■ ' X' REMARKS § wit0-^aginal JfiataU, WITH AX ACCOUNT OF A NEW MODE OF SUTURE, SEVEN SUCCESSFUL OPERATIONS. BY J¥. BOZEIM, M. D., OF MONTG(fMERY~ ALA." ! I I* 4-- "-ong^l^l's office)! Mr ^ ^ MONTGOMERY: BAREETT & WIMBISH, BOOK AND JOB PRINTERS. 1856. m, ^5§V;; H C> i REMARKS ON $MW0-$8ght8l JfwtaU, WITH AN ACCOUNT OF A NEW MODE OF SUTURE, SEVEN SUCCESSFUL OPERATIONS, BY IV. BOZE1AH, M. »., OF MONTGOMERY, ALA. —«.- MONTGOMERY: BARRETT & WIMBISH, BOOK AND JOB PRINTERS. 1856. VESICOVAGINAL FISTULE. [From the Louisville Review for May.] It would appear, from the silence of the older authors in regard to vesico-vaginal fistule, that it was a subject to which they paid little or no attention. But it would not be a fair inference from this circumstance, that the affection did not ■ exist, or that its subjects did not apply for medical or surgical aid. The practice of obstetrics was less well understood then than at present; and it is reasonable to suppose that acci- dents resulting in fistule were comparatively more frequent. Surgeons must, therefore, at a very early period, have known something about it; but, being unable to afford the necessary relief, they probably supposed that it would be a waste of words to record anything upon the subject. And, indeed, in turning to the written experience of more modern surgeons, we find that no advance was made toward the proper under- standing and treatment of the disease until within the last quarter of a century. _ It is true, that previous to that time, it had been repeatedly described, and several methods of treatment had been proposed; but the profession manifested but little interest in the former, and the latter proved bene- ficial only in a very few cases. Now, however, there is no subject in surgery with the pathology and symptomatology of which we are better acquainted; and, as I hope to show in the few following pages, there is no disease of equal severity that is more amenable to operative procedure. But, before entering upon the subject, I shall premise a few anatomical considerations, which seem to me necessary to its proper understanding. 4 VESICO-VAGINAL FISTULE. Anatomy.—The base of the bladder, as is well known, rests upon the anterior wall of the vagina, a small quantity of connecting areolar tissue alone intervening. The union of the two constitutes what is called the Yesico-Yaginal Sep- tum, which is composed, therefore, of muscular and erectile tissue, covered upon both surfaces by mucous membrane. The shape of this septum, i. e., the outline of the union of the two walls, resembles, somewhat, the heart upon playing cards, its base presenting upward, the neck of the uterus occupying the notch, and the apex downward and forward, toward the commencement of the urethra. Its area com- prises, usually, about four square inches; and it may be stated here, that a clear knowledge of its shape and extent is oftentimes of the utmost importance in a surgical point of view; for, immediately outside of the limits mentioned, the surfaces of the vagina and bladder are invested with perito- neum, and any operation involving this structure is of course attended with additional risk. Situation, Size, fyc.—The most common situation of the opening constituting vesico-vaginal fistule is usually about the centre of the vesico-vaginal septum; but it may occur at any point: I have met with cases in which it seemed to occupy the extreme border of the septum. The size of the orifice may be no larger than barely to admit a tolerably large probe; but instances are on record in which the whole septum had sloughed away, thus leaving a chasm of enormous dimensions, through which the superior fundus of the bladder protruded, and made its appearance at the vulva, in the form of a large, fleshy-looking tumor. The shape of the fistulous opening is as various as its size and situation, but may be stated, as a general rule, to be oval from above downward, although the long axis is not unfrequently oblique or even transverse in its direction. The number varies from one to several; but I have never met with more than two. Of ten cases that have come under my observation, four were of the double variety, and the remainder single. The presence of more than one fistule is a circumstance of considerable importance in reference to the chances of suc- cessful operation, as I shall presently attempt to show, and it is not a little surprising that writers upon the subject have VESICO-VAGINAL FISTULE. 5 so entirely overlooked this not uncommon complication. It is in cases of this kind that the method of operation which I am about to propose possesses, in my judgment, an advantage unequaled by any procedure heretofore invented. The common causes of vesico-vaginal fistule are impaction of the child's head in the pelvis in protracted labors, and the misuse of forceps in instrumental deliveries; the vesico- vagnial septum in either case being so much injured as to fall into a state of mortification, involving a smaller or larger part of its extent. It is also an occasional result of lithoto- my performed through the vagina; of malignant disease of the neck of the uterus, and of ulceration produced by the presence of a foreign body in the bladder or vagina. Mr. Brown, of London, reports a case which was occasioned by the combined presence of a calculus in the bladder, and the occurence of parturition. The symptoms of the disease are few, but well marked. Dribling of urine from the back part of the vulva coming on within a few days after labor, and producing excoriation of the nates and thighs, with an inability to empty the bladder in the natural way are usually conclusive; but, if any doubt should exist, a resort to a digital or specular examination will readily place the diagnosis upon a positive footing. The prognosis, formerly pronounced to be unfavorable in all cases, may be now stated to be favorable in the great majority—a change which, considering the loathsome and disgusting nature of the malady, cannot but inspire the heart of every truly philanthropic surgeon with just and unbounded pride in his beneficent and noble calling. Treatment.