ON KOLPOKLEISIS 
AND OTHER 
ALLIED PROCEDURES 
AS MEANS OF TREATING 
VesicoYaginal Fistule, 
BEING 
-A-lsT AETSWEB 
T O THE 
Article of the Late Prof. Gustave Simon, of Heidelberg; 
ENTITLED 
‘•A Comparison of Bozeman’s Operation with that of the Author.’’ 
BY 
NATHAN BOZEMAN, M I)., 
Consulting Surgeon to the St. Elizabeth’s Hospital, N. 1 
/ /7 . . . // / ✓ / 
REPRINT FROM RICHMOND AND TOUI?V7XTT: AfTTHOA-fj-JALC4iNAX 
LOUISVILLE, KY. 
RICHMOND AND LOUISVILLE MEDICAL JOURNAL BOOK AND PRINT, 
104 Green Street, 2d doer-west of Post-office. 
1877. ON KOLPOKLEISIS 
AND OTHER 
ALLIED PROCEDURES 
AS MEANS OF TREATING 
VEsico-Vaginal Fistule, 
881 N a 
_A.3ST ARTSWER 
T O TH E 
Article of the Late Prdf. Gustave Simon, of Heidelberg) 
ENTITLED 
“A Comparison of Bozeman’s Operation with that op the Author.” 
NATHAN BOZEMAN, M. A, 
BY 
Consulting Surgeon to the St. Elizabeth’s Hospital, N. Y. 
PROM OCTOBER NO. RICHMOND AND LOUISVILLE -ftftoicAl? J^^RNALi 
LOUISVILLE, KY.; 
RICHMOND AND LOUISVILLE MEDICAL JOURNAL BOOK AND JOB STEAM FftfN-T, 
104 Green Street, 2d door west of Post-office. 
1877. VESICOVAGINAL FISTULE. 
Introductory Remarks.—It was only a few months ago that 
I read in the January number of the “Richmond and Louisville 
Medical Journal,” for the first time, a translation from the Ger- 
man of the report by the late Prof. Gustave Simon upon the 
six cases of vesico-vaginal fistule treated by him and myself in 
the surgical clinic of the University of Heidelberg in the 
autumn of 1874. Scarcely need I say these cases were oper- 
ated upon by us with the view of determining the relative 
merits of our respective methods. I was glad to find that the 
views of the able German master had thus been laid before the 
readers of so popular a journal in this country, and especially 
to see the force or comprehensiveness of these views maintained 
by the introduction of all of the fac similes of the author's wood 
cuts, which were not produced by a prominent British journal in 
a later London translation of the same article. These wood cuts 
are, I conceive, of the greatest importance, not only to illustrate 
the peculiarities presented in these cases, but to show the differ- 
ences between our respective methods. 
The criticisms in the article upon me and my operation are 
such as would naturally be expected from a misapprehension of 
facts, and from a master who knew what be was about, and 
wished to present the subject in the strongest possible light 
from his standpoint. Those contained in the introductory re- 
marks of the translator “about certain things,” as he terms it, 
are unwarranted, and from the spirit in which they were made 
will be passed over unnoticed. Now, under all these circum- 
stances, I claim on the score of equal fairness and justice, and 
as an American, the right to lay before the readers of the “Rich- 
mond and Louisville Medical Journal” the other side of the 
question at issue between Professor Simon and myself, believing 
it will tend to a further advancement of science in this depart- 
ment of surgery at home and abroad, and to a corresponding 
amelioration of human suffering. 4 
VESICOVAGINAL FISTULE. 
The first part of my reply will comprise a brief historical 
sketch of the labors of Professor Simon and myself up to the time 
that we met in Heidelberg, a tabular statement of the thirteen 
operations performed by us upon the six cases presented for 
treatment, and a correspondence between us about a year after- 
wards in relation to certain points of practice and to the results 
following some of our operations. 
How, to complete a reply to the translation as found published 
in the “Obstetrical Journal of Great Britain and Ireland,” con- 
taining none of the wood cuts of Profesor Simon, and to introduce 
those necessary to illustrate my own views, as I propose to do 
in the second part of my reply, would be a manifest injustice to 
him and his operation, which I wish to avoid. The importance 
of this point will readily appear to all, when it is recollected 
that the review and criticisms of Professor Simon extend to my 
operations in the General Hospital at Vienna as well as to 
those at Heidelberg; and that in defence of the positions I have 
assumed, it will be as necessary for me to refer to the former as 
well as to the latter. Besides this, Professor Simon, before com- 
mencing his review and criticisms, addressed a note to Br. 
Beigel, of Vienna, in which he not only draws a comparison 
between his and my methods of operating, but between mine 
and that of Dr. Sims, which was made a pretext by Dr. B, 
through the ‘‘Wiener Medizinische Wochenschrift” to try to 
destroy the favorable impression made by my operations in 
Vienna, so ably reported by Dr. Ludwig Bandl, and to lug in 
side issues disparaging to my former labors at home and abroad, 
evidently intending by it to counteract the effects of the stun- 
ning blow already given by me to Professor Simon’s theory of 
kolpokleisis, and thus to bring into favor in the Austrian capital 
the method of Dr. Sims, but little known and appreciated there. 
So in order to continue my discussion of the subject in a con- 
nected manner, and to answer fairly the criticisms of Professor 
Simon, it will be far better for his claims, as well as for my 
own, to take as a guide the translation containing his wood cuts, 
as found in this Journal. Therefore the second part of my 
reply will comprise a letter addressed by me to my friend Dr. 
J. F. Chauvean soon after I left Heidelberg (published by him VESICO-VAGINAL FISTULE. 
5 
in the “New York Medical Eecord”), and a translation from 
the German of Dr. Bandl’s report with Beigel’s criticisms. 
After this will follow an analytical and critical inquiry into the 
peculiarities, operations and results in all six of the cases jointly 
treated by Professor Simon and myself, as well as in the four indi- 
vidually treated by me in the service of Professor Von Braun at 
Vienna. Next I propose to examine some of the French modes 
of operating for vesico-vaginal fistule, with the view of showing 
how they have been influenced by German and American prac- 
tice, and how little of real success surgeons there have been 
able to accomplish by the employment of the latter. In con- 
nection with this will also be presented the translation of a 
report by Dr. Paul Berger, of Paris, upon my operations in the 
service of Prof. Dolbeau at the Hospital Beaujon, with remarks 
and criticisms upon Dr. Sims’ method, and upon his refusal a 
short time afterwards to meet me in a scientific contest, as 
Simon and Braun had found it agreeable to do in two most 
difficult cases, which each of us, individually, had been invited 
to examine and pronounce upon as to curability in the service 
of M. P6au at the Hospital St. Louis. 
Now to indicate the scientific importance attached to eight 
of the eleven cases fairly submitted to me for treatment in the 
different hospitals at Heidelberg, Vienna and Paris, I will state 
here that they were regarded by the surgeons in charge as 
utterly beyond the resources of our art, except by such devices 
as kolpokleisis, regarded by me under all circumstances as un- 
necessary and unjustifiable. In the case at Heidelberg (the 
third of my series), a woman from Holland, Professor Simon pro- 
posed to me, as a test of our respective methods of exploration, 
that he would make the first examination and state to his class 
the result, and then immediately submit the case to me for a 
similar decision as to what course of treatment was called for 
under the circumstances. His opinion, expressed in the most 
positive manner, was that the fistule could not be displayed, and 
that oblique kolpokleisis was called for—such as he had per- 
formed in his first case of the kind at Bostock. My opinion, 
expressed in a manner no less positive, was that the fistule, 
by preparatory treatment (gradual or siege approaches) from 6 
VESICO-VAGINAL EISTULE. 
twenty to thirty days, could not only be fairly displayed, hut 
dosed with conservation of the generative functions. Scarcely 
need I say Professor S. upon the spot magnanimously turned the 
case over to me, instructing his assistants at the same time to 
give me all the cooperation needful to carry out ray treatment. 
The other seven cases were more or less of the same character, 
and will hereafter appear more in detail. All were, however, 
resigned to me for treatment somewhat in the same manner. 
Two of the eight cases after completion of the gradual dilatation 
of the vagina were perfectly cured, each at a single operation; 
one at two operations; two so near it, each after one operation, 
that everybody admitted its possibility; one from three weeks’ 
gradual dilatation was reduced to the greatest simplicity, but 
did not receive the necessary operation for closure of the fistule, 
as will hereafter be explained; one received only initiatory 
treatment, and was not again seen, but the result I afterwards 
learned was not satisfactory; one, the most hopeless of all, re- 
ceived initiatory treatment, but was abandoned for want of 
time and other reasons, which will hereafter be given. 
From this then it will be seen that the great secret of success 
in these cases lay not so much in position, speculum and form 
of suture employed, as in the preparatory treatment (gradual or 
siege approaches); a principle of practice first successfully ap- 
plied by myself’ and the one above all others that has been in 
my reply to Professor Simon kept constantly in view as the dis- 
tinguishing feature of our respective methods. 
As to the great value of this principle of treatment there 
can be among enlightened physicians or surgeons but one opinion. 
Professor Simon himself admits that it is thoroughly correct, 
but says the same result can be accomplished by immediate in- 
cisions and dilatation; but this is simply begging the question, 
as his long experience and my own observation of his practice 
abundantly prove. Professor von Braun, in a letter addressed 
to me April 10, 1877, since my return to New York, speaks of 
it thus: “All cases that have been operated upon after your 
method have entirely recovered; not one has been sent away 
uncured. I shall endeavor to make known the results of all 
cases operated upon in my service, so that physicians may learn VESICO-VAGINAL FISTULE. 
7 
its real worth. lam persuaded that it will find here, with each 
year, more and more adherents, and as to myself, I shall con- 
tribute all in my power to introduce it in Europe.”* 
Dr. Bandl, May 27, 1877, writes me as follows: “Already 
in Vienna the gradual dilatation of the vagina as a preliminary 
step to reach the borders of fistules in difficult cases is becoming 
well known. Professors Billroth and Saltzer are now employ- 
ing it. It will doubtless be gratifying to you to learn that 
Professor Saltzer invited me to operate in his service that he 
might better learn the method. This I did March 30tb. The 
fistule, of considerable size and situated high up, was, after four 
weeks’ dilatation, made quite accessible. I completed the opera- 
tion in one and a half hours, using six sutures and a suitable 
plate (button). I removed the apparatus on the sixth day and 
found the cure complete. I think Professor Saltzer will order 
your instruments and operating chair. Besides this case, I have 
cured outside the General Hospital another having a large 
defect, and fifteen in the clinic of Professor von Braun, the 
most of them being difficult. In three of them no one expected 
a cure could be effected. In all I have seventeen cases, which 
you will soon have the opportunity of reading and judging,” 
Professor LeFort, under date of July 25, 1877, writes me 
from Paris thus: “Your patient left my service (Beaujon) a 
very short time after you had removed the sutures. She did 
not speak to me of any incontinence of urine, at least I have no 
recollection of her having done so. She figures in my reports 
as a complete cure. I thank you for your good services.” 
Here we enter upon our subject: 
PART FIRST. 
A, Historical Sketch—B, Tabular Statement of our Opera- 
tions at Heidelburg—C, Our Correspondence.—Soon after the 
appearance of the paper in the “Wiener Medizinische Woch- 
enschrift,” Nos. 27-32, 1876, by Professor Simon as above 
entitled, I began a reply to the same, and had advanced very 
* The extracts from this and the following two letters I introduce here 
without asking the consent of their authors, feeling that the general scientific 
interest of their tenor fully warrants the liberty taken. 8 
VESICO-VAGINAL FISTULE. 
far with my work when the sad intelligence of the distin- 
guished surgeon’s death reached me at Paris. My first im- 
pulse was to finish my reply and publish it in accordance 
with the original plan, hoping that some one of the numerous 
followers of the German master would take up the discussion of 
the questions at issue between us, and answer the objections 
which I felt myself bound to make to his views of practice. 
But, after reflection upon all the circumstances of the case, I 
entirely abandoned the idea of a formal reply, and proposed to 
myself instead to review the whole field of French, German, 
English, and American operations. By this course I trusted to 
reach a solution of the important question, What is the best and 
safest operation at the present moment for the cure of vesico- 
vaginal f stale, with preservation of the generative functions f 
I have been deeply engrossed with the subject from that time 
to the present, and hope at no distant day to lay the result of 
my labors before the Profession, believing that I shall thus con- 
tribute in a greater degree to the end proposed than I could do 
by pursuing any other course. But since I have carefully read 
the English translations of the article in question, and have 
found several criticisms therein which place me in a false light 
before the Profession, I deem it to be my duty to reply without 
delay. 
Now, in order to do full justice to Professor Simon and his 
claims, and at the same time to place the differences between 
us as regards kolpokleisis and the best means of avoiding it in 
a clear light, I will here introduce a few extracts from publica- 
tions made by us respectively in 1868, 1869 and 1870. 
In the first place, however, it is proper to say that in two 
articles published by me (“ New Orleans Medical and Surgical 
Journal,” January, 1860, and “ New York Medical Record,” 
December 2, 1867), I contended for priority in the operation of 
transverse obliteration of the vagina in the urethral portion, kol- 
pokleisis, as a means of relieving incontinence of urine, sup- 
posed to be otherwise incurable. Professor Simon having 
anticipated me in this operation nearly four years, and having 
seen my claim in the last-named journal, felt himself called 
upon to prove his rights to priority, and this he did to my entire VESICO-VAGINAL FISTULE. 
9 
satisfaction in a letter addressed to me through the “ Deutsche 
Klinik,” numbers 45 and 46, 1868, and a translation of which 
he caused to be made and distributed among the Profession 
in America. Of the operation in question, and of his views at 
that date upon the treatment generally of vesico-vaginal fistule, 
he said: 
11 The reason why I have proved the validity of my claims of 
priority at such length is simply this, that, in my opinion, kol- 
pokleisis is the most important plastic operation which in the 
last decennia has originated from one single man. The opera- 
tion for vesico-vaginal fistula by uniting the borders of the 
defect is indeed, in its present perfection and precision, a much 
more important acquisition than kolpokleisis, and probably the 
greatest achievement of our century in plastic surgery; but it 
has not been carried to that perfection by a single man, but on 
the contrary, operators of all nations have contributed their 
share to it. The ‘ uranoplasty ’of our ingenious country- 
man, von Langenbach, could alone be placed by the side of kol- 
pokleisis, as far as the safety of the performance and its im- 
mediate success are concerned. It would rank higher still, on 
account of its more frequent occurrence, if its benefit for the 
voice in increasing its purity could be secured in all, or in the 
majority of cases. But as in many cases this result is not ob- 
tained at all, and in others only incompletely, kolpokleisis must 
be considered the more important operation, as in all cases it 
fully answers its purpose. This operation, which I invented at 
the time when the obliteration of the vulva, proposed by Vidal, 
proved inefficacious in re-establishing continence of urine, has 
already been performed more than fifty times with complete 
success. Through it many patients with incurable delects of 
the bladder have been freed of the most intolerable suffering; 
viz., the incontinence of urine. I have myself in eighteen cases 
succeeded in effecting perfect obliteration, and every German 
surgeon who practices the art of curing vesico-vaginal fistules 
has recorded one or more successful cases of that kind. 
“ Since the invention of kolpokleisis, however, I have not re- 
mained satisfied with that mode of operation, to which you still 
adhere. On the contrary, I have constantly labored to perfect 10 
VESICOVAGINAL FISTULE. 
the method of operating; to multiply its chances of success in 
the different parts of the vagina, and to render its indications 
more precise. Whereas I had, in my first cases, operated only 
in the lower parts of the vagina, and had repeatedly met with 
small remaining fistules which could not be brought to heal, 
such occurrences are now extremely rare, and I close, as the 
case may be, in any height of the vagina, and immediately below 
the defect. Nay, in one case, where the fistule was high up in 
the fornix, I needed only one-half of the latter for the obliteration, 
thus preserving the vagina in its whole length (see my “Bei- 
trage zur Plastischen Chirurgie,” Prag., 1868, p. 216). More- 
over, whereas I used to consider kolpokleisis indicated only 
where very large defects existed, I have now limited this indi- 
cation a good deal, having cured at later periods very consid- 
erable defects by uniting the borders of the wound by sutures 
like these T, A> A)> by resorting to incisions along the sides 
and parallel with the sutures, and even by transplanting a flap 
from the vesico-vaginal wall. The size of a defect has, for 
the reasons enumerated, during the last five or six years, not 
been in my eyes an indication for kolpokleisis. On the other 
hand, I have found, among the large number of difficult and 
complicated cases which have come under my treatment, several 
in which it was either impossible or too dangerous to unite the 
borders, so that here I resorted to kolpokleisis. 
“So much for kolpokleisis. I avail myself of this opportunity 
to present to you, esteemed colleague, and to your countrymen, 
a statement of the growth and progress of the operation for 
vesico-vaginal fistules in Germany, as much on this subject may 
still be unknown to you. My statements will no doubt be for 
you—the most experienced operator on fistules in America—of 
the greatest interest, as you will thereby perceive that the oper- 
ation in question was fully practiced in Germany before you and 
Sims came forth with it in England and France; that in this 
country it has been carried to a simplicity, perfection and cer- 
tainty of success which it has not attained in any other coun- 
try, and that especially your American method and its modifi- 
cations have been surpassed in every respect. Without fear of 
contradiction, I believe myself justified in considering that, of VESICOVAGINAL FISTULE. 
11 
all surgeons, I have been most extensively occupied with this 
operation, practically and theoretically, and have most promoted 
its perfection. For this reason it will not seem extravagant to 
you if I speak in the following more particularly of my method 
of operating and the results achieved thereby My 
results in toto are consequently the following : 
Of 118 fistules which existed in 105 patients— 
104 “ “ “ “ 92 “ were completely cured. 
“ 5 “ “ “ “ 5 “ closed except small openings. 
“ 3 “ “ “ “ 2 “ as incurable, dismissed. 
• “ 6 “ “ " " 6 “ died. 
“Thus in comparing the results of 1859 by the old imperfect 
method with those attained after that year by means of the im- 
proved one, the proportion is considerably in favor of the latter. 
