted for 
treatment April 12, 1855. It will be recollected that this case 
first came undeV the joint care of Dr. Sims and myself for 
treatment in Montgomery, Ala., early in March, 1853. It was 
then stated that Dr. Sims Operated upon the case with his 
clamp-suture (see Fig. 9), which proved a total failure from NATHAN BOZEMAN. 
43 
ulceration and the cutting out of the clamp on the left side, 
this border of the fistule being thickened and indurated ; and 
that I repeated the same operation, under the same circum- 
stances, about two months and a half later, June 1, 1853, with 
the same unfortunate result. It will be recollected that it was 
the cicatricial contraction of the vagina in the case which led 
me at that time to make a modification of Dr. Sims’s form of 
the lever-speculum with regard to the length and shape of the 
blade, and the angle formed by this with the handle of the in- 
strument, as shown in Fig. 11. 
Below is the concluding part of the history of the case,1 
and it will here be seen in my report that I avoided direct 
reference to Dr. Sim’s failure with his clamp-suture: 
“The following spring [March 15, 1853] she was operated 
upon according to the method of Dr. Sims, hut was not relieved. 
She came under my charge a short time afterward, and, upon 
examination, I readily discovered a circular opening of about 
the size of a No. 6 catheter, occupying the vesico-vaginal sep- 
tum near the neck of the uterus and a little to the left side. 
On the right side the tissues were in a normal condition, but 
on the left very much indurated. After due preparation of 
the system, I applied the clamp-suture in the usual way. On 
the thirteenth day I examined and found that the clamp on the 
left side had cut entirely out, and the aperture considerably 
enlarged. 
“ Shortly after this unsuccessful operation the patient’s gen- 
eral health became very much impaired, and it was thought 
advisable to allow her to return home. I heard no more of the 
case until April 12, 1855, when she was again placed under my 
care, having, in the mean time, entirely regained her usual 
good health. I found, on making an examination, that the fist- 
ule was somewhat smaller than when I last saw her, but the 
induration of the left border still existed. Aside from this 
latter circumstance, I considered the case altogether favorable, 
and felt very confident that an operation would prove success- 
ful. Accordingly, on the 17th of April, I applied the clamp- 
1 See Case I, op. cit. 44 
THE CLAMP SUTURE. 
suture again. The edges of .the fistule came together beau- 
tifully, but, owing to the indurated condition on the left side, 
the corresponding clamp could not he made to imbed itself, 
and consequently rested on a plane higher than the one on the 
opposite side. Notwithstanding this rather unfavorable feat- 
ure, I was very sanguine of success. 
“ On the thirteenth day I examined the parts, and, to my 
great mortification, saw that the left clamp had again cut out, 
and thus enlarged the opening,” (See Fig. 16.) This was my 
last operation with the clamp-suture. 
“ After two (three in all) such signal failures with the only 
operation that I then considered worthy of confidence, I was 
much discouraged, and had serious thoughts of abandoning 
the case altogether ; but it was only a week or two subsequently 
that the principle of the button-suture first suggested itself to 
me, and I immediately determined to subject the case to an 
experimental trial. All things being ready, on the 12th of 
May (1855), I put the new method in operation. 
Fig. 18. 
Fig. 17. 
« Everything seemed to progress favorably. On the thir- 
teenth day I removed the apparatus, and, to my great delight, 
found the fistule completely closed, and not the slightest evi- 
dence of irritation except what might be naturally expected 
around each suture.” 
Fig, 17 shows the operation completed, and the adaptation 
of the apparatus to the parts, the general condition of the lat- 
ter being precisely the same as in the previous three operations, NATHAN BOZEMAN. 
45 
with the increase added each time, of course, of the cicatricial 
hardness of the tissues, arising from the ulceration and cutting 
out of the clamps, which had to be placed on the thickened 
border of the fistule. 
In the construction of this button-suture, the silver wire 
and perforated shot used were, of course, borrowed from the 
now discarded clamp-suture method of Dr. Sims; but it is 
proper to state in this connection that Dr. Henry S. Levert,1 
of Mobile, Ala., was the first, certainly in this country, to 
point out the innoxiousness of silver wire, and its superiority 
on that account to ligatures made of organic substances. 