While previous to 1859, of 22 fistules, only 14 (equal 64 per 
cent.) were cured, and 2 patients (equal 9 per cent) died, after 
that period of 96 fistules which existed in 83 patients, 89 (equal 
92f per cent.) fistules in 77 patients were cured, and only 4 
patients per cent.) died. 
“With what safety the cures are effected by my simplified 
method, the following report of my latest operations may serve 
to inform you, besides my works of 1862 and 1868, in which 
the results are given in detail. During six months’ residence 
at Heidelberg (from May to October, 1868), we have operated 
on, in the hospital, 14 fistules in 14 patients. I have performed 
12, and my assistants, Messrs. Heine and Hotz, each 1. Three 
of the fistules were very small; they had remained after pre- 
vious operations at Rostock; the other 11 were new cases, but 
6 of them had been operated already once or several times by 
other surgeons. Several of them were of considerable size; in 
5 cases 12 sutures were required in order to close them; in 1 
even 15. Moreover, different complications existed, which made 
it necessary three times to embrace the posterior lip of the os uteri 
in the suture; once to overlap an existing atresia of the urethra; 
once to remove one; twice to perform kolpokleisis; and once to 
make a transplantation of a flap from the vulva.* Yet not- 
withstanding these troublesome circumstances all 14 patients 
* The italics are mine. 12 
VESICOVAGINAL FISTULE. 
were cured by 17 operations. Of these, 11 required only 1 
operation; 3 had to be operated on twice each; among them 
were 2 small fistules which had remained from previous 
operations, 
“ After such results, you will agree with me, esteemed col- 
league, that fine silk thread, which is much easier to apply than 
silver wire, is in no wise inferior to it, and that the catheter in 
permanence is an unnecessary and even detrimental burden to 
the patient. And you will also feel yourself in justice bound 
to acknowledge that the operation of vesico-vaginal fistula has 
reached, in Germany, a higher degree of simplicity, perfection, 
and certainty than in any other country.” 
As further proof of the value attached by Professor Simon 
about that date to kolpokleisis, I will quote the views enter- 
tained by him upon the extension of the principle, as found 
published in his justly popular work on Plastic Surgery (“Bei- 
trage zur Plastischen Chirurgie,” Prag., 1868, p. 216). Having 
found that transverse obliteration of the vagina in its lower 
third necessitated too great a sacrifice of the vaginal tract in 
cases where the fistule was small, but inaccessible on account 
of its height, he added two other forms of procedure, making 
in all three, and designated them topographically as follows: 
“1. Transverse obliteration of the vagina in the urethral 
portion. 
“2. Transverse obliteration of the vagina within the limits 
of the base of the bladder. 
“ 8. Oblique obliteration of the vagina in one or the other 
of the vaginal arches, according to the right or left situation of 
the fistule.” 
Again, as a guide for the employment of these classified pro- 
cedures, he laid down (op. cit., p. 229) the following eight indi- 
cations, based principally on tbe pathological conditions of the 
vagina and cervix uteri: 
“1. Great loss of substance, making it impossible to bring the 
two sides of the fistule together. 
“2. Inaccessibility of the fistule from its high position, from 
the inversion of its edges, etc. 
“3. Loss of the infra-vaginal cervix, and danger to the peri- 
toneum. 13 
VESICOVAGINAL FISTULE. 
“4. Haemorrhage into the bladder, where considerable, after 
operations. 
“5. Confinement by adhesions of the stump of the cervix 
uteri, inside the bladder. 
“ 6. Atresiae vaginae above the fistule, with immobility of the 
posterior border of the latter. 
“7. Obliteration of the urethra, with one fistule below and 
another above. 
“8. Uretero-vaginal and uretero-uterine fistules.” 
The next year (“Deutsche Klinik,” No. 15, I860), in an arti- 
cle entitled “Effects of Urine and Saliva upon Tissues deprived 
of Epithelium,” Professor Simon recorded some fifteen experi- 
ments made upon man, dogs, and rabbits, with the view, as 
stated, of controverting a popular error, with regard to the in- 
jurious influences of these secretions upon fresh wounds. Of 
the effects of urine he said : 
“It has been an undisputed dogma until quite recently that 
urine by its chemical properties has a very injurious effect 
upon the unprotected tissues of animals; that it prevents union 
by first intention; that it destroys fresh cicatrices, and that 
when infiltrated in the tissues it leads in the end to their necro- 
sis. This view has been held not only with regard to decom- 
posed and alkaline, but with regard to undecoraposed and still 
acid urine. The latter has been supposed either in itself to 
have an injurious effect, or to rapidly undergo an ammoniacal 
decomposition when in contact with unprotected tissues, and 
then to develop destructive properties. Repeated observations 
which I have had the opportunity of making at the bedside, and 
experiments on animals, by which I have sought to confirm and 
to complete these observations, have contradicted this dogma 
in its main points; and I have already, in several papers re- 
lating to operations on the generative and urinary organs of 
women, expressed my disbelief in it. In these papers, however, 
the experiments were only mentioned, and not described in 
detail, so that my views, as therein expressed, were without 
their complete demonstration. lam therefore induced by the 
importance of the subject to repair my omission here, and at 
the same time to explain the practical conclusions which may 
be drawn.” 14 
VESICO-VAGINAL PISTULE. 
The first five of these experiments were made with fresh 
urine showing acid reaction. After injecting the fluid into the 
subcutaneous tissue of several rabbits and dogs, and seeing 
that it disappeared by absorption in a few hours without leav- 
ing any trace of its effects, it was then tried upon man, with a 
like negative result. Here the exposed surfaces resulting from 
incisions for hare-lip, and from other plastic operations about 
the face, were washed with the secretion, and then brought to- 
gether with sutures in the ordinary way. In every case union 
by the first intention was said to take place with the same 
readiness as though water had been used. Even urine from a 
case of vesico-vaginal fistule loaded with pus and mucus, though 
still showing acid reaction, was used upon several dogs without 
changing the above results in the slightest particular. 
The sixth and seventh experiments were made with ammo- 
niacal urine, unfiltered and filtered. From their importance as 
relates to the operation of kolpokleisis, I will here copy in ex- 
tenso: 
“ Experiment 6. From two to four drachms of alkaline 
urine, containing triple phosphates, mucus, and pus, were in- 
jected into several dogs and rabbits. Result: In all cases a 
large abscess was produced, containing dark and offensive pus, 
and the skin covering it soon sloughed, and left a large, slowly 
healing ulcer. 
“Experiment 7. From two to four drachms of alkaline 
filtered urine were injected subcutaneously on several occasions 
into dogs. Result: In all these cases also abscesses were pro- 
duced, but they ran their course with less destruction of the 
skin than in experiment 6; they made a smaller aperture in 
breaking, and healed more rapidly.” 
The eighth, ninth, and tenth experiments were made upon 
the urine itself in open and closed vessels exposed to an average 
temperature with the view of determining under varied circum- 
stances the time necessary to convert acid into alkaline urine. 
As these experiments are also important as illustrating the 
principle underlying the employment of kolpokleisis, I will copy 
these in extenso: VESICOVAGINAL FISTULE. 
15 
“ Experiment 8. Half a drachm of good pus was mixed 
with half a pound of urine, and the fluid exposed daily for five 
or six hours to a temperature of 30°-50° 0. The glass was 
not closed. Result: Alkaline reaction did not appear till the 
sixth day. 
“ Experiment 9. Two drachms of lean meat one day old 
were placed in one pound of fresh urine. The vessel was left 
open, and exposed daily for four to five hours to a temperature 
of 30°-50° 0. Result: Alkaline reaction first appeared on the 
fifth day (after 106 hours). 
“ Experiment 10. The same experiment was performed with 
the modification that the vessel, having been completely filled, 
was closed, so as to exclude the air. Result: On the tenth 
day, when the vessel was opened, the urine was still acid, and 
the meat was not decomposed." 
The remaining five experiments were made with the view of 
explaining the mechanism and evil results of infiltration of urine 
resulting from rupture of the male urethra, and from other 
causes. 
The deductions drawn by Professor Simon from these experi- 
ments are to be found in his concluding remarks, which, from 
their direct bearing upon the subject before us, I again quote 
in extenso: 
“The doctrine established by the foregoing experiments of 
the harmless effects of acid urine upon unprotected tissues, 
wounds, and cicatrices, which was first suggested to me many 
years ago by my observations at the bedside, and which has 
since received manifold confirmation in the experience of sur- 
geons and gynaecologists who operate on the sexual and urinary 
organs, has a bearing, the extensiveness of which can not be 
overrated, upon the mode of performing and upon the result of 
such operations. In former days, when operators used the 
utmost care to convey the urine away from the wound, but paid 
much less attention to the mode of executing the operation, the 
result of the operations was most unfavorable. Since, however, 
the opposite plan has been adopted of expending the utmost 
care upon the execution of the operation, and adopting few or 16 
VESICO-VAGINAL FISTULE. 
no precautions for the conveying away of the urine, most re- 
markable success has been attained. A good many years ago, 
Wutzer, in operations for vesico-vaginal fistula, used to punc- 
ture the bladder above the pubes in order to convey the urine 
away, and fastened the patients by straps in the prone position 
until the effects of pressure on knees and elbows rendered it 
impossible to maintain it longer. He was compelled, however, 
to repeat the operation ten or twenty times for the cure of the 
smallest fistulas, and could only exceptionally record a complete 
cure. I, following an absolutely contrary principle, never even 
introduce a self-retaining catheter, and have often allowed the 
patients soon after the operation to leave their beds, and go for 
a walk with the sutures in place. Nevertheless, I have already 
cured more than a hundred fistulae, most of them by a single 
operation, and, in common with all operators of the present day, 
I regard an incurable fistula as an extremely rare exception. 
But although the mode of executing this and other plastic oper- 
ations upon, or in the neighborhood of the urinary organs, such 
as that for recto-vaginal fistula, or ruptured perineum, as well 
as urethrorraphy and urethro-plasty in the male sex, has been 
immensely improved; although it is scarcely now maintained 
that acid urine hinders union by first intention, yet the doctrine 
of its harmless effects upon wounds and cicatrices, and especially 
the fact that no alkaline decomposition is set up in it by the 
secretion of united wounds, have not yet been so fully recog- 
nized as might be desired in the interests of the patients con- 
cerned. For American, English, and French surgeons after the 
operation for vesico-vaginal fistula or similar lesions about uri- 
nary or genital organs still always employ the self-retaining 
catheter, or at any rate believe that they must not allow the 
urine to be passed at pleasure, but only to be drawn off by 
catheter. But this precaution, which causes so much incon- 
venience both to patient and surgeon, and which may set up 
mischief through irritation of the bladder and urethra, will, 
with better knowledge, vanish from the after-treatment and 
give place to the far simpler and more rational mode of man- 
agement, which I have followed for years with the best results; 
namely, to'provide for the cleansing of the external genital organs 17 
VESICOVAGINAL FISTULE. 
and the vagina, and to allow the urine to be passed at pleasure 
{see my article ‘On Kolpokleisis and the Operation for Vesico- 
Vaginal Fistula in Germany/ in this Journal, 1868. Numbers 
45 and 46). 
“In the rare cases in which the urine of a patient, on whom 
the operation of vesico-vaginal fistula is to be performed, has 
an alkaline reaction, and is therefore actually injurious, the 
operator will endeavor first to render the urine again • normal, 
by treatment of the causes of its alkaline decomposition (ex- 
traction of a calculus, treatment of vesical catarrh, etc.). He 
will never undertake the operation while the urine is alkaline, 
unless, for other reasons, it is impossible to defer it. In such 
cases the utmost care must be used in the operation, that not a 
drop of urine may be able to penetrate between the margins of 
the wound. A self-retaining catheter is not to be introduced, 
because it would not be tolerated, and by increasing the irrita- 
tion, might set up acute cystitis. In one case of vesico-vaginal 
fistula, in which I was obliged to carry out the operation while 
the urine was alkaline from the effect of obstinate vesical catarrh, 
I attained the cure by using the most minute care in the execu- 
tion of the operation; in a second case the attempt failed twice, 
and I did not succeed in closing the fistula until I had cured 
the vesical catarrh. 
“With regard to the treatment of infiltration of urine, this 
consists, according to the direction of surgical text-books, in 
deep incisions into the most prominent parts. It is intended by 
this means to let the infiltrated urine escape from the tissues, 
and to allow a free outflow to that which still forces its way 
through the lesion in the bladder or urethra. But relying on 
the experiments above described, I would, in a future case, 
somewhat modify this method of treatment. Instead of the 
numerous incisions, I would make an opening between the per- 
ineum and urethra; that is to say, I would perform perineal 
section, and for the first few days leave in place a catheter 
passed through the wound into the bladder. The urine already 
infiltrated I would leave to its fate. In this way the wound 
produced would be much less than with the treatment hitherto 
adopted. Any further infiltration would be most completely VESICOVAGINAL FISTULE. 
V« ' 
prevented, the urine having a direct outlet; and the urine 
already infiltrated would not, as has been hitherto feared, 
develop any injurious properties; but, as the experiments show, 
would be reabsorbed without harm. Even when a slough has 
been already formed, I consider opening the urethra by perineal 
section to be the best mode of treatment.” 
From the foregoing extracts there can be no doubt of the 
fact that Professor Simon, in 1868, was thoroughly convinced of 
the value of kolpokleisis, performed for whatever cause; and 
equally evident is the error into which he had been led as to 
the extent of my appreciation of it. Had he known that I had 
employed it only a single time in about the same number of 
cases that he had then treated, he would not have spoken so 
disparagingly of my method of operating, and of the methods 
of other surgeons in comparison with his own. An advance 
from 64 per cent, of cures, as shown by his old method, to 92f 
per cent, under the new or simplified method, was indeed enough 
cause for congratulation, and fourteen successful operations out 
of seventeen—82 per cent.—undoubtedly marked a very high 
degree of surgical skill. But what was the character of these 
fourteen cures ? The lines in the first extract, which I have 
italicised, should be carefully read, showing that five must be 
subtracted from the fourteen, being the number of cases in which 
the generative functions were destroyed, when nine—64J per 
cent.—of legitimate cures remain, to say nothing about the 
hiding away of the obliterated part of the urethra in one case, 
and unusual expedients in the other two. 
These results of Professor Simon justify me in putting the 
question thus: If 35| per cent, of expedients which destroyed 
the generative functions were necessary in the treatment of 
ninety-six fistules in eighty-three patients from 1859 to 1868, 
when he had reached his highest degree of success, what did 
they amount to in the twenty-two fistules in twenty-two patients 
who were treated by his “old, imperfect method ” from 1853 
to 1859 ? I will return furthermore to the subject of alkaline 
urine and the deductions drawn by Professor Simon from his 
experiments. 
Here I may be permitted to tabulate my experience during a VESICOVAGINAL FISTULE. 
19 
part only of the^*'old, imperfect method” of Professor Simon, 
extending from May, 1855,* to June, 1859 : 
* This was the date (May, 1855) at which 1, at Montgomery, Alabama, first 
associated my new form of suture with incisions and dilatation of vaginal 
atresias (gradual preparatory treatment), in complicated cases of vesico-vagi- 
nal fistule, and thus established the standard of my form of cure with preser- 
vation of the generative functions, to which I have ever since adhered with- 
out modification, except in the two cases here noted, both of which occurred 
before I had fairly perfected my system. Professor Simon, at Darmstadt, as 
appears from a comparison of his recorded experience with mine, in the same 
year and in the same month, associated his double interrupted silk suture 
(doppel naht) with his new principle of kolpokleisis, as a means of compen- 
sating for loss of tissue, leaving vaginal atresias untreated, entirely sacrificing 
the generative functions, and so established the standard of his form of cure, 
to which he adhered with but little modification up to the time of his decease. 
Dr. Sims, who has unfairly claimed the first success in the treatment of vesico- 
vaginal fistule in America, was at this date using in New York his defective 
clamp or quilled suture, which was totally inapplicable to any form of fistule 
associated with vaginal atresia. Fourteen months later, however (June 24, 
1856), and only six weeks after the description of my new system appeared 
in the “Louisville Review,” Dr. Sims renounced his old form of suture, and 
employed for the first time the simple interrupted silver suture, which he soon 
afterwards associated with his improved duck-bill speculum, with the fold- 
ing of the edges of the fistule, and sometimes the cervix uteri into the 
bladder, and with gradual preparatory treatment of vaginal atresias, sacri- 
ficing to a limited extent the generative functions, and thus established the 
standard of his form of cure, to which he and his followers have ever since 
adhered, with but little, if any, modification. I had previously (from June, 
1853, to May, 1855) been a follower of Dr. Sims with his defective clamp 
suture, and had succeeded in curing only two simple cases of vesico-vaginal 
fistule out of six (33| per cent.), which was very little, if any, less than his 
success with it, according to the results which he had recorded up to that date. 
It was therefore only after Dr. Sims had been driven from the support of 
his clamp suture contrivance, as I expect to show more in detail after I shall 
have finished my reply to Professor Simon, that he caught up at the eleventh 
hour the simple interrupted silver wire, which he fastened on the torsion prin- 
ciple of Methauer and Gosset, in use already by them for twenty-five years, 
and which he united with the principle of vaginal dilatation then in use by 
me for more than three years, all too without the slightest acknowledgment. 
His procedure, thus made up, he heralded forth to the world as something en- 
tirely new, claiming that his discovery of silver wire (adroitly purloined from 
the published experiments of the late Dr. Henry S. Levert, of Mobile, Ala- 
bama, Am. Jour. Med. Sciences,” May, 1829) had done all this and even 
more, and that in the interest of posterity he had the right to proclaim the fact 
not only before the New York Academy of Medicine at one of its anniversary 
meetings, but from the house-tops (Silver Sutures in Surgery, 20 
VESICO-VAGINAL FISTULE. 
Upon fifty-two fistules in forty patients sixty-eight operations 
were performed. 
Upon forty-four fistules in thirty-four patients fifty-three 
operations were performed. These were completely cured with 
entire preservation of the generative functions. 
Upon one fistule in one patient two operations were performed, 
by including the posterior lip of the cervix uteri, with loss of 
the generative functions (May, 1856). 
Upon one fistule in one patient one operation was performed, 
for kolpokleisis, with restoration of continence of urine, but 
loss of the generative functions (March, 1859), 
Upon four fistules in two patients eleven operations were per- 
formed. These were completely cured, with preservation of 
the generative functions, but relapsed, owing to the incomplete- 
ness of the preparatory treatment (incisions and dilatations). 
Upon one fistule in one patient one operation was performed. 
Patient died on the sixth day, though the autopsy showed com- 
plete closure of the fistule. 
Upon one fistule in one patient no operation was performed. 
Considered incurable, and discharged without operation. 
The details of the above cases are to be found in the “ Louis- 
ville Review,” May, 1856, the “North America Medico-Chirur- 
gical Review,” July and November, 1857, and the “ New Orleans 
Medical and Surgical Journal,” January, March, and May, 
1860. 
I think I am warranted in saying that this series of cases 
was the largest, and embraced a greater proportion of legitimate 
cures than had ever been published before by any single sur- 
geon. Forty-four fistules in thirty-four patients, cured in fifty- 
three operations, with preservation of the generative functions, 
give a result that scarcely admits of comparison with that ex- 
hibited by Professor Simon at the date of his “ simplified 
method,” nine years later, including even his cases in which the 
Such are the facts briefly stated upon which rest the American claims to 
superiority in the treatment of vesico-vaginal fistule, and these I present here 
for the reasons that it will better enable me hereafter to distinguish true from 
false teachings both at home and abroad, and to point out some of the errors 
still operating to retard scientific progress in this branch of gynaecological 
surgery. VESICO-VAGINAL FISTULE. 
21 
generative functions were impaired or destroyed, and points to 
some other explanation than that of the position of the patient, 
the speculum, or the silk or silver sutures. What is that ex- 
planation? The recognition of the curability of the atresias 
of the vagina, and the adoption of a successful mode of treat- 
ing them, simply as a preparatory measure. This I contend to 
have done almost at the outset of my experience, and I asso- 
ciated therewith a form of suture which combined advantages 
in the utilization of inodular tissue which were possessed by no 
simple interrupted suture, whether of silver or of silk, which 
had been previously in use. A careful examination of the 
details of the forty cases which I have tabulated above will 
show that a very large proportion of them presented very great 
obstacles. These difficulties were first met and surmounted by 
means of the knife and the dilator, and afterwards the cases 
were treated, as regarded the fistules, on general principles. 
Having now learned from Professor Simon’s letter (1868) to 
what extent he and his followers in Germany had carried the 
operation of kolpokleisis, and having become convinced of the 
greater advantages which are secured by my dilating speculum 
and support for the knee-chest position in the treatment of 
vaginal atresias and of the fistules which complicate them, I was 
led to the conclusion that kolpokleisis, which I had regarded 
up to this time as deserving favor, might in future be greatly 
curtailed in the range of its employment. I discovered that 
out of eight indications laid down by Professor Simon for the 
application of kolpokleisis, in only a single instance, according 
to my experience, was the operation admissible; viz., loss of 
tissue and impossibility from coexisting adhesion of bringing 
the two sides of the fistula together. Even under these cir- 
cumstances I began to think that, by greater perseverance in 
the preparatory treatment, in which, as before remarked, I had 
made so decided improvements, kolpokleisis might be avoided. 
Becoming strengthened in this conviction, my investigations 
and observations finally presented the whole subject to my 
mind in a new aspect, bearing upon the moral, chemical and 
physical results of the operation. Upon these several points I 
hope at some time to speak more fully. It will suffice at present 22 
VESICO-VAGINAL FISTULE. 
to say that patients came under my notice presenting reaction- 
ary complications of the most dreadful character, whose fistules 
had been treated by such expedients as felling or basting 
their edges, or folding them in the bladder, sometimes at the 
expense of incarcerating the cervix uteri in the bladder, and 
not seldom of obstructing the urethra—these expedients all 
growing out of the necessity of securing broad refreshed surfaces 
in the operation and in increasing the chances of success as 
regarding the relief of incontinence of urine. 
At this juncture, and in this train of investigation, I con- 
ceived it to be of the greatest practical interest to learn the 
condition of cases, after some years, in which the operation of 
kolpokleisis was known to have been completely successful. I 
accordingly addressed a note to Dr. E. P. Means, of Hickory 
Grove, Ala., who had had my first and only patient upon whom 
kolpokleisis had been performed (1859) under observation for 
several years, requesting him to make a thorough investigation 
of the case and report to me the result. Here is his answer: 
“Jane Finley is living, and her general health is very good. 
She can retain her urine while walking about sometimes, but it 
occasionally dribbles. If when lying down she immediately 
answers the call to urinate, she can retain the urine long enough 
to get up and go out doors. She does not complain of any 
pain, but says that she used to retain her water much better 
soon after the operation on her than she can now.” 
About the same time I wrote to Professor Wernher, of 
Giessen, who was the first in Germany to secure a complete 
result from kolpokleisis, as stated by Professor Simon in his 
writings, and from him I received the following reply, dated 
December 12,1869, with regard to his case: 
“My patient died last summer. At the autopsy, I found in 
the vagina, above the seat of closure, a stone as big as a pigeon’s 
egg-” 
A few months after I had learned the unfortunate result, at 
the end of twelve years, of Professor Wernher’s case, and had 
ascertained, after the lapse of ten years, that time was becoming 
more and more envious of the success in my first and only case, 
there came under my care, by a strange coincidence, a case of VESICOVAGINAL FISTULE. 
23 
spontaneous kolpokleisis, which not only confirmed the two re- 
ports just cited, but thoroughly convinced me that the expedient, 
at least, was only temporary in its beneficial results, and that, 
from its liability to he followed in a large proportion of cases by 
sequences dangerous to life, it ought to be condemned. 
In an article published in the “American Journal of Medi- 
cal Sciences,” of July, 1870, I reviewed the subject, and after 
sharply criticising the eight indications which Professor Simon 
1 ad laid down as a guide to the operation, I reported in detail 
the case of spontaneous kolpokleisis above referred to, which I 
here copy as an argument in support of the correctness of the 
position I then took. I said : 
“Under our treatment at this moment is a fair example of 
Nature’s kolpokleidic operations, in which, after having covered 
up and hid away old lesions, she has left the parts in a state 
analogous to that of surgical obliteration. The results before 
us teach what are to be expected from the latter, and confirm 
the previsions of pathological chemistry. 
“ Mrs. , of Mobile, Alabama, aged twenty-three, a per- 
fectly well-formed woman, after a first labor of eighty-four hours, 
March 31, 1865, lost, by sloughing, part of the lower third of 
her vagina, which, on healing, left a small urethro-vesico-vagi- 
nal fistule, and a recto-vaginal fistule higher up, with loss of con- 
trol over the passage of either urine or faeces. Under this persist - 
ent local irritation the vagina just below the urinary fistule con- 
tinued, however, to contract, enfolding both fistules, until by de- 
grees she had regained control over the excretions. Her general 
health improved, but eighteen months after the first injury, and in 
the fourth month of a second pregnancy, she miscarried. Cystitis 
soon after set in, with a profuse discharge of bloody mucus. Five 
or six days of such painful inflammation continued, recurring at 
intervals of three or four months. It seemed to be provoked by 
the exertion of standing or walking too long. Still menstruation 
remained normal, and general health fair, with increased reten- 
tive power. By the end of the third year her vagina seemed 
completely closed; she lay dry all night, and could walk about 
in the day for several hours at a time without dribbling. But 
now came a change for the worse. Upon over-exertion she be- VESICO - VAGINAL FISTULE. 
came conscious of a fullness, as though something in the lower 
part of the vagina was pressing to come away, with urging to 
micturate every few minutes. This trouble increased until it 
culminated in an attack of cystitis. The urine, now always 
turbid, deposited a thick tough slime, and smelled very strong 
after standing a little while. A year ago fatigue in nursing a 
friend brought on a severe attack, which continued a whole 
month. The sanguinolent or brown turbid and offensive char- 
acter of the urine has continued from that time with variations 
in degree up to the present date, at which we find it largely 
mixed with pus. During the past year her health has suffered 
much; she has become excessively nervous, and her menstrua- 
tion painful. A deep-seated pain is assigned to the left ovarian 
region, and soreness is complained of over the whole abdomen. 
Since last autumn the flow has lasted but two days, and the 
epochs been retarded eight or ten days. Excruciating lumbar 
pains coincide with the cystic exacerbations at intervals of only 
eight or ten days. She has repeatedly swooned from their 
severity, and remained for hours unconscious. This unrelent- 
ing march in the gravity of her condition produced a state of 
anguish which, without positive derangement of mind, still 
urged toward suicide, but in this contention of spirit wiser 
counsels happily prevailed, and she has sought from the resources 
of surgery a salvation to which Nature has proved inadequate, 
although she had effected complete kolpokleisis, ‘ that most im- 
portant plastic operation which, in the last decennia, has origi- 
nated from one single man!' 
“Actual State, March 10th, 1870.—The vagina admits only 
a No. 6 bougie. The urethra is closed half an inch from the 
meatus. The vulva is much excoriated, with scalding on pass- 
age of urine, which has been the case from the first. Attempts 
to dilate the vaginal stricture cause extreme pain. 
“ Preliminary Operations.—Our first indication being to re- 
store the vagina, we proceeded, after etherization, assisted by 
Drs. T. C. Finned and J. H. Hinton, of New York, to cut deep 
into the cicatricial band, from one-half to three-fourths inch 
thick along its sides. Then we incised the posterior wall, in- 
troduced our speculum, and exposed the vagina above, which 25 
VESICOVAGINAL FISTULE. 
was deeply congested and dotted with little red spots over its 
anterior wall. A small urethro-vesico-vaginal fistule was brought 
into view, just within the point of vaginal occlusion, and ad- 
mitted a No. 4 bougie. The vaginal surface for nearly an inch 
above this point was studded with granulations that bled at the 
slightest touch. The neck of the womb was much enlarged, 
and its mouth patulous. Pus escaped with the urine through a 
catheter in the bladder. We all three verified the purulent 
character of this discharge. The recto-vaginal fistule was re- 
opened by our dilatation of the vagina. Spontaneous atresia 
of the vagina had here restored continence of urine by drawing 
the small fistule up into the cicatricial band. The vaginal mus- 
cles could then aid the sphincter vesicae in controlling the flow 
of urine through the urethro-vesical and vaginal orifices almost 
in juxtaposition. The urine, however, flowing into the vagina, 
had attacked its mucous membrane and the cervix, as betrayed 
by their congested, haemorrhagic, and patulous state. Endome- 
tritis and ovaritis had supervened upon the cystitis and vagi- 
nitis. The discharge of muco-pus tinged with blood is now 
about half a pint in twenty-four hours. The subjoined analysis 
by a highly competent person—Dr. William B. Lewis, of this 
city—was made on a specimen of the urine drawn at the last 
exacerbation of our patient’s cystic trouble, which occurred a 
few days after the operation pre-cited: 
“ March 18th.—Odor pungent, aromatic. Color and appear- 
ance, reddish, densely turbid. Sediment, after standing, one- 
eighth bulk of specimen, rather close, but light, of a brownish- 
white color. Reaction alkaline. Specific gravity, 1025. Earthy 
phosphates completely precipitated from supernatant fluid, but 
chlorides abundant. Albumen, half of the whole volume. 
Microscopical, oil globules, minute crystals of triple phosphates, 
pus corpuscles, amorphous urates and epithelium from the blad- 
der. No casts were found. If present, they would be discov- 
ered with great difficulty, as the strongly-marked chemical 
characters of the specimen cloak the organic sediments and 
render their microscopical characters indefinite. 
“ ‘ The objects discovered by the microscope are'in great part 
such as are naturally observed in alkaline urines. The features 26 
VESICOVAGINAL FISTULE. 
of this specimen indicate that the cystitis from which the patient 
suffers is largely due to retained urine and pus. The large 
proportion of the latter accounts for the albumen present.’ 
“We should state here, while the general character of the 
urine in this attack remained the same, as observed by the 
patient for months before this preliminary operation, there was 
marked amelioration in her sufferings. Only a few moments at 
one time was the pain so severe as to cause swooning. The par- 
oxysm was much shorter than usual, lasting only about two 
days, but the flow of mucus and pus continued the same as 
formerly, though diminished in quantity. 
“ The patient’s good constitution and the conservative reac- 
tions of her organism during the earlier stages of her traumatic 
malady, its continued and vigorous efforts for self-recovery, 
more frequent in ratio to the local irritation; in short, the whole 
picture before us confirming and elucidating the pathologic his- 
tory forbids us to attribute the decline of health or sympathetic 
sufferings to other than hydraulic and chemical causes; viz., 
the stagnation of urine retained in contact with mucous sur- 
faces unprepared to resist its irritating salts, and whose exuda- 
tions of protective mucus have but increased the mischief by 
accelerating putrid fermentation. To open a free passage for 
the discharge of these morbid secretions is the first step dictated 
by experience towards removing their causes. 
“ We do not exhibit the foregoing as anything more than the 
particular application of a general principle. Lesions, appar- 
ently the same, occasion different degrees of suffering in different 
patients. European, and especially German, peasant-women, 
may be more robust, more phlegmatic, than our American 
women, but chemistry and mechanics are invariable. To their 
laws are due the fearful sufferings we have witnessed in case of 
spontaneous kolpokleisis, and we venture to suggest that if the 
luminaries of German surgery will descend from their Olympian 
heights, look up their kolpokleidic cases, and look into them 
again, they will see cause to change the note of triumphant 
gratulation with which Professor Simon announces his success- 
ful operations. 
11 In the annals of surgery, nay, even in those of psychology, VESICO-VAGINAL FISTULE. 
27 
we have met with nothing more astounding than Professor S.’s 
assertion, by a gentleman of Professor Simon’s rank in our pro- 
fession, that, after effecting kolpokleisis, the urine becomes 
healthy and does not harm the uterus, when we consider the 
deep pocket formed in the vagina with no other outlet than the 
small fistule into the bladder. These fistules, moreover, are 
very often found at the highest point of the vaginal pocket, 
thus favoring the retention of urine, which at every menstrua- 
tion will be mixed with the blood of this eliminative secretion, 
an admixture which can hardly fail to promote decomposition 
and its irritative sequences. Would Professor Simon attribute 
then to the vaginal raucous membrane the property of arrest- 
ing fermentation, of preventing those well-known changes which 
urine undergoes when long confined in the bladder, forming 
earthy deposits, calculi, and acrid ammoniacal lixivia? 
What is vesico-vaginal fistule? A solution of continuity, 
maintained in the vesico-vaginal septum by the passage of urine, 
the contact of which is a chief obstacle to the process of healing. 
“In what does the cure of a fistule consist ? In the union of its 
edges without serious lesion to the functions of the bladder, 
vagina, or uterus. No result inferior to this is a true cure, 
however complete the continence of urine. This physiological 
standard should never be lost sight of in our choice of remedial 
methods. What is kolpokleisis? The conversion of the vagina 
into a urinal, with prevention of the sexual act and generative 
function, restricting the uterus to the part of an excreting 
organ. Per contra, it claims to obviate the incontinence of urine. 
“ Of Professor Simon’s eight indications for kolpokleisis, we 
recognize as valid only the first one; viz., a loss of substance 
such as to prevent the coaptation and consequent union of the 
fistulous borders. 
“ No loss of substance can prevent a cure so long as the womb 
can be drawn down to fill the aperture. In cases where this 
seemed impossible at first, it has gradually yielded to our daily 
tractions with polypus forceps on the cervix and stretching of 
the surrounding tissues, until the two sides of the fistule would 
meet. This once effected we feel confident of cure by our 
button-suture. Since its invention we have never had recourse 28 
VESICO-VAGINAL EISTULE. 
to incisions, in order to relax tissues and take the strain off our 
sutures, as Jobert was so much in the habit of doing, and as 
Professor Simon, after condemning it, has been fain to practice 
likewise. Even when a force of several pounds has been 
needed to bring the sides together, our button-suture has always 
sufficed to maintain them in apposition until their complete 
union. Incisions we apply only to the preliminary treatment of 
cicatricial bands, or to points of atresia, which, after opening, 
we dilate with tents, not attempting to close the fistule until we 
have removed, as far as possible, such obstacles. 
“ All Professor Simon’s indications pre-cited, except the first, 
have been met and overcome in our practice, without having 
recourse to kolpokleisis. At ‘ uretero-uterine’ fistules, indeed, we 
may place a point of interrogation, for their diagnosis does not 
appear to us well founded in the cases stated. Bdrard describes 
such a case in full detail. He injected colored fluids into the 
bladder; he introduced a probe into the cervical canal, and 
another through the urethra, so that it should strike the first, 
if a fistulous communication existed. He measured separately 
the fluid escaping from the vagina, and what escaped from the 
urethra; he smelt what escaped from the os uteri. Now such 
means may aid in ascertaining the existence of a vesico-uteriue 
fistule, but they can not determine whether the communication 
between the uterine cavity and the urinary apparatus occurs at 
a point beyond that of the normal contiguity of these organs. 
A fistule x + y, of track unknown, may exist; the pre-cited 
means of diagnosis may fail to prove it vesico-uterine; they 
can not, however, prove it uretero-uterine, and we have seen 
vesico-uterine fistules in the diagnosis of which they failed, be- 
cause of the extreme smallness of the fistulous track and its 
valvular condition. We have been unable to pass a colored 
fluid through it from the bladder in quantity sufficient to be seen 
in the cervical canal; nor could we pass a probe, however deli- 
cate, in the same direction, yet the two streams of urine—one 
from the vagina, the other from the bladder—always flowed 
separately. Was this a proof that the urine of the vaginal 
stream came from the cavity of the womb? Post hoc, ergo, 
propter hoc, will not answer here, as the linen test has fre- VESICO-VAGINAL PISTOLE. 
29 
quently attested in our hands. By this test we have detected 
the precise situation of a passage between the bladder and the 
cervical canal, even when the fistule was too small to be seen by 
the strongest reflected light. In one case cured by us January, 
1869, the point of communication with the cervical canal was 
near the internal os and the fistulous track above, bounded only 
by the utero-vesical fold of peritoneum; this membrane was 
punctured while operating, but no serious consequences ensued. 