Dr. J. P. Mettauer, of Prince Edward, Ya., three years later 
demonstrated the advantages of simple interrupted lead su- 
tures, secured by twisting over those silk for recto-vaginal 
fistule and laceration of the perineum. My form of suture 
was, properly speaking, a button interrupted suture, being, 
in principle of action, a combination and extension of the 
old principles of the interrupted and twisted sutures. The 
originality, therefore, was in the combination and extension 
of these two principles, just as the clamp-suture of Dr. Sims 
was a combination and extension of the old principles of the 
interrupted and quill sutures; his originality being the sub- 
stitution of Levert’s silver wire for silk, and of small, round 
perforated lead bars for the quills, and in the use of perfo- 
rated shot to secure the whole. 
As an essential feature of the radical change of principle 
and form of suture made at this juncture in the history of 
the subject, I deem it important to introduce, in connection 
with the same, the accompanying illustration of my suture 
adjuster (Fig. 18), as a means of quick coaptation of the de- 
nuded edges of the fistule without the intervention of the 
fingers inside the vagina. This consisted in doubling or 
shouldering large-size silver sutures, one after another, and 
thus quickly drawing the denuded edges of the fistule in 
close and firm contact; the loops in the wire in all cases being 
1 American Journal of the Medical Sciences, May, 1829. 46 
THE CLAMP SUTURE. 
sufficient to hold the parts together until the process was com- 
pleted, and the line of closure could be examined, as shown 
by Fig. 19. When the latter was found unsatisfactory, from 
defective or ragged paring, it was easy to undo the loops 
and complete properly this important step of the operation, 
Pig. 18. 
Pig. 19. 
thus making it mathematically accurate. The coaptation of 
the denuded edges being now finished, and the line of union 
seen to be perfect, the next step was to hermetically seal it, 
by sliding down upon the doubled and shouldered wires the 
perforated button or shield over the structures and then NATHAN BOZEMAN 
47 
firmly securing it. This was effected with perforated shot 
slid down upon the wires in a similar way, and compressed 
with a pair of strong forceps successively upon the top of 
the button, thus completing the procedure in two distinct 
stages. 
No such instrument for specially adjusting wire sutures 
had been used prior to this date. Surgeons1 formerly had 
been in the habit of putting together the two ends of each 
wire outside the vagina, and then twisting them like a cord 
from right to left, or left to right; thus the two edges of the 
denuded fistule were slowly dragged into contact and loosely 
or firmly coaptated as the chance experience of the operator 
might determine. In the operation with the clamp-suture,2 
such an instrument was not required, as both ends of each of 
the several wires had to be disposed of and secured sepa- 
rately. 
Whether, in the use of this suture adjuster, the two ends 
of the several wires be first passed through the hole outside 
the vulva, and the instrument then be slid down upon them 
to the extent of forming a small, closed loop and coaptating 
the edges of the fistule, as preparatory to their fixation with 
the button and perforated shot; or whether the hole in it be 
slit out to its extremity and the two ends of the several wires 
be received into it inside the vagina, where the instrument is 
firmly held against the edges of the fistule, preparatory to 
their fixation by twisting alone, as in the use of simple inter- 
rupted sutures—is a matter of no consequence ; the principle 
is one and the same. The instrument may be called a suture 
adjuster, or, as variously modified, a “ fulcrum,” a “ prop,” a 
“ support,” or anything else; but the originality and prior- 
ity of its use constitute a part of the invention and first em- 
ployment of the button-suture, May 12, 1855. 
The Woman’s Hospital of the State of New York threw 
its doors open on May 1, 1855. My last operation with the 
clamp-suture, as above shown, was performed thirteen days 
1 Mettauer, loc. cif., 1882; Gosset, Lancet, November 21, 1834, 
8 Sims, American Journal of the Medical Sciences, January, 1852, 48 
THE CLAMP SUTURE. 