Here, even when the cervical canal was fully dilated, a strong 
reflected light failed to reveal the fistulous orifice, although while 
the patient lay upon her back the urine flowed freely from the 
os externum. Now, on mopping dry the cervical canal, and 
laying a bit of old linen on its anterior wall, its saturation 
showed at once the orifice at that point, by closing which we 
cured the patient.* No organ was injured, no function com- 
promised by our operation.” 
With regard to the subsequent history of the case above cited, 
I have only to add that the improvement which was indicated 
after the preliminary operation was continuous. Under repeated 
incisions and gradually increased distention of the vagina, one 
sequence after another slowly disappeared, but it was not until 
the dilatation had been carried to a diameter exceeding six 
centimetres, which required several months to accomplish, that 
the bladder was found to be in a sufficiently healthy condition to 
justify its closure by suture. One operation with my button- 
suture proved sufficient for this, and several months later a like 
result by the same means followed the operation upon the recto- 
vaginal fistule. The latter at the time of the operation was 
almost large enough to admit three fingers into the rectum. 
This augmentation in size resulted from the inelasticity of the 
surrounding inodular tissue and the high degree of vaginal 
dilatation found to be necessary; but, notwithstanding this 
seemingly grave complication of the preparatory treatment, it 
proved of no consequence, as, by gliding healthy tissue from 
above, the closure of the fistule was easily effected at a single 
operation. At the end of eight months the patient was dis- 
* For the linen test, see our more extended notice in the “ Transactions of 
the New York State Medical Society,” p. 154, 1869. 30 
VESICOVAGINAL FISTULE. 
charged perfectly cured, with preservation of the functions of 
all the organs involved—a condition of health in which she has 
continued ever since, now nearly seven years. Only a few 
weeks ago I heard from her, and the report was most satis- 
factory. 
The lessons of the above case are most instructive. In this 
instance, kolpokleisis, resulting from the blind operations of 
Nature, was scarcely less effective than if it had been produced 
by the knife of the most skillful surgeon. Yet how important 
it was to undo Nature’s handiwork in order to save the life of 
the individual. Like causes produce like effects, and there is 
no reason to think that the results in this case would have been 
better had kolpokleisis been effected by the surgeon’s knife, no 
matter how expertly and judiciously it might have been used. 
It is scarcely necessary to say that, holding this opinion, I 
visited Heidelberg in the autumn of 1874, to learn from per- 
sonal observations what I had so long wished to know; namely, 
the German operation for vesico-vaginal fistule, as performed by 
the master himself. I was most kindly received by Professor 
Simon, who invited me to take part in the treatment of a con- 
siderable number of cases which he was then expecting to enter 
the clinic of the University, thus showing himself to be the true 
physician. Our distinguished confrere, Mr. Spencer Wells, was 
present at the opening of the concours. 
Tabular Statement of our Operations at Heidelberg.—Seven 
operations in the aggregate were performed upon six cases— 
four by Professor Simon and three by me (two jointly upon 
the same patient). Professor Simon has described all these 
cases and operations in his article, together with the five 
additional operations which he found necessary to complete the 
treatment after ray departure from Heidelberg. 
Our results may be tabulated thus: 
Upon 7 fistules in 6 patients 13 operations were performed. 
Case I.*—Upon 1 fistule in 1 patient 3 operations were per- 
formed by Professor Simon; completely cured with preservation 
* The numbering of the cases in the above table corresponds with the order 
in which they were reported in the Paper of Professor Simon. See the “Ob- 
stetrical Journal, vol. iv, p. 436 et seq. and Wiener Med. Wochenschrift. VESICOVAGINAL FISTULE. 
31 
of the generative functions, but only partial restoration of con- 
tinence of urine, owing to loss of urethral substance from repeated 
operations. 
Case ll.—Upon 1 fistule in 1 patient 2 operations were per- 
formed by Professor Simon; the first—six years previously—for 
completing a morbid kolpokleisis in the urethral portion of the 
vagina, with complete loss of the generative functions; the 
second for reclosure of the same obliterated point after it had 
been reopened by the passage of a calculus. Death on the sixth 
day. Autopsy showed suppurative pyelitis of both kidneys and 
the blocking up of the left ureter by a calculus. 
Case lll.—Upon 2 fistules in 1 patient 2 operations were 
performed by Professor Simon, after the removal of a previous 
kolpokleisis by another surgeon, with restoration of the normal 
outlet of the catamenia and of continence of urine, though a ring- 
formed contraction of the vaginal orifice still remained as a 
serious impediment to the generative functions. 
Case IV.—Upon 1 fistule in 1 patient 3 operations were per- 
formed by Professor Simon, after incisions and immediate dis- 
tension of the vagina, with restoration of continence of urine, 
and maintenance of the normal outlet of the catamenia; but 
there afterwards remained obliteration of the vagina above the 
fistule to the size of a No. 10 bougie, and loss of generative 
functions. 
Case I.—Upon 1 fistule in 1 patient 1 operation was perlormed 
by myself, and was completely cured, with entire preservation 
of the generative functions. 
Case ll.—Upon fistule in patient 1 operation was per- 
formed by myself, after seven-eighths closure of the original fistule 
by Professor S. (little Russian), with the result of almost com- 
plete closure; but the success was afterwards lost by reopening 
of the fistule, due mainly to an abnormal relationship of the 
parts, brought about by the preceding operation, which result 
could only have been avoided by reproducing the original fistule 
and making the closure de novo. 
Case lll.—Upon 1 fistule in 1 patient 1 operation was 
performed by myself (after the patient had been pronounced 
incurable by Professor Simon, and condemned to complete ob- 
literation of the vagina—kolpokleisis), with complete preserva- 32 
VESICO-VAGINAL FISTULE. 
tion of the generative functions and closure of the fistule to a 
point, quite simple, and admitted by Professor S. himself to be 
easy of cure at another operation. 
Of the four cases treated by Professor Simon and estimated 
by my standard of cure, one (25 per cent.) came completely up 
to it, and two partially, with a death rate of 25 per cent. 
Of the two cases treated by me individually, one came com- 
pletely up to the mark, and the other so near it that no one for 
a moment questioned the practicability of its completion at 
another little operation—loo per cent. 
Our Correspondence.—l shall here introduce the correspond- 
ence which passed between Professor Simon and myself about a 
year after the specified operations were begun, in order to show 
the views which we both entertained at that date with respect 
to the causes of failure in the so-called “ little Russian ” (Case 
II) upon which we operated jointly, and to indicate the value 
attached by each of us to the points distinguishing our respect- 
ive methods of operation. This course seems to be particu- 
larly called for, since Professor Simon has referred in his paper 
to several of these points relating to my particular views, with- 
out connecting them with the circumstances under which they 
were at that time discussed. Therefore, in justice to myself 
and likewise to my distinguished opponent, I submit, as a part 
of my reply, the letters which we interchanged, believing that 
no sort of objection can be raised to this procedure, because of 
the purely scientific interest of the correspondence. 
[translation.] 
“Honored Colleague,—Up to this time we have vainly hoped 
for your visit. We have still in the hospital the patient (little 
Russian) upon whom you performed the operation with unsuc- 
cessful result. I would be very glad if you would again operate 
upon this case, as I believe the cure will now be very difficult, 
since you have cut out so much substance. 
“We have also several more fistules, which lie in the anterior 
part of the urethra, for you to operate upon. The rest I will 
communicate to you verbally. 
“Yours respectfully, 
“ Professor Simon. 
“Heidelberg, September 25th, 1875.” 33 
VESICO-VAGINAL FISTULE. 
“My dear Professor Simon,—With regard to the case to 
which you refer (little Russian), it is to me most interesting, 
and I should be delighted to complete the cure, as I feel very 
confident I could at another operation, were it possible for me 
to return to Heidelberg. 
“ The failure of my first operation resulted, I am satisfied, 
from an improper understanding on my part of the relationship 
of the end of the urethra to the anterior lip of the uterus. 
This little point constitutes, I conceive, a most important differ- 
ence between your operation and mine, and when one follows 
another, as in the order of this case, without proper considera- 
tion, a similar failure is liable to take place in a majority of 
cases. This mainly arises from the difference existing between 
us in the position of the patient. Your position (Steiss-Riick- 
enlage) requires that the uterus shall be pulled down to the 
mouth of the vagina, thus placing the anterior surface of the 
cervix uteri under and opposite the urethral surface of the 
vagina. In this relationship the two opposing surfaces are pared 
off, and with your silk sutures lapped one upon the other. In 
this relationship they usually unite, I have no doubt, with con- 
siderable certainty, unless the traction be very great, and in 
that event a partial failure is likely to follow from the cutting 
out of the central sutures, as happened after your operation in 
the case. In either event, however, there must result from the 
retraction of the uterus a curvature of the urethra at the seat 
of union, with the concavity presenting to the pubic arch. In 
my position {the knee-chest), the parts, on the contrary, are oper- 
ated upon in situ, without being changed in their normal rela- 
tionship. The result is that the edges of the fistule, instead of 
the surfaces named, are pared perpendicularly and coaptated 
without subsequent distortion of the urethra. In the event of 
failure at any point in the line of union, the little remaining fis- 
tulous track extends directly through between the original bor- 
ders, and not between flat opposing surfaces as happened after 
your operation. 
“ In my operation in the case in question, it was from not 
knowing the extent to which the urethra had been overlapped 
by the cervix that I was unconsciously led to remove so much 34 
YESICO-VAGINAL FISTULE. 
of the urethra in the paring process, and from which you now 
apprehend incontinence of urine when complete closure is effected. 
Had I understood the relationship of the parts involved at the 
time I operated as well as I do now, as I believe, I should have 
divided your cicatrix on either side of the fistule to the extent, at 
least, of restoring the opposing edges of the fistule to a smooth 
plane, just as I am in the habit of doing in cases where the 
cervix uteri is fixed in the bladder. Even in the third operation 
now called for I should proceed in this manner, and should 
expect to get a good result, both as to closure of fistule and 
retention of urine. 
" Now, Doctor, these are my views of the case, frankly stated. 
If yours should differ, may I ask you to be equally frank in 
stating them. The point I conceive to be one of great practical 
importance, and well deserves serious consideration. My great 
regret is, that I am unable to come to Heidelberg and talk with 
you on the subject. I still hope, however, to see you again be- 
fore I return to America next year. 
“Yours very truly, 
“ Nathan Bozeman. 
“Paths, September 30,1875.” 
“ Highly respected Colleague,—l write to you once more to 
invite you to come to Heidelberg in the course of eight or ten 
days. It is only necessary for you to spend from eight to four- 
teen days, perhaps even a shorter time, to carry out everything 
which will enable us to complete our judgment upon your 
method of operating. I will mention the matters which I would 
most gladly have settled, and at the same time will refer to you 
other points which may be interesting to yourself. 
“ 1. I would like you to carry out the operation in the case 
of the little Eussian, which you have yourself proposed. I had 
consulted with my assistants concerning the same method, but 
I fear that continence will not be obtained in this manner, even 
if a perfect cure take place. Before your operation upon the 
fistule, only the size of a pea, the urethra was 2J centimetres 
long, and, after the same, only to centimetre. Should 
[translation,] VESICO-VAGINAL FISTULE. 
35 
the urethra be again treated in the same manner—viz., be cut 
out with so great a loss of substance—there would remain only 
one-quarter to one-half a centimetre. Therefore, the cure of 
the defect would, by your method of operation at this point, be 
very doubtful, because the edge of the urethra is very thin, and 
the posterior edge, lying within the uterus, would be bruised to 
some degree by excising with the scissors. I would have more 
confidence in the plan if the entire operation had been carried 
out with the knife alone, and if the urethral part of the defect 
had been saved as much as possible. As, however, it happens 
that you count with great confidence upon the cure, even if you 
excise with the scissors, I beg you, on that account, to carry 
out the operation yourself. 
“2. I have again five patients here with fistules. You can 
now operate upon fistules which lie against and in the urethra, 
while I will operate in those cases which lie deeper in the vagina. 
“3. I have further to inform you that the patient upon whom 
you last operated, and in which case, at the time she left Heidel- 
berg, a fistule remained through which the point of the finger 
could enter the bladder, will only return here next spring. At 
present she believes she could not endure so trying an operation. 
“4. Finally, I desire to convince you also of the ulterior 
results in the cases of the two women upon whom I operated 
for urethro-vaginal fistule. You doubtless remember the case 
of the woman (Feige) upon whom another surgeon had per- 
formed transverse obliteration of the vagina, and which I again 
separated. In this case there was an oblique-lying urethro- 
vaginal fistule, and after the widening operation of vagina by 
yourself, there was a second small fistule, the size of the button 
of a probe, in the neighborhood of the mouth of the womb. 
The first fistule which I operated upon in your presence, and in 
which a small opening remained, turned out precisely as I had 
said in advance, and as I have already informed you, on the 
occasion of your passing through Heidelberg; viz., healed of 
itself without any further operation and without any cauteriza- 
tion, after the third week, by cicatricial contraction. The 
second little fistule, which lay at the mouth of the womb, I 
operated upon later, and healed. 36 
VESICO-VAGINAL FISTULE. 
“In the second urethro-vaginal fistule (Weick), in which the 
widening by incisions with the subsequent treatment by tam- 
pons, was alike without result, I brought about the closing of 
the opening, as you will remember, by means of six sutures. 
But immediately after the operation the urine flowed off. Upon 
examination, after the cicatrization, the fistule was found to be 
healed along the entire line of union. Only a very small slit 
of the outermost left angle, which lay outside of the suture, still 
remained open. This little slit was obviously not closed by the 
suture, and, on this account, the flow of urine immediately after 
the operation can be explained—this little slit was afterwards 
united and healed by means of two fine sutures. The patient is 
now very well,and she menstruates regularly through the vagina, 
which is certainly very much narrowed. She often comes here, 
and we have recently examined her condition. 
“ In the course of the summer we had many cases of fistules, 
and, on that account, I am most sorry that you did not visit us. 
I have cured six fistules, among them two lying very deep in 
the vagina, both being cured by the first operation. As yet I 
have made no use of your method. 
“ With the wish that you will at once write me whether you 
can come at any specified time, and in the hope of soon greeting 
you personally, I subscribe myself, 
“ Your obedient colleague, 
“ Simon. 
“ Heidelberg, October 13th, 1875.” 
“ My dear Professor Simon,—Your favor of the 13th instant 
was duly received. 
“ Your kind invitation to me to visit Heidelberg again for 
the purpose of operating with you in the hospital for vesico- 
vaginal fistule I fully appreciate, and I assure you I would come 
most willingly were it not that I am confined here with my 
children. I should like to take more time with you than it is 
possible for me to afford at present. 
“ There are two or three points, independent of the operation 
required for the little Eussian patient, that are of the greatest 
practical importance to gynaecological surgeons, that I should VESICOVAGINAL FISTULE. 
37 
like to discuss with you by the practical mode of dealing with 
the subject that we have already so satisfactorily inaugurated. 
I refer to cicatricial contractions of the vagina and to partial 
and complete obliteration of the same for the relief of inconti- 
nence of urine. I will, therefore, put the questions in the form 
of propositions and ask your answers to the same, believing that 
they will represent more exactly the state of the science in 
Europe at the present time than any information which might 
be obtained from any other surgeon known to me in connection 
with the subject. 
“ 1. Is the existence of a cicatricial contraction or narrowing 
of the vagina an insurmountable obstacle to the closure of a 
fistule situated above it, and to the preservation of the functions 
of the organs involved ? And, if so, why ? 
“ 2. Is partial or complete obliteration of the vagina, with 
incomplete or perfect perversion of the functions of the organ, 
justifiable for the relief of incontinence of urine? And, if so, 
what are the principal conditions demanding one or the other 
of these procedures? 
“Of the first class of cases there is a pretty fair illustration 
to be found in the case of the young woman, Weick, who, you 
say, is cured of her incontinence of urine, and now menstruates 
regularly through the ‘small remaining vagina.’ The only 
objection that could be possibly urged against the result in this 
case is the existing vaginal atresia. In the General Hospital 
at Vienna a somewhat similar case, in the service of Professor 
Joseph Spaeth, was brought to my notice by his first assistant 
Dr. Massara, during my visit there last spring. But here the 
atresia, which was almost complete, was situated higher up the 
vagina than in your case, and the fistule of small dimensions 
presented itself just above in the has fond of the bladder. This 
atresia of the vagina was the result, as I was told, of typhus 
fever, and was found to be of a very resisting character. The 
fistule was produced accidentally in an unsuccessful attempt to 
overcome the atresia of the vagina, as I was informed by Pro- 
fessor Karl von Braun, who had had the case under observation 
from time to time for four or five years. Another case in the 
same hospital, a Jewess from Hungary, in the service of Pro- YESICO-VAGINAL FISTULE. 
fessor Braun, waa presented to me for an examination and an 
opinion. The accompanying sketch will serve to give you an 
exact idea of the situation and size of the urethro-vesico-vaginal 
fistule, as well as of the recto-vaginal fistule, twelve centimetres 
from the anus. Here the cicatricial narrowing of the vagina, 
to the extent of about one-half of its calibre, existed just above 
the neck of the bladder, across the middle of the vesical fistule. 
Through the fistule the fundus of the bladder protruded, pre- 
enting itself at the vulva in the form of a tumor as large as as 
medium-sized orange. It was only possible to pull down the 
uterus by the aid of hooks, to the extent of placing the edges 
of the fistule not nearer than two centimetres from each other. 
“ How, as to the practicability of overcoming the atresia in 
the case of Weick, and giving her a useful vagina, before your 
operation for closure of the fistule, I think you told me that 
you did not believe it possible. I said that I thought it was 
feasible, and, at your request, made the first incisions and insti- 
tuted the process of dilatation. The result, as you know, proved 
unsatisfactory, and you proceeded to perform your operation for 
the incontinence of urine, which you inform me was successful 
after the second sitting. In justice to myself, however, and to 
the procedure adopted in this case to overcome the obstacle in 
question, I should say that my efforts were not a fair test of 
what might be accomplished under such circumstances. Hav- 
ing lost many of my dilators before going to Heidelberg, I had 
to resort to expedients which were not commensurate with the 
ends to be accomplished. Since that time I have supplied 
myself with a good and suitable assortment of dilators, such as I 
am in the habit of using, and I am now prepared to deal with 
difficulties of the character in question in a more effective 
way. lam sure you would be interested in any efforts to give 
this young woman a useful vagina, and I doubt not a great deal 
toward it can yet be done by the employment of the means indi- 
cated ; and, if I had five or six weeks’ time to spare, I should 
like to undertake the operation in your presence. You will 
pardon me for saying that I believe this treatment to be of the 
greatest importance, and that I believe there is much to be 
learned by us all before we can hope to reach the highest limit VESICOVAGINAL FISTULE. 
39 
of success in our operations either for incontinence of the urine 
or the faeces. 
“In the second case cited, that of Dr. Massara, may I ask 
you what you would have advised under the circumstances ? 
Am I right in supposing that the condition described called for 
obliteration of the vagina below the seat of stricture ? 
“ The third case, that of Professor Braun, presented the un- 
usual complication, as was stated, of recto-vaginal fistule, twelve 
centimetres from the anus, almost large enough to admit the 
point of the index finger. With the impossibility here of draw- 
ing the two sides of the vesical fistule together, and with the 
constant presence of faeces and urine in the vagina, may I again 
ask what you would have done? Would it have been possible, 
under the circumstances, for you to close such a faecal fistule by 
your procedure ? and, if not, would you consider obliteration 
of the vagina in the urethral portion justifiable? 
“ The second class of cases, comprising those which are com- 
paratively free from cicatrized narrowing, and demanding a 
complete obliteration of the vagina, is known to be large, and 
the range of the operation itself is also known to vary with the 
experience of the operator. It is proper to state that two im- 
portant subdivisions of this class of cases have been made and 
fully described by you in several of your published articles 
under the respective designations of transverse and oblique ob- 
literation of the vaginal-kolpokleisis. To these I may add a 
tnird and a fourth, under the names of felling and folding the 
edges of the fistule, with shortening of the anterior wall of the 
vagina. 
Now these expedients are all well known to surgeons, and 
are at present largely employed, even in cases where the uterus 
is movable and the vaginal walls are in a comparatively healthy 
condition—the adoption of this mode or that, varying, as I have 
just stated, with the experience of the operator. You remarked 
to me during my visit at Heidelberg that you now did not have 
occasion to resort so often to obliteration as formerly, because 
3 our greater experience enabled you to overcome obstacles to 
the closure of the fistule itself, which previously had been 
thought insurmountable. So it is with all young and inexperi- 40 
VESICOVAGINAL FISTULE. 
enced operators now; and even in this advanced state of the 
science the result is, that we find many of them adopting some 
one of the expedients named, under circumstances which you 
and I would regard as unjustifiable. As to the exact extent 
to which you consider oblique or transverse obliteration of the 
vagina necessary at the present day, I confess myself ignorant; 
but, as you have given the matter so much attention, lam sure 
there is no one better prepared to define it. Therefore, in the 
existing advanced state of your experience and knowledge, will 
you have the kindness to give me your views upon the subject? 
“The case of the woman from Holland,in your service, upon 
whom I operated last December, presented a funnel-shap'ed 
vesico-vaginal fistule of no great size, it is true, but which was 
situated entirely to the right of the median line, with both 
edges deeply inverted, and the lower one firmly adhering to the 
posterior surface of the corresponding pubic bone. After your 
examination you said that you had only seen one similar in- 
stance, and that occurred at Rostock, when you first applied 
the principle of oblique obliteration, and you remarked further 
that the same procedure was called for in this case. I may 
state that I operated successfully upon a similar case in the 
hospital at Vienna, in the service of Professor Karl Braun, in 
which it was previously thought that oblique obliteration, in 
accordance with your method, was necessary. 
“ I suppose that, in the case of the little Russian patient, if 
the urethra is thought to be too short to justify an operation 
upon the fistule itself, you would advise transverse obliteration. 
Again, in uretero-vaginal fistitle (Harnleiter-Scheidenfistel), I 
believe you still practice perforation of the vesico-vaginal septum 
and then oblique obliteration. Besides this, I infer that there 
are quite a number of deep, and even small fistules (im Gewolbe) 
associated with immobility of the uterus which call for oblique 
obliteration. 
“The circumstances justifying transverse obliteration I think 
I understand very well. 
“Of the other two expedients referred to; viz., felling and 
folding the edges of the fistule, I also understand the extent of 
their applicability. These two methods are very largely prac- VESICOVAGINAL FISTULE. 
41 
ticed in America by Dr. Sims and bis followers. They necessi- 
tate, as you know, the turning of one or both edges of the fis- 
tule into the bladder, with more or less shortening of the anterior 
wall of the vagina. 
“Therefore you will understand that my great object in ask- 
ing you the foregoing questions is to ascertain, as nearly as 
possible, the conditions of the vagina and the peculiarities of 
the fistules which call for transverse and oblique obliteration. 
These procedures having been given to the profession by you, 
now about twenty years since, your present views as to their 
applicability and usefulness can not be otherwise than of the 
highest interest to me, a co-laborer with you in the same branch 
of practice. 
"Hoping to hear from you at your convenience, I remain, 
dear Doctor, 
“ Yours very truly, 
“Nathan Bozeman, 
' “Paris, October 19th, 1875.” 
Now from the tabular statements of the six cases jointly 
operated upon by Professor Simon and myself, and the corre- 
spondence given. I am warranted, I think, in making the fol- 
lowing deductions: 
1. That Professor Simon charges me with destruction of one to 
one and a fourth centimetres of the urethra by my method of 
refreshing or paring the edges of the fistule with scissors in 
the person of the little Prussian (his Case I and my Case II): 
and that he believed it was not possible after the bruising and 
loss of tissue by such means for me to complete a cure. 
2. That Professor Simon attached very little, if any, import- 
ance to my plan of gradual preparatory treatment attempted 
to be carried out by me in the persons of Feige and Weick (nib 
Cases 111 and IV) previous to the commencement of Us plan of 
immediate preparatory treatment, and that he considered my 
final operation upon the Holland patient (my Case III) of no 
particular consequence, since she had returned to her home with 
a fistule remaining large enough to admit the point of the 
finger, and did not think she could again “ endure so trying an 
operation.” 42 
VESICO-VAGINAL FISTULE. 
3. That Professor Simon regarded the results secured in his 
two cases named, on the plan of immediate preparatory treat- 
ment, with partial loss of the procreative functions, as entirely 
satisfactory to all parties concerned, and beyond the scope 
of surgical, legal, or moral criticisms, and that he believed 
they were just as conclusive in a practical and scientific point 
of view as those achieved by me in my Oases (I and III) with 
preservation of the procreative functions. 
4. That Professor Simon considered as paramount to all other 
questions at issue between him and myself the one of whether 
his or my method of operating was better suited, on the one 
hand, to fistules involving the urethra, or, on the other, to fis- 
tules implicating the cervix uteri, and that he believed to settle 
this disputed point only eight to fourteen days longer trial of 
the two methods would be necessary. 
5. That I believed the whole difficulty in my operation upon 
the little Russian arose from the unnatural and forced relation- 
ship between the anterior lip of the cervix uteri and the urethra, 
caused by the lapping of the former upon the latter in the pre- 
vious operation by Professor Simon in the lithotomy position 
(Steiss-Eiickenlage); and that the loss of tissue in the urethra, 
imputed to my use of scissors by Professor Simon, resulted from 
the cutting out of his central sutures lodged within its calibre. 
6. That I believed my operation would have been entirely 
successful had I in the outset recognized the above abnormal 
relationship of the parts, and had, instead of attempting to close 
the remaining fistule as presented, proceeded at once to reestab- 
lish the original opening in the bladder, and then to close it by 
direct coaptation of its edges, as I had previously been in the 
habit of doing under like circumstances in the knee-chest posi- 
tion. 
7. That I did not regard Professor Simon's reputed success 
in the case of Weick (notwithstanding her relief from incon- 
tinence of urine) as a cure at all; and that, judged by my 
standard of utility, the case was still almost as much an object 
of surgical interest as before the commencement of treatment. 
8. That I considered Professor Simon’s exposure and direct 
closure of the two fistules in the case of Feige an immense im- VESICOVAGINAL FISTULE. 
43 
provement upon the previous operation by “ another surgeon,” 
although far from what it should have been, since the case was 
left with a recontracted condition of the vagina below the seat 
of the fistules, and with the liability to further injury in the 
event of another accouchement. 
9. That I regarded Prof. Simon’s fatal result (Case II) as most 
damaging to his theory of kolpokleisis, since the disease of the 
kidneys, the remote cause of death, stood in the relationship of 
effect to his first operation, and that I believed his second oper- 
ation in the case only hastened the end which would otherwise 
have followed in a short time as a legitimate sequence. 
10. That I considered my success in the case from Holland 
as settled by the plan of treatment already partially carried 
out, and that to complete the whole only a little more time and 
a simple operation were needed. 
11. That I attached the greatest importance to morbid con- 
tractions or distortions of the vagina, as complications ot fistules, 
and none whatever to the situation or size of fistules; and that 
I believe the removal of the former by the principle of grad- 
ual preparatory treatment was the best and only rational 
mode of accomplishing the cure of the latter. 
12. That it was ray object in the correspondence with Pro- 
fessor Simon to elicit from him the precise circumstances under 
which he then considered partial or complete obliteration of the 
vagina necessary as a means of securing continence of urine, 
and thus to learn the exact range of applicability or real use- 
fulness of his mode of operating. 
PART SECOND. 
A. Extract from my Letter to Dr, Chauveau,—This was a 
Private letter addressed to Dr. J. F. Chauveau, of New York, 
who, believing it would be of general interest to the medical 
profession, had it published in the “ New York Medical Record,” 
July 24, 1875, and a French translation of the same in the 
“Annales de Gynhcologie,” Paris, September, 1875. It was 
written early in April, just after my last interview with Pro- 
fessor Simon at Heidelberg with regard to our operations and 
their results, but from some unaccountable delay did not appear 44 
VESICO-VAGINAL PISTULE. 
in the sheet mentioned until the date given. Neither did I 
know it had been published nor see it until just about the 
time (October) the correspondence ensued between Professor 
Simon and myself. 
Now whether Professor Simon, previous to our correspondence, 
had seen this letter in the “ Kecord ” and taken exceptions to 
it, there is no evidence before me to show, but certain it is he 
did see it very soon afterwards, and made it the subject of severe 
criticisms, as shown by his published report, nearly a year later, 
of our joint operations. Suffice it for the present to say, that 
all I then wrote concerning our different cases and operations 
was fully warranted, as far as related to their peculiarities and 
unfinished state. The seeming discrepancies between my state- 
ments and his, as shown in his report of the same, are easily 
reconciled, and will be fully explained when I come to answer 
his criticisms and explain why he omitted to include his fatal 
case (Case II) among the others in his estimate of the compara- 
tive value of our respective methods. I mention these circum- 
stances here in connection with this letter to Dr. Chauveau as 
corroborative evidence of my fair dealing from the beginning 
towards- Professor Simon and his mode of operating. Farther, 
the statements contained in this letter itself will be found, I 
think, almost if not entirely in harmony, with those embodied 
in my two letters addressed to Professor Simon from Paris. 
They were presented by Dr. Chauveau under the caption, “ Op- 
erations for Yesico-Vaginal Fistule,” as follows : 
“In my last letter I told you also I would give you soon the 
result of. my operations in Heidelberg. . I was there with Pro- 
fessor Simon about six weeks. He received me very kindly, 
and seemed glad of the opportunity to make a practical test of 
our respective operations, with the view of determining the 
range of their applicability. He performed from first to last 
four operations by his method, with the following results: Three 
partial successes and one death. 
“ The first case presented a good-sized fistula, which occupied 
the base of the bladder. Here the uterus was movable and 
could be easily drawn down for the operation, which is essential 
to the success of Professor Simon’s method in fistulas situated 
high up. About seven-eighths of the fistula was closed. VESICOVAGINAL FISTULE. 
45 
“A second case was that of a woman upon whom he had per- 
iormed kolpokleisis seven years before. The result of the first 
operation was cystitis and the formation of a stone in the vagina 
above the seat of closure. This stone finally cut through the 
cicatrix, thus reopening the vagina. The patient’s condition 
having become unendurable, she applied to Professor Simon the 
second time. The operation he performed had for its object the 
reclosure of the vagina, which I witnessed. It was kolpokleisis 
the second time. On the tenth day the patient died. Autopsy: 
-fistula or rather the vagina not closed; the denuded edges 
throughout having separated. Both kidneys extensively dis- 
eased and a calculus in the right ureter near the bladder; old 
adhesions around the uterus. Contraction of the bladder with 
cystitis. The original fistula only large enough to admit the 
end of the index finger. Vagina contracted and shortened. 
“ I may say, therefore, in this subject were found all the 
morbid lesions resulting from kolpokleisis which I pointed out 
ln my paper about the subject (“American Journal of Medical 
Sciences,” July, 1870), and which will result in a majority of 
cases. 
“The next case Professor Simon tried was a woman from 
Russia, who had been operated upon successfully by another 
surgeon nine months before for kolpokleisis. The woman’s hus- 
band becoming dissatisfied with the shutting up of the vagina, 
und the little improvement as regarded the retentive power of 
the bladder, consulted Professor Simon. Upon examination he 
found the fistula small, and therefore proceeded to reestablish 
tbe vagina. After effecting the latter, he proceeded to close 
the fistula itself, situated at the root of the urethra. The oper- 
ation was performed through my small speculum, which gave 
Brofessor Simon great satisfaction. The operation succeeded 
°foy to a limited extent, the failure being due probably to the 
cystitis, which still existed to a slight extent at the time of the 
operation. Nine or ten days after the operation the patient 
had what was supposed to be pyelitis, which probably existed 
to a slight extent as a sequence of the kolpokleisis and cystitis. 
-the fourth case of Professor Simon was a young woman, 
aged about twenty. She had a small fistula at the root of the 46 
VESICO-VAGINAL FISTULE. 
urethra with complete atresia of the vagina above, with no 
outlet for the menses. Professor Simon proposed in this case to 
close the fistula as the first step of the treatment. But instead 
of closing the fistula as he intended, he closed the vagina below 
the fistula, thus making the operation one of kolpokleisis, with 
no provision for the escape of the menses. The result was only 
a partial success, and further treatment will be required to com- 
plete the occlusion. 
“ Now as to my three cases. The first one presented was a 
very small woman, with a good-sized fistula involving the cervix 
uteri. I employed five sutures with a suitable button, and com- 
pleted the closure at the first operation. 
“ The second case was the one Professor Simon first oper- 
ated upon with partial success. The fistula was small and in- 
volved the cervix uteri, perfectly simple and easy to get at, as 
shown by the fact that it took only thirty-five minutes to com- 
plete the operation. The case was just such a one that I would 
have guaranteed a cure in eight days if I had had the entire man- 
agement of the after-treatment. But, as it turned out, the after- 
treatment was not properly carried out, and cystitis resulted, 
which caused the fistula to reopen two days after the suture 
apparatus was removed. On the sixth day the closure was 
found complete, as shown by the fact that not a drop of urine 
escaped pervaginam during two hours. During this time there 
was no catheter in the urethra, and the quantity of urine drawn 
off showed that the retention was complete. 
“ My third case was a woman from Holland, aged about thir- 
ty-eight. Professor Simon placed her in his position (the Steiss- 
Eiickenlage), and with his instruments attempted to display the 
edge of the fistula, which he utterly failed to do. He stated 
to his class that he had met with a similar case at Rostock, in 
which he performed oblique obliteration of the vagina, kolpo- 
kleisis, and such an operation he would do in this case, thus cut 
off the cervix uteri from a vaginal outlet and place it in commu- 
nication with the cavity of the bladder. In this way would be 
made a cul-de-sae in the vagina, into which the urine could 
enter through the fistula and cause serious trouble; viz., vagi- 
nitis, endometritis, and calculus, with all their attendant symp- 
toms. VESICO-VAGINAL FISTULE. 
47 
“After Professor Simon had finished his remarks upon the 
case, he requested me to examine it in my position, with my in- 
struments, and say what I would do under the circumstances. 
I found the vagina very capacious, and the fistulous openino' 
funnel-shaped, with the apex—the edge of the fistula proper 
turned into the bladder and partially united to the right side 
of the pelvis. 
“ In front of the fistula, in the anterior vaginal wall, there 
was transverse contraction, which offered an additional obstruc- 
tion to the view of the fistula. But notwithstanding all those 
complications in the case, I was abie to get a sufficient view of 
the edge of the fistula to enable me to say promptly I could 
unite them, and thus preserve the functions of all the organs 
involved. 
“ Thereupon, Professor Simon requested me to perform the 
operation, as he wished to see it. After dividing the constricted 
part referred to, and dilating the vagina with tents ior ten days, 
I proceeded to perform the operation indicated for closure of 
the fistula. The operation proved tedious and protracted, 
though it was entirely satisfactory. Professor Simon expressed 
himself satisfied, and said he did not see how it coula fail to 
succeed. 
“ Six or eight hours after the operation I found an unusually 
small quantity of urine passing per catheter, which at once 
aroused my suspicions as to the right ureter being closed be- 
tween two of my sutures. A few hours later the patient had 
great pain in the right kidney, and then felt a gush of urine 
into the vagina, with complete relief. When I saw her again, 
about eighteen hours after the separation, and learned the true 
story of the case, I told Professor Simon we would have a par- 
tial failure of the operation, corresponding to the point at which 
the right ureter lay in the posterior edge of the fistula. The 
same accident having occurred some years ago in a case in the 
Hotel-Dieu, of Paris, upon which I operated, and in other cases, 
I felt confident of the final result a partial failure. The 
removal of the suture apparatus on the eighth day in this case 
fully confirmed my explanation. .'A small fistula remained about 
the middle of the line of cicatrization, which was nearly two 48 
VESICO-VAGINAL FISTULE. 
inches in length. This remaining fistula is, properly speaking, 
a vesico-urethro vaginal fistula. Now that the precise situation 
of the ureter is known, there can be no difficulty in the next 
operation, when a complete cure may be expected ; I shall prob- 
ably return to Heidelberg and perform it. 