before, and my first with the procedure of the button-inter- 
rupted suture twelve days after that date. While all this 
was going on, Dr. Sims, the surgeon-in-chief of that institu- 
tion, was just about beginning the second series of cases with 
his clamp-suture, to be hereafter presented. In that connec- 
tion I shall show the extraordinary coincidence that his last 
operation with the clamp-suture took place in the Woman’s 
Hopital, in the case of Emily Stebbins, on May 12, 1856, 
twelve days after the first account of my new procedure 
appeared in print.1 I shall also show, in this connection, 
that Dr. Sims performed, in the same institution, his first 
operation with the simple-interrupted suture secured by 
twisting (as first practiced by Mettauer with lead sutures) 
in the case of Ellen Quidre, about six weeks later, June 23, 
1856 ;* and that, in this new procedure of his, the modifica- 
tions of my suture-adjuster, Eig. 18, under the name of “ful- 
crum of support,” and of my sponge-dilator, Fig. 13, under 
the designation of “glass plug,” form distinguishing feat- 
ures without which even the most skillful operator at the 
present time would be almost as powerless as he was with 
his old clamp-suture in endeavoring to master the real dif- 
ficulties appertaining to the treatment of the simple class of 
vesico-vaginal fistules. 
B.—Two Fistules, one Vesico-vaginal and one Vesico-utero- 
vaginal—Situation of Former below Center of Septum and 
of Latter in Fas fond of Bladder, against Cervix Uteri— 
Between the two Openings, Cicatricial Contraction of Vaginal 
Tract down to the: Size of a Surgeon's Probe—Urine exceedingly 
acrid and loaded with Triple Phosphates—Vaginitis of High 
Grade—Extensive Excoriations of the Labia Mafora, But- 
tocks, and Thighs—All Five of the Principles embodied in the 
Button-Suture Procedure beautifully illustrated—Closure of 
the Vesico-vaginal Fistule at One Operation ; Denuded Edges 
of Fistule effectually shielded from all Extraneous Influences 
Cicatricial Contraction of Vagina attacked and overcome 
1 Louisville Review, May 1, 1856. 
2 “ Silver Sutures in Surgery,” 1858. NATHAN BOZEMAN. 
49 
—Anterior Lip of Cervix Uteri without Incisions made sub- 
servient to Closure of the Yesico-utero-vaginal Fistule at One 
Operation—First Step toward superseding the Necessity of cut- 
ting loose the Cervix Uteri from the Bladder to avoid Trac- 
tion upon the Sutures, as previously recommended by Jobert de 
Lamballe—Patient discharged cured. 
Kitty Johnston,1 colored, aged eighteen, applied for treat- 
ment May 24, 1855, under the following circumstances: 
“ Found the thighs, the buttocks, and the labia majora almost 
completely incrusted by calcareous matter, and so sensitive 
that the least effort to separate them caused excruciating pain. 
Before the vagina could be explored, this deposit had to be re- 
moved, and even then the suffering was considerable, owing to 
an extremely irritable condition of the organ, and a protrusion 
of the mucous coat of the bladder through the fistulous open- 
ing. When the speculum was introduced, the posterior wall 
of the vagina could not be raised up with the usual facility. 
This I soon found resulted from a morbid attachment of its 
two walls. The adhesion extended obliquely across from the 
right side of the cervix uteri to the left side of the vagina, thus 
concealing from view the os uteri, and rendering an explora- 
tion of the entire canal impossible. A fistulous opening [vesico- 
vaginal] three quarters of an inch in length occupied the ves- 
ico-vaginal septum, and extended from near the beginning of 
the urethra obliquely upward and to the left, terminating 
abruptly at the point of contraction. Here a careful examina- 
tion revealed a small opening which allowed a probe to pass 
into the cul-de-sac above, and from thence into the bladder, 
showing clearly that another fistule [vesico-utero-vaginal] ex- 
isted in this situation. [See Fig. 20,] 
“ Having thus ascertained the true condition of things, I 
became satisfied that two operations would be required. The 
fistule first described was accessible, and demanded my first at- 
tention, owing to its larger size and the very irritable state of 
the mucous coat of the bladder which protruded through it. I 
thought it advisable, however, before attempting any operation, 
to improve the patient’s general health. 
1 Case 11, op. cit. 50 
THE CLAMP SUTURE. 
“ June 12.—[The patient being in the supported knee-chest 
position] I proceeded to apply the button-suture to the lower 
opening. Much difficulty was encountered in paring the edges, 
owing to the great resistance of the patient and the herniated 
Fig. 20. 
Fig. 21. 
condition of the mucous coat of the bladder. Four sutures 
were required; the button was seven eighths of an inch in 
length, and about five eighths in width. [See Fig. 21.] 