“At the second operation of Professor Simon and myself, 
which we performed the same day, Dr. Koeberffi, of Strassburg, 
the celebrated ovariotomist, was present. He came to Heidel- 
berg and spent two days to see us operate. Professor Simon 
frankly admits the superiority of my operation in all cases when 
the fistula is situated high up. He is delighted with my specu- 
lum, and, indeed, has- ordered all my instruments to be copied, 
even my operating chair. 
“ I expect to go to Vienna next week, and if the opportunity 
offers, will probably operate there. 
“ Yours, etc., 
“ Nathan Bozeman. 
“ Saxe-Coburg, April, 1875.” 
Note.—lt is proper to state in connection with this letter that Professor 
Simon, in his report of our joint operations (“Wiener Medizinische Wochen- 
schrift”), refers to it, and another publication in a public journal touching 
the same subject as untimely and unwarranted by facts. After speaking of 
the agreement between us to renew our operations in the summer of 1875, 
and expressing his regrets at my inability to do so, he says: “As early as 
July, 1875, Bozeman, without my knowledge, published an article in the 
“New York Medical Record,” and in August a second in a public journal of 
Geneva, concerning our competitive operations. I only heard of them acci- 
dentally, and a long time after their publication. While I pass over the latter 
article in silence, as it was only intended for the general public, I must 
answer the former, as it was written for physicians, and contains many inac- 
curacies and much unfairness.” 
In answer to this complaint of Professor Simon, I have only to say the 
article in the Geneva Journal (“ Swiss Chronicle ”) was furnished as a matter 
of news by a correspondent of that sheet, and totally without my knowledge 
or consent. As to the letter here published in full from the “ Record,” it 
speaks for itself, and will be found, I think, to differ in no essential particu- 
lars from the tabular statement previously given of his and my cases, nor 
from the views maintained by me in the correspondence that took place be- 
tween us. 
In addition to this, I will say there were several reasons for my failure to 
return to Heidelberg, as agreed between Professor Simon and myself at our 
last interview, April, 1875. Among them was a prolonged engagement with VESICO- VAGINAL FISTULE. 
49 
Professor Karl von Braun in the General Hospital at Vienna; subsequently 
my health was seriously impaired; obligations to my family likewise inter- 
posed hindrances; and perhaps I ought to add that Professor Simon had 
shown so much impatience when I was with him, in allowing the necessary 
time for carrying out my preparatory treatment, that I was not specially en- 
couraged to overcome the difficulties in the way of resuming the work with 
him. 
B. Extract from a Second Letter hy me to the Editor of the 
“New York Medical Record.”—ln this letter, published Sep- 
tember 25, 1875, my main object was to call attention to the 
system of medical schools in Austria for midwives, and to give 
such facts relating to the subject as I thought would interest 
the Profession in the United States. In the course of my 
remarks I took occasion to refer to vesico-vaginal fistule and its 
treatment by kolpokleisis in Vienna, where I was then staying. 
But this was not done with any idea of forestalling the report 
of Professor Simon upon his and my operations the previous 
autumn, as he unjustly attributed to me afterwards in the criti- 
cisms before referred to. On the contrary, as may be seen, I 
studiously avoided any allusion to the particulars of these oper- 
aicons. I did this because I thought Professor Simon would 
*oon report -them at length, and would fairly make his deduc- 
tions as to the comparative merits of the two methods, which I 
preferred he should first do. These are ray remarks: * * * 
“ With regard to vesico-vaginal fistule, I found here com- 
paratively little advance in its successful treatment, excepting 
through the doubtful expediency of kolpokleisis, recommended 
professor Simon, of Heidelberg. 
‘All operators here in this disease, so far as I can learn, as 
WOH as those throughout Germany, are his strict followers in 
expedient, and perform it in a very large proportion of their 
cases. Even the few imitators in Germany of Sims find it 
necessary also in a considerable number of their cases to resort 
to kolpokleisis. 
* This I consider a very interesting fact in connection with 
the treatment of vesico-vaginal fistule, and affords an admirable 
clue to the range of applicability of these two methods, as com- 
pared with my own. 
“ My great object in visiting Germany has been to study this 50 
VESICOVAGINAL FISTULE. 
operation of kolpokleisis, and see if possible the advantages of 
it, so highly extolled by Professor Simon. The results of my 
observations upon the subject so far are most interesting, based 
upon the experience of leading surgeons. 
“Through the kindness and liberality of Professor Simon, I 
had the opportunity last fall of testing with him, in the hospital, 
in a practical way, the applicability of our respective opera- 
tions in the face of obstacles regarded by him as insurmounta- 
ble, excepting by his expedient of kolpokleisis. 
“In Vienna three similar cases have been presented to me 
for operation by Professor Karl Braun, admitting only, accord- 
ing to his view, of kolpokleisis; and a fourth, thought by him 
to be incurable by any known method, owing to the complica- 
tion of a large recto-vaginal fistule situated twelve centimetres 
from the anus. Suffice it to say for the present, that in all of 
these cases I adhered to my standard of cure; namely, the coap- 
tation of the fistulous edges and preservation of all the func- 
tions of the organs involved. 
“ I hope soon to present my views upon this subject in a more 
extended form, and as the question at issue relates to the partial 
or complete unsexing of 30 per cent, at least of all sufferers 
from vesico-vaginal fistule, its importance, in a practical point 
of view, can not be over-estimated, and well deserves the serious 
attention of the Profession at large. * * * * 
“ Very respectfully, 
“Vienna, July, 1875 
“ Nathan Bozeman. 
C. A Description entitled “ Bozeman's Method of Operating 
for Vesieo- Vaginal Fistule, with a Report of Four Cases Op- 
erated upon hy him in the Clinic of Professor Karl von Braun. 
By Dr. Ludwig Bandl, Surgeon, Clinical Assistant and Lec- 
turer on Obstetrics and Gynceeology in the University of 
Vienna" (“Wiener Medizinische Wochenschrift,” Nos. 49- 
52, 1875).—It is proper to remark before presenting Dr. Bandl’s 
description of my operation, with details of cases, that my visit 
to Vienna took place about four months after the conclusion of 
the concour by Professor Simon and myself, and that three of VESICO-VAGINAL FISTULE. 
the four cases reported here by Dr. Bandl were only passed over 
to me for treatment by Professor Braun when found incurable 
by his method and the question as to the necessity of kolpokleisis 
arose. 
In presenting this report of Dr. Bandl, I propose to shorten 
it as far as consistent with his main object; namely, to furnish 
a complete description of my operation, and to show wherein it 
differed from that of Professor Simon. Therefore, the greater 
part of his historical sketch of the subject as relates to the 
labors of Professor Simon and other surgeons I will here omit, 
retaining only that which appertains to my own. This course, 
is fully justified on the grounds that the facts sought to 
be brought out are intended to show whether Professor Simon’s 
theory of kolpokleisis or my condemnation of it is correct. 
Professor Simon having in his report of our joint operations 
made prominent all the important points of his individual 
labors, renders it unnecessary for me to report them here. I 
will therefore simply introduce in this, my reply, Dr. Bandl’s 
report as relates to me, and my views upon the question in- 
volved. After referring to the importance of the labors of 
Deiffenbach, Wutzer, Jobert (de Lambolle), Mittauer, Hay- 
ward, Sims, Simon, Emmet, Ulrich, Neugebauer, and Braun, as 
directed to the improvement of the operation for vesico-vaginal 
fistule, Dr. Bandl continues in the following strain: 
Translation.—Among the first, the most effective and inde- 
fatigable advocates of this operation is Bozeman, who, in 1856,* 
published his first report of four cases cured by means of an 
original suture designed by himself. This was followed in 1857 
by another communication containing a report of fifteen success- 
ful cases, mostly of a difficult nature, and also suggesting further 
improvements in the method of operating. In order to advocate 
and make known his method, he did not hesitate (1858) to cross 
* Bozeman. Remarks on vesico-vaginal fistula, Montgomery, Alabama, 
(from the Louisville Review) May, 1856. Drethro-vaginal and vesico-vaginal 
fistules, North American Medical Chir. Review for July and November, 
1857. Urethro-vaginal, vesico-vaginal, and recto-vaginal fistules, New 
Orleans Medical and Surgical Journal for January, March and May, 1860. 
Vide also Bozeman’s operation, reported by Robert, of Paris, in the Gazette 
des Hdp., 1859, No. 1. VESICOVAGINAL PISTULE. 
the ocean, the results of which journey he published in 1860, 
having performed a number of most successful operations in 
London, Edinburgh, Glasgow, and Paris, in the presence of the 
leading specialists of these cities. During his present trip he 
visited Heidelberg, where he operated several times in Professor 
Simon’s clinic with his usual skill and the full approval of 
Professor Simon. Thence he proceeded to Vienna, where Pro- 
fessor v. Braun turned over to him for surgical treatment three 
of the most difficult cases, and a fourth of a more favorable 
nature. For three months this indefatigable and benevolent 
surgeon remained in Vienna merely for this purpose, and suc- 
ceeded in giving complete relief to four unhappy and miserable 
women, operating once in each case. I became thoroughly 
acquainted with his mode of procedure, and I believe that a 
publication of his method and of the four successful cases treated 
by him will best express the great thanks due him on my 
behalf as well as of the four patients. After this short retro- 
spect, I shall now proceed to describe Bozeman’s method of 
operating for vesico-vaginal fistule. 
In my opinion the great assurance of success lies in the 
preparatory treatment, the importance of which Bozeman * was 
among the first to discern and point out. Ernmet, the distin- 
guished surgeon of the New York State Woman’s Hospital, 
whose record of successful operations is very large, justly says 
that the whole secret of success depends upon it, and that the 
most skillfully-performed operation will fail if no attention is 
paid to it. He enlarges the vagina with glass plugs, as em- 
ployed by Sims. Bozeman himself lays the greatest stress upon 
it, and he frequently says; “Not to perform, but to prepare 
for the operation is often difficult.” 
The difference in his practice lies not merely in the incisions 
made by other surgeons for rendering accessible inaccessible 
* The leading idea of this systematic dilatation is already contained in 
Bozeman’s first article of 1856, where he describes how in Case 11, by intro- 
ducing bags of oiled silk stuffed with bits of sponge (tampons), by frequent 
incisions of cicatricial bridles, he succeeded in completely dilating an oblit- 
erated vagina after a few weeks, and, closing successfully two fistules, each at 
one operation. VESICO-VAGINAL FISTULE. 
53 
fistules distorted by cicatricial tissue, nor in amply dilating 
agglutinated places, as done by many, among others by Ulrich, 
with Indian rubber bougies; but he insists that the united 
wound, during the healing stage, must be exposed as little as 
possible to the strain brought to bear upon it by the surround- 
ing and retracting tissues. He ascribes to the omission of 
attending to this circumstance a large number of operative fail- 
ures in apparently uncomplicated fistules, which can only be 
avoided by careful exploration with the eye and finger, and by 
division of each cicatricial band and of each tract of thickened 
tissue. A thin cicatricial band, almost invisible, may cause 
the operation to fail. The importance of this exploration became 
especially evident in his first case here, where a cicatrix in the 
vicinity of the point of insertion of a suture was certainly the 
cause of a suture opening and remaining, as predicted exactly 
by Bozeman at the time of his operation. 
From what I have seen during Bozeman’s sojourn of three 
months of his preparatory treatment,* I am convinced of its 
great value; I saw that it made success sure; the vagina be- 
comes more accessible, and when the fistule is situated high up, 
no pulling down of the uterus is necessary. This method also 
renders it possible to unite fistulous edges which, heretofore, it 
was believed could be treated successfully only by diagonal or 
transverse obliteration of the vagina (kolpokleisis). 
The beginning of the procedure is, to pay attention to excoria- 
tions and abrasions of the vagina and of the external genital 
organs. He cuts off the hair found in the posterior vaginal 
angle, which is usually encrusted with deposits of urinary salts, 
greatly irritating the excoriated surfaces and causing great dis- 
tress to the patient. After this is carefully done, a solution of 
argenti nitras 5i to Si of water (grms. 4 to water grms. 16) is 
applied to all the abraded points inside and outside the vagina. 
By these means the woman is freed from pain, and soon her 
confidence is gained, which is absolutely necessary, especially if 
the treatment is to be protracted. At the same time during 
*ln mentioning the term “preparatory treatment,” Dr. Bandl always refers 
to Dr. Bozeman’s gradual dilatation of the vagina previous to the operation. 
Translator). 54 
VESICO-VAGINAL FISTULE. 
the first examination resisting cicatricial bands are divided and 
the vagina dilated as far as possible with the fingers. After 
this, dilators of gradually-increased sizes are kept constantly 
in the vagina. The latter consist of balls and cylinders of hard 
rubber. Seven-eighths of these, increasing in size from three- 
tenths to five-tenths millimetre, are sufficient for most cases. 
Both balls and cylinders are perforated near the surface or end, 
and a string is passed through, tied in a loop to facilitate re- 
moval from the vagina. According to the vaginal dimensions, 
therefore, a cylinder is inserted and allowed to remain from 
ten to twelve hours. It is then withdrawn and the vagina 
flushed thoroughly with tepid or cold water, or the woman is 
placed into a hip-bath to recover from this first proceeding. 
Already after three or four days one is surprised at the effect 
produced by this treatment; the hard dilator, firmly encircled 
everywhere by the surrounding walls of the vagina, softens the 
tissues; cicatricial bands, heretofore unperceived, are recognized; 
and last, but not least, the bladder, which had previously pro- 
jected outside the vulva in consequence of the great deficiency 
existing in the posterior vesical wall, is now found to have re- 
sumed its proper place, when the patient is placed in the knee- 
elbow position. Superficial incisions are afterwards made when- 
ever any resistance is found in the vagina and is likely to cause 
obstruction, and a dilator of larger size, either ball or cylinder, 
is introduced. The woman soon becomes accustomed to this 
procedure; she even bears it gladly, for she is enabled now to 
remain in bed for hours in a dry condition. While thus treated 
she can easily attend to her household duties if she chooses, and 
also enjoy comfortable nights. After persisting in this course 
from three to five days, or even a longer time, the vagina, pre- 
viously hardened and stiffened by cicatricial tissue, becomes soft 
and enlarged, while the edges of the fistule are clearly visible. 
Only an eye-witness, who has seen this preparatory treatment 
and been present at the operation itself, is able to appreciate the 
great importance of this systematic dilatation for the purpose of 
obtaining a perfect and clear knowledge of even the most com- 
plicated cases, although it can be partially understood even by 
the report of the four cases made at the end of this article. VESICOVAGINAL FISTULE. 
55 
Cases II and IV especially prove the remarkable success of 
systematic dilatation; for by this method alone was it possible to 
effect a cure and preserve the natural functions of the organs 
involved, while otherwise it would have been necessary to sew 
the uterus into the bladder or to make diagonal or transverse 
obliteration of the vagina (kolpokleisis). For in the second 
case it required three weeks of preparatory treatment to ren- 
der the upper border of the fistule sufficiently movable to 
get the two edges together. In the fourth case many weeks of 
careful and painstaking preparation were required, until it could 
be ascertained that it was possible to unite the fistulous edges, 
and thus avoid the usual expedient of enclosing the uterus 
in the bladder. 
From my experience concerning cases prepared in this man- 
ner, previous to the operation, I am convinced that the system- 
atic dilatation of the vagina increases the chances for a successful 
operation, in whatever manner it may be performed, whether 
the edges are freshened and united after Simon’s or Sims’ 
method. Professor von Braun also highly appreciates the 
great advantages of this preparatory treatment, and has adopted 
the entire method for his operations. 
Already during this preparatory treatment the patients are 
accustomed to the position in which they are placed by Bozeman 
during the operation. It differs materially from the position 
which other well-known specialists cause the patient to assume. 
Thus Simon operates in the exaggerated lithotomy position 
(Steiss-Euckenlage); Baker Brown and Ulrich recommend the 
one commonly used for stone in the bladder, while Sims and 
Emmet have adopted the left lateral. Bozeman, however 
fastens his patients upon a support or chair designed by himself 
for operations on the sexual organs; it weighs only seventeen 
pounds, and was brought over from America by himself, together 
with all his instruments. It can be placed upon and secured 
to any small-sized table, and by fastening the patient upon it in 
the knee-chest position, it renders the operator entirely inde- 
pendent of the patient’s movements. The abdominal muscles 
are relaxed, the vagina is widely opened, respiration and circu- 
lation are in no wise disturbed, while the patient can be kept 56 
VESICOVAGINAL FISTULE. 
under the influence of chloroform for any length of time as well 
as in any other position; neither does vomiting disturb the pro- 
gress of the operation to any unpleasant extent. 
In the four cases operated on by Bozeman in the General 
Hospital here, this table proved to be a perfect success. It is 
hardly possible to give the reader a clear idea by merely describ- 
ing it. I add a drawing (figure 1), which shows how the 
Figure 1. 
apparatus is attached to a common table A B, by clamps C 
G, and how the patient is securely fastened to it. Its length is 
ninety-five centimetres and the width forty-seven centimetres. 
Bozeman’s entire method also needs but very little assistance 
during the operation. This desire induced several surgeons to 
devise certain contrivances whereby the speculum could be 
kept securely in its proper position without requiring the aid 
of an assistant. Thus Spencer Wells is reported to have per- 
formed several operations without any assistance whatsoever by 
employing Sims’ speculum,* modified by Foveantin such a man- 
ner.as to connect it with a plate attached to the sacral region. I 
have myself assisted in several operations where this modified 
speculum was used, but I was obliged to pay so much attention 
to the sacral plate that I should have almost preferred Sims’ 
beak with Simon’s handle. Emmetf attached a similar plate 
* Marion Sims, Gebarmutter Chirurgie, page 18, Deutsch von Beigel. 
f Emmett, page 25. VESICOVAGINAL FISTULE. 
57 
to a two-bladed speculum, with the remark, however, that it 
does not always answer its purpose as well as Sims’ speculum. 