“ For two or three days after the operation there was con- 
siderable fever and pain in the hypogastric region, and I feared 
something serious might result; but things soon took a favor- 
able turn, and the case seemed to do well until about the sev- 
enth day. At this time a great discharge of urine occurred 
from the vagina, and my first impression was that the sutures 
had given way ; but, upon examining the parts carefully, I dis- 
covered the whole of the difficulty to depend upon tympanitic 
distention of the bowels, attended at times with powerful peri- 
staltic action. . . . 
“ Feeling a little uneasiness as to the result, notwithstand- 
ing the discovery of the source of the trouble, I determined on 
the ninth day to remove the apparatus. Upon the introduction 
of the speculum into the vagina, the parts presented a most un- 
promising appearance ; the mucous membrane was of a deep- 
red color, and the button completely incrusted with earthy mat*- NATHAN BOZEMAN. 
51 
ter. I now had a firm presentiment that all was not right; hut 
when the sutures were clipped and the button raised, I found 
to my great satisfaction that union of the parts was perfect. 
“In a few weeks I made preparation for the other opera- 
tion by breaking up the morbid adhesion between the two walls 
of the vagina, so as to expose the fistulous opening above. To 
prevent reunion of the parts, a hag made of oil-silk and stuffed 
with bits of sponge was introduced into the vagina. This was 
renewed daily, and injections of cold water used, by which 
means the upper extremity of the vagina was dilated in a few 
weeks to its normal size and the fistule well exposed. 
“ August 23.—Everything appearing as favorable as could 
be expected, I proceeded to operate. Only three sutures were 
required ; but, as in the former operation, I had much diffi- 
culty, owing to the resistance 
of the patient. Tympanites 
supervened again several days 
after the operation, and caused 
the patient a good deal of suf- 
fering ; but with this exception 
the case did well. [Fig. 32 
shows the vagina restored to its 
normal caliber, the form of su- 
ture used, and the utilization of 
the anterior lip of the cervix 
uteri for closing the fistule 
without incisions or dissection 
of the cervix uteri from the 
bladder, as insisted upon by 
Fig. 22. 
Jobert de Lamballe. AB is the line of cicatrization of the 
first fistule closed.] 
“ On the ninth day [September 1, 1855] I removed the ap- 
paratus, and had the satisfaction of finding an entirely success- 
ful result; not the slightest irritation had been produced. The 
improvement of the patient in every respect was very rapid, 
and when I discharged her in September she was as active and 
sprightly as though she had never had a sick day. 
“Remarks.—The bad health of the patient, the existence of 
two fistulous openings, a herniated condition of the mucous 52 
THE CLAMP SUTURE. 
coat of the bladder, a morbid attachment of the two walls of 
the vagina, and an exceedingly irritating quality of the urine, 
were all circumstances which strongly militated against the 
treatment. It is, indeed, one of the most remarkable cases that 
have ever come under my observation, and I may add that a 
better case for illustrating some of the advantages claimed for 
the button-suture, and especially that of protection to the de- 
nuded edges of the fistule from the poisonous effects of the urine, 
could not have been selected. After removing the button em- 
ployed in the first operation, its very shape and size were found 
impressed upon the parts over which it rested during the heal- 
ing process, and the pale-red color of the mucous membrane 
contrasted beautifully with the deep-red and fiery appearance 
of that which had been exposed to the urine escaping through 
the upper opening.” 
C.—Two Vesico-vaginal Fistules, one situated at Center of 
Septum, and the other near Cervix Uteri—Latter not discov- 
ered until after the Former was closed—No Complications 
present—Each Fistule closed at a Single Operation by the But- 
ton-Suture Procedure—Patient discharged cured. 
Dinah,1 a colored woman, aged forty-seven years, applied 
for treatment, June 28, 1855 ; 
“ Upon examination, I found a fistule near the center of the 
vesico-vaginal septum, circular in shape, and sufficiently large 
to admit the index-finger into the bladder. Supposing this to 
be the only opening, on the sth day of July I applied the but- 
ton-suture. On the tenth day it was removed, and the parts 
found to be perfectly united, not the slightest irritation having 
been produced by the apparatus. In a few days afterward the 
patient was allowed to get up ; but, to my surprise, there was 
still dribbling of urine. I apprehended, therefore, that the 
newly formed cicatrix had given way, and there was a repro- 
duction of the fistule ; but, on making an examination, I dis- 
covered that such was not the case. I was now at a loss to 
account for the appearance of urine ; but, upon a more careful 
exploration of the vagina, I found another very small opening, 
situated far up on the right side, at least an inch from the one 
I had closed. 