In the apparatus designed by Ulrich and Neugebauer the 
speculum is fixed by more complicated contrivances. 
Bozeman’s table already dispenses with any assistance for 
fixing the body of the patient; neither does his two or rather 
three-bladed speculum require an assistant, as it remains at- 
tached to the anterior vaginal wall as soon as the blades are 
expanded by the turning of a screw. His first communication 
concerning his speculum appeared in the “New York Medical 
Record,” January, 1868. The drawings of bis table and spec- 
ulum are contained in his article published in 1869.* It fully 
serves its purpose in every case in which the vagina had been 
completely dilated. I lay 
especial stress,upon this 
circumstance, and I know 
of no other similar two- 
bladed speculum which 
equals Bozeman’s in use- 
fulness. For it enables 
the surgeon to minutely 
examine and to perform 
every operation on the 
cervix and vagina in 
whatever position the'pa- 
tienFmay be placed, and 
without much assistance. 
Bozeman employs four 
different sizes, according to the capacity of the vagina”, making 
it a general rule, “ the larger the fistula , the smaller the 
speculum.” 
The drawing (figure 2) gives one-third size and three-fourths 
view of the medium-sized speculum; it is opened almost entirely, 
while the dotted lines show where the third blade is attached. B 
shows the under surface of the third blade when inserted into the 
vagina and slid under the projecting arches c and d, and there 
Figure 2. 
* Bozeman. Operation of vesico-vaginal fistula without the aid of assistants. 
From “New York Medical Journal,” February, 1869. 58 
VESICO-VAGINAL FISTULE. 
fastened. It must, however, be admitted that the use of the third 
„.blade is not always practicable; in several operations Bozeman, 
instead of using it, caused the posterior wall of the vagina to be 
raised by means of spatulse of various shapes and sizes. The 
two-bladed speculum, however, is still the best adapted and most 
useful. Bozeman employed in his four operations only two 
assistants, one to attend to the chloroform, and another to hand 
the instruments. The latter, however, could be dispensed with 
on a pinch. The method of paring the fistulous edge does not 
differ in any way from that used by Professor Simon, as demon- 
strated in his work published in 1862 (page 53), and also 
approved of by Ulrich, of Vienna. Bozeman has freshened for 
a number of years, leaving either perpendicular or steep funnel- 
shaped borders through the entire thickness of the vesico- 
vaginal wall; nor, when it seems proper, does he hesitate to pare 
the mucous membrane of the bladder. He specially avoids the 
flat, funnel-shaped freshening, as this affects principally the 
vaginal surface, and is now but rarely advocated by anybody 
(except by Sims and his followers). In cutting the edges of the 
fistule and applying the sutures, Bozeman does not pull down 
the uterus (as first recommended by Jobert and afterwards 
adopted by Simon), even when the seat of operation is in the 
upper part of the vagina. Simon uses for this purpose first 
Museux’a forceps, and then applies a noose in order to dispense 
with the forceps and gain more room. Ulrich invented special 
double hooks to accomplish the same end. 
For paring the edges Bozeman employs knives with a long 
handle of various forms and sizes; some straight, some bent at 
an obtuse angle with the cutting edge to the right and left side. 
He also uses two pairs of scissors to be employed to the right 
and left respectively; they serve principally the purpose of form- 
ing the angles. For steadying the edges small hooks are used; 
one bent at a right angle is more suitable for the upper, while 
a crooked hook is used for the lower margin. 
In the first and third cases, where the deficiency was com- 
paratively slight, he seized the anterior edge with the crooked 
hook, and with two strokes of the knife circumcised the entire 
edge of the fistule. In the second and fourth cases, where a VESICO-VAGINAL FISTULE. 
59 
large deficiency existed, Tie pared the lower edge with the knife, 
the upper one with the knife and scissors, and for forming the 
angles, the right and left-cutting scissors were employed. 
In his article of 1857 he directed attention to the ureters 
opening into the upper edge of the fistule, where a considerable 
deficiency existed, and he had already at that time divided, in 
one case, the ureters towards the bladder one centimetre with 
a slender crooked knife, thus insuring their opening into the 
bladder after the wound was united. Simon also directed atten- 
tion to this circumstance. He found, down to the year 1868, 
the ureters embedded four times in the edge of the fistule; 
he incised it once. Simon knows of no case in which occlu- 
sion caused any particular symptoms during life, but Boze- 
man warns the operator against this danger while closing 
the wound, as he is convinced that the operation might 
fail on this account (see Case II), In paring the root of the 
urethra he pays great attention to forming a smooth surface. 
Any bleeding during and after the cutting is carefully stopped 
by injections of cold water. 
The suture employed by Bozeman for uniting the edges is 
quite peculiar (the button suture), and he, like Sims, prefers 
silver wire in its construction; but while Sims has abandoned 
his clamp suture, which he recommended in 1852, and now 
simply twists the wire, Bozeman still adheres to his suture, as 
first described by him in 1856, without any change, in spite of 
the many attacks made upon it. After the wires are passed 
through the borders of the wound he fastens them, by means of 
small perforated shot, to a perforated plate of lead, which rests 
upon and is closely adapted to the united borders with a con- 
cave surface. He seems to me, and justly too, to lay more 
stress upon the concave lead plate keeping the united edges 
safely and securely together than upon the employment of silver 
wire ; be merely uses this because it can be fastened more con- 
veniently to the lead plate than silk threads. 
I will describe the application of the suture apparatus as it 
occurred in Case I, where only two sutures were employed. In 
every case Bozeman uses straight, spear-pointed needles of vari- 
ous lengths. He prefers the straight to the crooked needles, as 60 
VESIGO-VAGINAL FISTULE. 
they can be passed through the edges easier and more safely. 
Only in extraordinary cases is the crooked needle made use of. 
The silver wires are very thick and well annealed, and about 
forty centimetres long. The bent end of the wire is connected 
with a silk thread previously passed through the margins of 
the wound, and then made to take the place of the latter. In 
order to prevent any traction upon the tissue, a small fork is 
used for keeping the wire in the right direction. The wires are 
thus drawn into place without injury to the tissue. 
The sutures are inserted about one centimetre from the edges 
of the wound; they perforate the entire thickness of the vesico- 
vaginal wall, leaving out only the mucous membrane of the 
bladder. The sutures are distant from each other usually one 
centimetre. After all the sutures have been inserted, and, upon 
examination, the raw surfaces are found to touch each other 
closely (wires seem to me to be better adapted than silk) the 
wires are passed through a little hole (a, figure 3) and thus 
adjusted. By pressing the instru- 
ment (suture adjuster) close to the 
surface of the wound and then tight- 
ening the sutures in succession, com- 
plete coaptation of the edges of the 
fistule is effected. Next a plate of 
lead, one mm. thick, is cut to a proper 
form and length, perforated by holes 
corresponding to the sutures, and 
finally pressed into a concave shape with a suitable forceps. 
The wires are passed through the holes of the plate, as 
shown by figure 4, and then pressed with its concave surface 
firmly upon the united wound by the above- 
described fork. The blood oozing from the 
wound through the holes of the plate shows 
how firmly its borders are pressed together. 
In order to make complete union perfectly 
sure, the plate is lifted once more, when it 
will be seen that the edges of the wound are 
closely united, and that the plate prevents any 
traction of the surrounding tissue. Figure 5 shows a transverse 
Figure 3. 
Figure 4. YESICO-VAGINAL FISTULE. 
61 
section of a finished suture, a h the united edges, c the plate 
fastened by means of a silver wire and a small compressed shot* 
Here the two ends of the wire are seen cut off and bent over 
the side of the shot. 
The shape and size of the plate de- 
pends upon the shape assumed by the 
edges after being united by the wires. 
The latter sometimes do not lie in a 
straight plane, but are convex or undu- 
lating. The plate in this event must be cut or bent in a 
manner to correspond to the line of adjusted sutures, other- 
wise derangement of the united edges of the fistule is liable to 
occur. This circumstance had to be taken into consideration 
in the second, third and fourth cases. 
In 1857 Bozeman published some cases which, previous to 
the preparatory treatment, he himself believed to be incurable, 
except by occlusion of the vagina, yet he finally succeeded in 
successfully uniting the fistulous edges. In the same article 
minute directions are given concerning the refreshment of the 
edges of the fistule and the shape of the plate in cases where 
the cervix uteri or the urethra is involved; and also where the 
united edges do not form a straight line, but run in a curved, 
angular or undulating direction. The directions prove the ex- 
traordinary care taken by Bozeman to preserve and improve 
every possible chance to bring about union by the first inten- 
tion, and to make the first operation successful without the 
necessity of repeating it. 
Union was accomplished in all the four cases here reported 
in a straight line in a more or less transverse direction. This 
will certainly be possible in most cases, provided the prepara- 
tory treatment is persisted in. As the edges can be united 
more securely in a straight line than under several angles, the 
chances of success are greatly insured and the value of the en- 
tire method is proportionately enhanced. 
I have now merely to add that Bozeman always introduces a 
catheter into the urethra whenever there is a large-sized fistule, 
in order to determine the relations of the canal to the anterior 
border of the fistule on either side, since the sutures are applied 
Figure 5. 62 
VESICOVAGINAL FISTULE. 
in accordance with these relations. Great attention is also paid 
to the situation of the ureters in the excised surfaces, so as to 
prevent their being included in the sutures. In order to secure 
the opening of both towards the bladder, I saw him slit the cut 
ends and apply the wires rather close on either side. 
As soon as the sutures are completed, the bladder is cleaned 
from blood with cold water. Bozeman’s suture has been imi- 
tated by many, especially in England, Scotland and France. 
Baker Brown* already, in 1858, had operated on and published 
ten cases of fistule, varying in size, position and difficulty, 
according to Bozeman’s method. This article is prefaced by a 
dedication to Bozeman, rendering justice to and freely acknowl- 
edging the superiority of his method. In Austria and Ger- 
many, however, Bozeman’s method, until recently, was but little 
known. Neither has Professor Simon abandoned bis method of 
operating. Ido not presume, to decide upon the relative merits 
of these two methods, whether the one or the other succeeds 
better in causing a union of the fistulous edges; an experience 
of twenty years has caused each surgeon to adhere rigidly to 
bis own method. Neither do I know Professor Simon’s present 
opinion after having seen Bozeman operate and having noticed 
the results. Bozeman remained seven weeks in Heidelberg, 
operating on several fistules in the presence of Simon and 
Koeberle, the latter having come from Sirassburg for this 
special purpose. I find in an article published by Bozeman in 
the “New York Medical Eecord,” July, 1875, that Professor 
Simon frankly admits the superiority of his operation in all 
cases where the fistule is situated in the upper portion of the 
vagina. Whether Simon refers principally to the suture, lam 
unable to say, but he evidently places great value upon the gen- 
eral method of operating, since be has ordered Bozeman’s in- 
struments and operating chair to be copied. 
Bozeman’s four operations have convinced me that his (but- 
ton) suture greatly insures a cure by the first intention, though 
at his first operation, when only a small fistule had to be united, 
* Baker Brown on Vesico-Vaginal Fistula and its Successful Treatment. 
Read before the British Medical Association at Edinburgh, July 31. London, 
1858. VESICOVAGINAL EISTULE. 
63 
I did not appreciate its value so much as I did afterwards in 
witnessing the results in the second and fourth cases, where the 
lines of union were respectively five and four and a half centi- 
metres long. By his method the borders are kept in close jux- 
taposition during the entire healing process, and perfect union 
takes place. The plate gives rest and support to the fistulous 
edges, keeping them in exactly the same plane in which they 
were united. This plate also protects the wound against ex- 
ternal influences and obnoxious secretions. Bozeman has 
achieved complete success in many cases with long lines of 
union. 
Concerning the after-treatment, Bozeman "rigidly adheres to 
his former opinion with regard to the obnoxious influence of the 
urine on the united borders, especially when the fistule is of 
large size. In almost every case he introduced permanently a 
common English, medium-sized elastic catheter, and took great 
pains to prevent its becoming clogged up. In the second and 
fourth cases he came himself several times during the day to 
examine and clean the catheter. On his departure from Vienna, 
before the fourth case was cured, he entrusted the after-treat- 
ment to my care, with the strict injunction to attend carefully to 
the permeability of the catheter, and not to remove the sutures 
too late. Emmet, like Bozeman, also adheres to the use of a 
catheter, though he employs in his cases the one (metallic) de- 
signed by Marion Sims, which he allows to remain in the blad- 
der until the sutures are removed. Both have achieved great 
success at the first operation. 
Simon, however, declares in his article of 1862 that it is un- 
necessary, and even obnoxious, to leave the catheter permanently 
in the bladder. Ulrich also agrees with him, and both allow 
the normal function of the bladder to be performed immediately 
after the operation for closure of the fistule. I, myself, have 
seen a number of operations performed on fistules with perfect 
success without the use of the permanent catheter. Which 
plan, then, promotes a cure with greater certainty? 
Bozeman, after his acquaintance with Simon, seems to have 
somewhat modified his opinion concerning the use of the per- 
manent catheter. In his third case here, where a small fistule 64 
VESICO-VAGINAL FISTULE. 
was united without causing any tension, no catheter was in- 
serted, the urine merely being drawn off every four , hours. 
This proves that Bozeman has abated his idea, heretofore rigidly 
adhered to, of always keeping a catheter in the bladder; no 
longer considering it absolutely necessary in small-sized fistules, 
when the capacity of the bladder is greater and the mechani- 
cal action of the urine of less importance. Where, however, 
the fistule is of long standing and there is a long line of union, 
the capacity of the bladder is lessened, and he still employs the 
permanent catheter. This modified view of Bozeman is proba- 
bly due to the personal influence of Simon, and I believe that 
the acquaintance of these two masters with each other will 
greatly promote the operation for vesico-vaginal fistule. During 
the first days after the operation opium is ordered by Bozeman. 
The sutures were removed in each case on the seventh day 
after the operation. This was easily done; after seizing success- 
ively the small shot with a pair of bent forceps, the wires are 
cut beneath with a pair of long-curved scissors, the plate is 
removed and the suture loops opened and drawn out of the 
wound. 
Case I.— Three Vesico- Vaginal Fistules of the size of Hemp- 
seed of Eight Months' Standing— Vagina in its upper third con- 
tracted by firm cicatricial tissue to a diameter of three centi- 
metres—Cure after the first operation.—A. S., primipara, twenty 
years old, a strongly-built and good-looking woman, admitted 
May 14, 1875. She was delivered in Gallicia, after four days 
of labor, by craniotomy. Two weeks after the birth she was 
unable to retain the urine. The patient remained in bed for 
two months on account of sickness. In the third month men- 
struation took place. In the recumbent posture she is able to 
hold the urine for several hours, in the sitting posture for about 
two hours, in walking or standing the urine flows uninter- 
ruptedly. 
May 16th, I tried to bring the fistules into view by means of 
Sims’ and Simon’s speculum, but was prevented from so doing 
by the cicatricial tissue in the upper third of the vagina, espe- 
cially on the right side. All I could see was a funnel three cen- 
timetres wide embedded in the cicatricial tissue, through which VESICO-VAGINAL FISTULE. 
65 
the urine flowed into the vagina. Two centimetres from the 
border of the funnel a small opening was found, through which 
a bent uterine sound could be passed into the bladder. From 
the funnel, on either side, tough cicatricial bands proceeded 
towards the posterior vaginal wall, thus narrowing the lumen 
of the vagina to three centimetres. Bozeman introduced his 
smallest speculum; it passed the most constricted point, and 
now the obstructing cicatricial bands could be seen, without 
enabling us, however, to obtain a clear and complete view of 
the fistule. Bozeman took charge of the case May 21st. After 
having introduced his smallest speculum, he cut the most promi- 
nent scars on either side three to four millimetres deep, using for 
this purpose a slender, long-handled knife. These incisions gave 
a clearer aspect, for now could be seen three fistules of the size 
of hempseed separated from each other by slender tissue bands 
three to four millimetres broad comprised within a space as large 
as a ten-cent silver coin (kreutzer) and one centimetre below the 
junction of the vagina with the cervix uteri. A small, hard 
rubber cylinder was now inserted; the patient was examined 
every third or fourth day, and the scars near the funnel, previ- 
ously described, superficially incised. Balls and cylinders of 
increasing size were then introduced, and a solution of nitrate of 
silver repeatedly applied to every abraded point. After a month 
of preparatory treatment Bozeman believed it to be about the 
proper time to perform the final operation. The vagina was 
now softened and nearly of normal width; the fistules were 
all in one plane. At the lower border of the fistule to the right, 
a cicatrix, although invisible, could be felt, and for the removal 
of this Bozeman would have continued the dilatation longer if 
he had been able to remain in the city. He operated, however, 
but feared that a suture opening would remain and prevent a 
complete union. The operation took place on the 22d day of 
June. After fastening the patient upon his supporting chair 
and placing her under the influence of chloroform, the fistules 
were exposed to view by speculum Ho. 2, with rectal plate. He 
cut through the entire thickness of the vesico-vaginal septum 
with two strokes of the knife, steadying with a small hook the 
portions to be excised. After bleeding had ceased two sutures 66 
VESICOVAGINAL FISTULE. 
were passed through the freshened funnel, now measuring 1.5 
centimetre. Next the borders were adjusted and the wires 
fastened to a small plate of proper shape in the manner de- 
scribed before and shown in figure 4. The concave edge of 
the plate was turned toward the anterior lip of the cervix 
uteri. 
The operation was finished in thirty minutes. A catheter 
was afterwards introduced into the bladder and kept there for 
seven da}?s; on the 25th an intense redness of the skin (scar- 
latina) was observed, especially on the chest and abdomen, with 
high fever. On the 29th, the fever abated and the sutures 
were removed. The fistule was found closed, but some urine, 
however, oozed through a suture opening to the right and below 
the scar previously mentioned, through which a surgical probe 
could be passed. Symptoms of double nephritis appeared 
August 6th, when an examination showed both fistule and 
suture opening to be closed. Still a small quantity of urine 
escaped into the vagina. A subsequent examination revealed 
the existence of a capillary fistule. This was proved by placing 
a small piece of thin linen (Bozeman’s linen test) upon the sus- 
pected spot. By using this method the existence of a small 
invisible fistule can easily be ascertained. The symptoms of 
nephritis soon disappearing and no more urine passing into the 
vagina, the patient was dismissed cured November 16th. 