1 Case 111, op. cit, NATHAN BOZEMAN 
53 
“ The whole difficulty was now explained. Another opera- 
tion was required ; but, owing to the bad health of the patient, 
I was not able to perform it until the 10th of September. 
“ The fistule, although small, had a peculiarity I had never 
met with before. It was valvulous—i. e., the opening through 
the vaginal part of the septum did not correspond to that of 
the vesical. Two sutures were sufficient to bring the edges to- 
gether. Things went on well, and on the tenth day I removed 
the apparatus, and found union perfect. 
“ Remarks.—In this instance the fistulous openings were of 
eighteen years’ standing, the patient old, and her general health 
not very good; yet the result was as prompt and decided as 
could have been desired. One of the great advantages claimed 
for the button-suture—namely, 'protection to the denuded edges 
of the fistule—teas again forcibly illustrated in this cased’ 
D.—Two Vesico-vaginal Fistides—/Situation below Center 
of Septum on a Transverse Line, one to the Left' of Median 
Line, and the other reaching to the Right Lateral Wall of 
Vagina—Roth Angular Mstules, resulting from Closure in 
the Middle of a Large Opening after Ten or more Operations 
with the Clamp-Suture in the Hands of L>r. Sims—No Compli- 
cations present, further than the Co-existence of Two Fistules 
and the Cicatricial Hardening of the Tissues, resulting from 
the Repeated Gutting-out of the Clamps—Each Fistide closed 
at One Operation by the Button-Suture Procedure—Patient 
discharged cured. 
Delia,1 a mulatto girl, aged twenty-five years, servant of Dr. 
Sims, was re-admitted for further treatment September 10,1855. 
The case, it will be recollected, was treated jointly by Dr. 
Sims and myself in May, 1853. He performed his last opera- 
tion with the clamp-suture at that time, the after-treatment 
being conducted by me. He used a pair of clamps upon each 
fistule at the same sitting. Nothing unusual attended the after- 
treatment. When I examined the parts, however, on the 
twelfth day, I found that both upper clamps had ulcerated out, 
and the result was a total failure. It will also be recollected 
that the case had then been under treatment between three and 
four years, and that Dr. Sims had, from first to last, performed 
1 Case IV, op. cit. 54 
THE CLAMP SUTURE. 
ten or more operations with the clamp-suture. Here is the 
patient’s own brief account of her previous history, to which 
are appended the results of my examination and of my opera- 
tions with the button-suture at this juncture. In ray first report 
it will again be seen that I avoided direct reference to the 
number of failures with the clamp-suture by Dr. Sims : 
. “She also states that she was sent to Hew Orleans, and 
there treated [after confinement in 1846] for a long time, with 
but little, if any, benefit. Since then she has been operated 
upon several times according to the method of Dr. Sims, but 
the relief afforded was only partial. 
“Upon examination, I found two fistulous openings—one 
about two inches from the cervix (uteri), and a little to the 
left side ; the other, a little larger, was situated far to the 
right, at a point just where the anterior and posterior walls of 
Fig. 23. 
Fig. 24. 
the vagina become continuous. [Fig. 23 shows the situation 
of the two fistules, and the f>artially detached clamp-suture 
upon each, as I found them on the twelfth day after Dr, Sims’s 
last operation, May 20, 1853. The dark line between the two NATHAN BOZEMAN. 
55 
fistules indicates the cicatrix of the closure of the fistule in the 
middle by Dr. Sims in his previous operations.] 
“On the 10th of September [1855], I proceeded to apply 
the button-suture to the larger opening. It was my intention 
to close the other also at the same time, but the patient pre- 
ferred to wait. Only two sutures were required, and on the 
tenth day I removed the apparatus, and found union perfect. 
“ October the 18th, I operated upon the Other fistule. This 
I found presented the same peculiarity that was observed in the 
preceding case, in being of a valvidar form. Only two sutures 
were required, and on the tenth day I removed the apparatus, 
and found adhesion perfect, without the slightest irritation in 
the surrounding parts. 
[Fig. 24 shows the situation of the two fistules to be the 
same as in Fig. 23, the one on the right illustrating the button 
in position, as it appeared at the time of removal; and the 
other on the left showing the button ready to be slid down 
upon the sutures and secured with the perforated shot follow- 
ing it, which resulted in a complete cure, October 28, 1855.] 
“ Remarks.—The result in this case was as satisfactory as 
could be desired ; it needs no comments. If it proves anything, 
it is that the button-suture was better adapted to the case than 
the clamp-suture, which latter had been long and perseveringly 
tried. 
“Conclusions.—Having now finished a description of 
my mode of treating vesico-vaginal fistule, together with the 
narration of all the cases in which it has been employed, I 
propose, in conclusion, to compare its results with those ob- 
tained by other methods. 
“Since the 12th of May last [1855], I have performed 
seven successive operations without a single failure. This is 
the amount of my experience with the button-suture. How, 
to form anything like a proper estimate of the several modes 
of treatment heretofore recommended, it is necessary first 
to ascertain what proportion of the operations, according to 
each, have been successful when compared with the .whole 
number performed. In this way only can their respective 
merits be properly set forth. To effect this object I have ex- 56 
THE CLAMP SUTURE. 
amined, so far as my opportunities allowed, the records, both 
of Europe and this country; but, as the data are imperfect, 
I have not been able to arrive at very satisfactory conclusions. 
“ Chelius speaks of Wutzer as having had the greatest 
success. Of eighteen cases operated upon, three were radi- 
cally cured. We are not informed how many operations 
were performed in all. 
“ Jobert, by the anaplastic process, cures, I am induced 
to believe, about one half of his cases. What proportion of 
his operations fail, I have not been able to learn. 
“ Mr. Henry Earle is said to have operated thirty times 
upon one case before succeeding. The failures here were as 
twenty-nine to one. 
“Mr. Brown operated ten times upon three cases, and 
obtained one successful result. The failures here were as 
nine to one. 
“ Dr. Hayward operated twenty times upon nine cases, 
and obtained three successful results. The failures here 
were as seventeen to three. 
“ I am not prepared to state positively what proportion 
of the whole number of operations performed, according to 
the method of Dr. Sims, has been successful. Judging from 
my own experience, and from what I have seen of it in the 
practice of others [referring alone to that of Dr. Sims], I 
am inclined to think that the average is not over one half.1 
1 “ A few weeks since there appeared in the * New York Medical Gazette ’ a 
notice of the number of the ‘ Louisville Review ’ containing the above article, in 
which the writer says that I am mistaken in regard to Dr. Sims’s success, and 
asserts that he (Dr. Sims) has cured, during his residence in New York, thirty 
cases without a failure. 
“ From this it would seem that I had done Dr. Sims great injustice. While 
I here disclaim any such intention, I will simply add that my language in refer- 
ence to his and other operations, as compared with mine, is explicit, and I am 
surprised it should have been construed into a meaning so unjust. 
“ That Dr. Sims has done what is claimed for him [with his clamp-suture], I 
have not the slightest doubt; but this fact has no bearing upon the statement 
made by me. The point which I endeavored to arrive at was, what proportion 
of the number of operations performed according to each of the different meth- 
ods indicated had been successful. The opinion expressed as to the clamp- NATHAN BOZEMAN. 
57 
“ In regard to my own eases, it may be supposed by some 
that they were all peculiarly favorable, which accounts for 
my unprecedented success; but this was not the case. A 
reference to their individual histories will show that they 
were quite the reverse. The very fact of two of them 
having resisted the repeated application of the clamp-suture 
[in Dr. Sims’s own hands], is proof sufficient upon this point. 
The other two were each double fistules, and therefore very 
unfavorable. One of them, Case 11, I consider the most un- 
promising I have ever seen that was at all curable. 