Case lI.—A Vesico- Vaginal and a Recto- Vaginal Fistule of 
Three Months' Standing, the former of enormous dimensions, the 
latter of the size of a quarter of a dollar, with inversion of the 
Bladder—Cure of the Vesico■ Vaginal Fistule at the first oper- 
ation with the exception of a very small point.—K. C., thirty- 
two years old, of Hungary, admitted June 14, 1875. After 
having borne seven children spontaneously, she was delivered, 
without the use of instruments, of a dead child after four days 
of labor; it seems to have been a face presentation. Upon 
leaving her bed, a week afterward, urine and faeces escaped 
involuntarily. 
The inverted bladder, of the size of a child’s fist, is visible in 
front of the vulva; after replacing it the smallest speculum 
of Sims-Simon was with difficulty introduced, revealing a VESICOVAGINAL EISTULE. 
67 
fistule five centimetres broad with edges four centimetres apart 
longitudinally. Only a partial view of the cervix uteri and 
rectal fistule could be obtained. The upper edge of the fistula 
having been seized with a double hook, an attempt was made 
to puli it down, but it was nearly immovable, the left edge espe- 
cially, where it adhered to the posterior surface of the left 
pelvic bone. 
Bozeman incised, June 26th, a tough cicatrix running in the 
direction of the sacro-ischiatic ligament and introduced a cylin- 
drical dilator, to be replaced the next day by one of increased 
size. On the fourth day the beneficial effects of this method 
became evident. In the knee-elbow position the bladder 
already no longer protruded, and both fistules could be brought 
into view by introducing the smallest of Bozeman’s specula. 
The rectal fistule, of the size of a quarter of a dollar, became 
visible at the posterior roof of the vagina, surrounded by not 
very tough borders. As a most important circumstance, the 
upper edge of the urinary fistule was now somewhat movable. 
We measured the force necessary to bring in contact the upper 
with the lower edge by inserting two double hooks in the cervix 
uteri and attaching them to spring-scales. For accomplishing 
this purpose, 2,800 grammes, nearly six pounds, were found to 
be necessary. Dilatation with cylinders of increasing size was 
continued. The abraded spots were touched with a solution of 
nitrate of silver. 
July 13th, Bozeman concluded that the propor time for oper- 
ating had arrived. The patient was secured upon his sup- 
porting chair, chloroform administered, and the urinary fistule 
exposed to view in a splendid manner by the introduction of 
speculum No. 1, with the rectal blade. Professor Billroth, G. 
Brown, Karl v. Braun, Spath, and many other physicians 
were present. The spring-scales showed that now only 120 
grammes were necessary to approach the upper to the lower 
edge. The fistulous borders were stretched out smoothly, and 
the distance from the mouth of the urethra to the lower border 
of the fistule was 3.5 centimetres, from the upper border to the 
insertion of the vagina two centimetres, and from the lower 
border of the rectal fistule to the posterior angle of the vagina 68 
VESICO-VAGINAL FISTULE, 
or fourchette 11.5 centimetres. The opening of the right ureter 
could now be plainly perceived at the upper edge, urine flowed 
from it and a surgical sound was passed up for several centi- 
metres. Nothing was seen of the left ureter. The rest of the 
vagina was soft and wide with the exception of a small portion 
towards the left angle, which was still somewhat hardened. 
Freshening with the knife and scissors was tedious on account 
of the large size of the fistule. Only a very small amount of 
tissue could be spared for this purpose, and in order to econo- 
mize the latter as much as possible, the knife was passed through 
the entire thickness of the vesico-vaginal wall in front, and then 
the required strip was shaved off carefully all around the entire 
circumference. Before applying the sutures a catheter was 
inserted into the urethra in order to determine its exact relation 
to the freshened anterior border; the greater portion of this 
was found situated to the right side of the urethra. Before 
uniting the edges of the fistule, Bozeman slit open the right 
ureter with the vesical mucous membrane about one centimetre, 
in order to insure the uninterrupted flow of urine into the blad- 
der. After nine sutures had been introduced, five to the right 
and four to the left side of the urethra, and adjusted in the 
manner described, it was found how free from fault the union 
of the edges (one centimetre in thickness) had been made. The 
line of union was concave upwards; it did not, however, run in 
an even, but rather in an undulating plane. 
In accordance with this 
circumstance Bozeman 
shaped the plate in such 
a manner as to make it 
conform exactly with the 
undulating plane, thus se- 
curing in an admirable 
manner a close and exact 
union of the two raw sur- 
faces. 
Figure 6 shows the general form of the plate as viewed upon 
the upper surface, and the relation of it to the catheter sup- 
posed to be lodged in the urethra. The line below indicates the 
curvature upon the concave surface. 
Figure 6. VESICO-VAGINAL FISTULE. 
69 
A catheter was kept permanently in the bladder. After the 
operation feeble pains occurred, lasting, however, but one day. 
The patient was without fever, and remained dry until the fifth 
day, when a small quantity of urine escaped into the vagina, 
July 20, Bozeman proceeded to remove the wires, remarking, 
at the same time, that he would be satisfied if there was union 
only to the extent of five sutures. To our great surprise, how- 
ever, the fistule was found almost completely closed; only a small 
opening remained between the seventh and eighth sutures on 
the left side, through which a surgeon’s probe could be passed 
into the bladder. Bozeman ascribed the partial failure to the 
probable obstruction of the left ureter within the united edges 
of the fistule. The patient retained the catheter five days longer, 
when she was allowed to hold the urine for one-half to three- 
quarters of an hour, and to discharge it spontaneously. Boze- 
man said, in view of the hot weather and the necessity of 
further preparatory treatment, that closure of the small remain- 
ing opening and the rectal fistule should not be undertaken for 
three months; so the patient was sent home for the present after 
the small opening had been twice cauterized. 
Case lll.—Fistule as large as a bean, three centimetres 
distant from the Cervix Uteri, of Seven Months' Standing—Cure 
at the first operation.—Mina S., a healthy-looking woman, thir- 
ty-five years of age, was admitted May 18, 1875. Has had 
twelve children, four of which, however, after a tedious labor, 
were still-born. The last confinement took place seven months 
ago, when the forceps were employed and labor terminated after 
forty-eight hours’ duration. The pelvis measured in the antero- 
posterior diameter 9.5 centimetres. The patient was able to 
retain the urine for hours while lying on her back, but on her 
arising it escaped immediately. Since her last confinement 
menstruation has twice taken place; then it ceased for two 
months with symptoms of pregnancy. Thi’ee previous opera- 
tions were attempted for closure of the fistule, without giving 
her any relief. Five days after the second operation a two- 
months’ ovum was expelled, it having been destroyed by the 
exudation of blood within the decidua. 
July 13, Bozeman explored the fistule with speculum Ho. 4 70 
VESICO-VAGINAL FISTULE. 
and corresponding rectal plate. The fistule was as large as a 
bean, situated a little to the right of the median line at a dis- 
tance of three centimetres from the cervix uteri. The borders 
of the fistule and surrounding tissue seemed at first sight to be 
normal, but on closer examination a cicatrix could be seen and 
slightly felt running in a transverse direction just below the 
fistule. Bozeman introduced the largest cylindrical dilator into 
the rather large vagina, but finding simple dilatation insuffi- 
cient, he incised the cicatrix after two days and continued the 
dilatation. 
On the 21st he again, in the 
presence of Professor Salzer, ex- 
plored the vagina with speculum 
.No. 3, when the cicatrix could 
be neither seen nor felt. He then 
rapidly freshened the edges, some- 
what less steep and a little further 
from the fistulous border than 
in his previous operations, as is also done by Simon whenever 
there is an uncomplicated vesico-vaginal fistula. He then 
closed the fistule with five wire sutures and a plate of the 
shape and size as shown in figure 7. The borders of the ap- 
proximated wound, measuring nearly four centimetres, were 
thus united as closely as could be wished, and the success of the 
operation seemed to be fully insured. The line of union pre- 
sented, together with the neighboring tissue, a slight depression. 
Bozeman shaped the plate so as to conform exactly to this de- 
pression (see figure 7). The united edges extended not in a 
transverse but in a diagonal direction, the left angle pointing 
upwards, consequently the plate also assumed a diagonal posi- 
tion. 
Por the first three days the catheter was worn, but on the 
fourth the patient was allowed to pass the urine spontaneously. 
July 28, Bozeman having left Vienna, I removed the sutures in 
the presence of Professor v. Braun, and found that a complete 
cure was the result. The patient could now hold and pass the 
urine naturally. Only slight symptoms of catarrh of the bladder 
were present. She left for her home August 2d cured. 
Figure 7. 71 
VESICO ■ VAGINAL FISTULE. 
Case IV.— Vesico- Vaginal Fistule of Five Months duration 
3.5 centimetres broad, with the edges separated 2.3 centimetres and 
embedded in cicatricial tissue—Prolapse of the right fallopian 
tube into the Vagina caused by the division of a cicatrix invad- 
ing Douglas' Cul-de-sac—Cure at the first operation.—Johanna 
Schmutzer, thirty-four years old, from St. Andrae, was admitted 
May 22, 1877. The patient looks delicate and feeble. Was 
delivered spontaneously, four years ago, for the first time after 
several days’ labor of a dead fully-developed child. Five months 
ago she was again delivered, with forceps, of a dead child at full 
term forty-eight hours after the water broke. On the seventh, 
day after the confinement urine escaped involuntarily. The 
patient has been sick almost ever since. The pelvis is shortened 
to nine centimetres in the antero-posterior diameter. 
An exploration was made by me with the smallest Sims- 
Simon speculum, aided by a spatula. At the distance of 3.5 
centimetres from the meatus urinarius a funnel-shaped depres- 
sion was observed, measuring 4.5 centimetres transversely and 
three centimetres from above downwards, to the bottom of which 
the normal mucous membrane of the vagina continued. 
The entire funnel, especially its right angle, was fixed against 
the anterior pelvic wall. It was sufficiently large to admit the 
passage of two fingers, but it was impossible to examine its en- 
tire depth with the eye. The upper edge of the funnel was 
situated one centimetre from the cervix uteri, whose anterior 
lip, measuring two centimetres, was torn in the median line as 
far as the point of union with the vagina. 
May 28th, Bozeman began the preparatory treatment. He 
incised first the most prominent scars to the right and left, and 
then introduced a cylindrical dilator of suitable size. At the 
same time great relief was afforded the suffering patient by 
cutting off the hair around the vulva and touching the excori- 
ated points with a solution of argent, nitr., as before mentioned. 
The result was astonishing, for the pain had disappeared almost 
entirely on the succeeding day. The woman was now examined 
every other day, and superficial incisions made wherever any 
projecting cicatricial tissue showed itself, followed by dilators of 
increasing size. The latter the patient herself was able to in- 72 
YESICO-VAGINAL FISTULE. 
trodnce and remove. The woman had improved in one week’s 
time so much that she could walk out with but little discomfort, 
especially when wearing the dilating ball, while previously she 
spent her time mostly in bed or in a hip-bath, moaning with 
pain. 
June Bth.—'A tough cicatrix, situated at the upper edge of 
the funnel and running across the posterior vaginal roof, had 
resisted every effort made to dilate and soften it. Bozeman 
nov/ made a deep incision a little to the right of the median 
line, and then introduced the finger for the purpose of ascer- 
taining the yielding character of the sub-lying tissue. The 
latter suddenly gave way, and after withdrawing the finger the 
right fallopian tube was seen to protrude into the vagina to the 
extent of four centimetres. 
This accident did not disturb me much, for I had already 
once before observed the prolapsus of a tube while amputating 
an inverted uterus. When this happened the galvano-caustic 
loop had not yet cut through entirely. On drawing the instru- 
ment back, however, after the amputation of the uterus, one of 
the fallopian tubes was found hanging within the noose, and 
was pulled down to the vulva. It was disengaged and replaced 
with a grooved forceps, and the woman recovered. I may men- 
tion here the interesting fact, that the peritoneal opening caused 
by the amputation was not yet closed four weeks after the oper- 
ation; a sound could be passed up until twenty-four centimetres 
were indicated on the sound. Thus the woman, although with- 
out a uterus, was perhaps for a long time exposed to an extra- 
uterine pregnancy. 
The woman—to return to our case—complained of pain in 
the right abdominal region after the accident referred to. After 
placing her in the knee-elbow position and gently seizing the 
tube with a grooved forceps, we easily returned it to its place, 
when the opening through which it had escaped became visible. 
The wound was two centimetres long and five minims wide. 
As Bozeman had to send for his operating chair and instruments, 
two hours elapsed before closure was effected. After excising 
the ends of the cicatricial band, the wound was closed from 
above downwards with four sutures and a suitable plate, as for VESICO-VAGINAL FISTULE. 
73 
an ordinary fistule. The woman had for several days slight 
pain in the right abdominal region and some fever. On the 
seventh day Bozeman removed the sutures. The entire vagina, 
and especially the wounds caused by the incisions, were lined 
by a croupous exudation, yet the spot covered by the plate pre- 
sented a normal appearance, and the wound was closed com- 
pletely. 
After a rest of three weeks, dilatation was renewed. The 
woman was then, at her own request, sent home for two weeks, 
where she continued dilatation, inserting and removing the 
dilators herself. She returned July 21st, and on the following 
day Bozeman operated in the presence of Professors Dumreicher 
and Braun and several other physicians. 
He fastened the patient in the knee-chest position, ha 4 chlo- 
roform administered, and after inserting speculum No. 2, caused 
the posterior vaginal wall to be raised with a spatula. The 
vagina was soft throughout; the edges of the fistule were plainly 
visible, but their inversion towards the bladder was not yet 
entirely redressed. The fistule measured transversely 3.5 cen- 
timetres. The distance from the meatus urinarius to its lower 
border was 3.5 centimetres, and from the cervix uteri to the 
upper border 1.5 centimetre. One sweep of the knife sufficed 
to freshen the lower edge from the right to the left angle. Parts 
of the vesicular mucous membrane were also removed. In 
paring the upper border some difficulty was encountered. It 
was very thin, necessitating the removal of all the tissue up to 
the cervix uteri; even the anterior lip of the latter had also to 
be freshened. But this was torn along the median line, and 
cicatricial tissue extended from the angle of the cleft. This 
latter circumstance rendered the formation of a smooth and 
even surface difficult. It was, however, skillfully accomplished 
after one and one-half hour’s labor. The lower edge was re- 
freshed vertically; the upper one a little obliquely through the 
entire thickness of tissue. 
The width of the wound thus produced was almost every- 
where one centimetre; only in the middle, which corresponded 
to the termination of the cleft referred to in the anterior cervix 
uteri, was it five centimetres, which point caused us some mis- 74 
VESICOVAGINAL FISTULE. 
givings about the success of the operation. Any other method, 
as by the use of the posterior lip or vaginal wall (kolpokleisis), 
would have destroyed the normal functions of the organs in- 
volved. After the bleeding had ceased, a catheter was intro- 
duced, when the fistule was found to be situated more on 
the right than on the left side. A piece of the root of the 
urethra being found to protrude over the lower freshened 
surface, was removed with scissors. According to the relation 
of the fistule to the catheter in the urethra, three sutures were 
inserted on the right and two on the left side. 
After this was done there were small particles of tissue still 
found to protrude above the upper surface. They were also cut 
off with scissors. On ad- 
justing the refreshed edges, 
it was clearly seen how 
nicely the upper diagonal 
surface was united parallel 
with the lower one, and how 
exact the union must neces- 
sarily be. The plate used 
for fastening the sutures was 
shaped as shown in figure 8, 
and slid down on the wires 
to its proper position. 
Figure 8. 
The place in which the united borders were situated formed 
a depression in the middle of the line, and to make the 
plate conform, it had to be bent in a suitable manner. The 
line of union formed two curves, and the holes in the plate were 
made to correspond. 
The insertion of the sutures and the preparation of the plate 
required three-fourths of an hour. A catheter was kept per- 
manently in the bladder, and the patient remained dry and 
comfortable. 
Bozeman having left Vienna, I removed the sutures July 
29th. They had cut deeply, while the upper edge of the plate 
had caused ulceration to the extent of 2.5 centimetres. This 
proved how the upper edge of the plate protected the united 
wound against the retraction of the surrounding tissue. Per- VESICO-VAGINAL FISTULE. 
76 
feet union had taken place. After keeping the catheter for 
several days longer in the bladder and washing the vagina with 
tepid water, the patient was allowed to leave the bed. After 
this she emptied the bladder spontaneously and remained per- 
fectly well. 
On August 18th, Dr Grtinfeld examined the patient with the 
endoscope. He found on the top of the entire cicatrix a yel- 
lowish-white mucous band 2.3 millimetres broad, and in the 
vicinity of the wound the mucous membrane presented a more 
reddened appearance. This examination caused the woman no 
pain, and she left for her home on the same day. 
Before concluding this article I deem it necessary to remark 
that the preparatory treatment requires the utmost care and 
circumspection, as it is not free from danger, as I have expe- 
rienced myself in several cases. In one case, where the fistule 
existed but two months, and where I incised within ten days, 
there were already several projecting scars. The gradual dila- 
tation progressed satisfactorily, but now symptoms of peritonitis 
appeared, and the whole treatment had to be suspended. It is 
proper to remark, however, that the patient was upon her feet, 
running up and down the stairs all the while, which may 
account for the unexpected result. Profiting by this experi- 
ence, I now proceeded more cautiously. In another case pain 
was felt in the vicinity of the vagina, and I had to resume 
the use of smaller dilators. 
The dangers incidental to the preparatory treatment are 
briefly these: In incising too boldly the peritoneal cavity or 
rectum may be injured. A finger, however, inserted into the 
rectum for guidance may greatly diminish this danger. By 
proceeding too rapidly inflammation of the surrounding tissues, 
as well as of the peritoneum, may follow. It must therefore 
be borne in mind, that in order to secure the best results from 
preparatory treatment in such cases as are here described, time 
is of no consideration.