“In conclusion, I freely acknowledge that the results 
thus far obtained by the use of the button-suture, although 
so remarkably successful, do not amount to a sufficient num- 
ber to justify an indisputable claim to its superiority over all 
other procedures; and I do not, therefore, urge its adoption 
by the profession without further trial. This is all I ask for 
it at present. My limited experience with it has led me to 
believe that the principles upon which it acts are more nearly 
correct than any heretofore suggested; but if, upon more 
careful examination, this be found not true, it will simply 
prove that the success of my seven operations was a most re- 
markable and heretofore unheard-of coincidence.1 
“Montgomery, Jan. 1, 1856” 
suture was principally based upon my own experience'with it. This amounted 
to eight operations, six of which had been complete failures. If lam in error 
as to the average success of other operators with it, it remains to be determined 
by statistical facts, which are not before me, and, so far as my knowledge ex- 
tends, have never been published. 
“As additional support to the advantages claimed for the button-suture in 
my paper, I will state that, since it was prepared for the press, I have per- 
formed eight more operations, making in all fifteen. My twelfth operation was 
a partial failure. All of the others were entirely successful. 
“July, 1856” 
1 I would remark, in this connection, that the statement of the writer in the 
“New York Medical Gazette” as set forth in the foregoing foot-note, was purely 
gratuitous, as I have since satisfied myself from a careful examination of the 
subject. Dr. Sims had not then cured thirty cases of vesico-vaginal fistule with 
his clamp-suture. His cures at that date, including all before and after coming 
to New York, within a period of about eleven years, exceeded very little, if at 
all, half the number stated, as I shall show in this study of the subject farther on. 58 
THE CLAMP SUTURE. 
SIMPLE STATEMENT OF THE PRECEDING- FOUR CASES TREATED 
THE BUTTON-SUTURE PROCEDURE BETWEEN MAY 12 
AND OCTOBER 18, 1855. 
Classification.—Of seven fist ales in four cases, there 
were of the first class six vesico-vaginal fistules, two single, 
two double, four simple, and two complicated. Of the com- 
plicated ones, the first presented induration and thickening 
of left border of the fistule, with cicatricial contraction and 
distortion of the corresponding lateral wall of the vagina 
opposite the same point; while the second combined the co- 
existence of a vesico-utero-vaginal fistule with almost com- 
plete occlusion of the vagina below, general vaginitis of a 
high grade, alkaline urine, calcareous deposits, internal and 
external excoriations, etc. 
The vesico-utero-vaginal fistule, belonging to the second 
class, was attended with loss of tissue and the co-existence of 
a vesico-vaginal fistule, this being the complicated case with 
partial occlusion, etc., described in the preceding class. 
Number of Operations.—Upon seven fistules in two 
classes, seven operations were performed. Six vesico-vaginal 
fistules got six direct operations. One vesico-utero-vaginal 
fistule got one direct operation. 
General Results.—The treatment of seven fistules of all 
classes yielded these results: Seven fistules were all com- 
pletely closed—loo per cent. 
Special Results.—Of seven fistules treated in different 
classes, six vesico-vaginal fistules of the first class were all 
completely closed—loo per cent; one vesico-utero-vaginal 
fistule of the second class was completely closed—loo per 
cent. 
Average number of operations—one to each fistule closed. 
Previous Operations with the Clamp-Suture.—Eleven by 
Sims, in Oases A and D—all failures. Two by Bozeman, in 
Case A—both failures. 
Of thirteen operations in all with the clamp-suture, per- 
formed by both surgeons, three were upon one small vesico- 
vaginal fistule, complicated with induration and thickening NA THAN BOZEMAN. 
of one border of the opening, with cicatricial contraction and 
distortion of the vaginal tract in the same situation, and ten 
were upon one vesico-vaginal fistule of medium size, without 
complications, which resulted in closure in the middle, leav- 
ing two angular openings as the final resulting failure. 
This brings us back again to the line of continuous nar- 
ration of the remaining seven eases of the class of vesico- 
vaginal fistules.1 
1 It will not be irrelevant to here state, en passant, that of the twenty re- 
maining cases of this series, only three were ever cured with the clamp-suture— 
one of the class of urethro-vesico-vaginal fistule, by Dr. R. D. Mussey, of Cin- 
cinnati, attended with slight loss of tissue, as illustrated by Fig. 4, and two of 
the class of vesico-utero-vaginal fistule, by myself, unattended with loss of tis- 
sue : the laceration in one extending into the anterior lip of the cervix uteri in 
this form, /\, and, in the other, simply up to the anterior lip, as illustrated by 
Fig. 5.