—Until within a few years past, so uniformly unsatisfactory were the results of the treatment of vesico- vaginal fistule, that many surgeons entirely despaired of ever being able to offer the poor afflicted subjects of this malady any hope whatever of permanent relief. But still, from time to time various plans were proposed, some of which proved more or less beneficial, and others again entirely useless. Among the former was cauterization with the hot iron, which having produced a few permanent cures, and mitigated many cases, was a step considerably in advance of the old practice of pronouncing all cases incurable. Indeed, this operation is 6 VESICO-VAGINAL FISTULE. still viewed by many otherwise intelligent surgeons, especially in Europe, as almost the only hope of relief. Among its most strenuous advocates may be mentioned M. Dupuytren and Mr. Liston, who, although now dead, are nevertheless considered as the representatives of modern surgery in the respective countries to which they belonged. That the actual cautery has done much good in many cases cannot be denied; but so uncertain a procedure, even in the hands of such men as the two just mentioned, justly claims but a minor consid- eration in the estimate of those who are fully acquainted with the present resources of the chirurgical art. Succeeding the actual cautery, came the suture, which is said to have been proposed for the relief of the disease about the middle of the seventeenth century by a Dutch surgeon by the name of Roonhuysen. The practice was afterwards adopted by Fatio and Yoelter, but with what success we are not informed; but it certainly could not have been very encouraging, as it soon fell into disuse. About the begin- ning of the present century, however, the suture was revived and, variously modified, has formed the basis of almost every successful mode of treatment that has been practiced both in Europe and this country. In Germany different modes of employing the suture have been from time to time adopted. Wutzer and Dieffenbach are said to have practiced it with the most success. The former is stated by Chelius to have advanced considerably farther than his predecessors by conjoining puncture of the bladder for the purpose of keeping this organ empty, and thus preventing the contact of the urine with the parts under operation. Little or no improvement, I apprehend, has been made upon the operation of these surgeons by their country- men, judging from the recent procedures of Roser, Simon, Teuner and Boeck.* In France the suture has undergone many ingenious modi- fications for the purpose of rendering it more efficient in the treatment of the affection under consideration, and for some of them considerable success is claimed. An account of them, however, would much transgress the limits of this * Amer. Med. Monthly, Aug., 1855. VESICO-VAGINAL FISTULE. 7 paper, and prove at best more curious than useful. Of their general success and the estimate in which they are held, some idea may be had from the following remarks of Yelpeau: " The suture, which must have first suggested itself to the mind, is of such difficult application that but few practioners have ventured to make trial of it, so that scarcely any men- • tion is made of it in the works which have issued from the school of Paris. To abrade the borders of an opening when we do not know where to grasp them, to shut it up by means of needles or thread when we have no point apparently to secure them, to act upon a moveable partition placed between two cavities hidden from our sight, and upon which we can scarcely find any purchase, has appeared to be calculated to have no other result than to cause unnecessary suffering to the patient."* Such is the opinion of the erudite and accomplished sur- geon of the Hopital de la Charite, an opinion derived doubt- less from a careful consideration of all the operative proce- dures that have been suggested or tried in France, Germany, and Great Britain. And the statement of his distinguished cotemporary M. Yidal (de Cassis) is not less discouraging. His words are : " I do not believe that there exists in the science of surgery a well-authenticated complete cure of vesico-vaginal fistule, a fistule due to a loss of substance from the bas-fond of the bladder."t Of the success of the auto- plastic operations devised and practiced by Jobert and Gerdy, we have no positive information. The former sur- geon also operates with the suture, and there is reason to believe that he has met with much more encouraging results than any of his European brethren. Turning now to Great Britain, what do we find has been accomplished there in the treatment of vesico-vaginal fistule ? London surgeons, with all their hospital advantages, until within a very few years past, gave this subject little or no attention. Neither Sir Charles Bell, Sir Astley Cooper, nor Mr. Samuel Cooper have so much as alluded to it, either in their writings or lectures. Mr. Robert Liston devotes to it but one paragraph, and, as it appears, attached more import- * Operative Surgery, Vol. 3. f Pathologie Externe. 2d edit. 8 VESICO-VAGINAL FISTULE. ance to what could not rather than what could be done by the surgeon. " Attempts," says he, " have been made to close the aperture by paring the edges, and then inserting sutures; but this is a proceeding both difficult in execution, and not likely to prove successful. The thinness of the parts, the presence of a secreting surface on each side, and the oozing of acrid urine betwixt the edges, all militate strongly against adhesion. No benefit can be expected from any treatment, unless the opening be of no great size; and, in such cases, the cautery will be found most effectual. * * * By the. cautery I have succeedeed in relieving many, and in curing a few cases."* Druitt, in his " Surgeon's Yade-Mecum," devotes to this and four or five other diseases, together with their treatment, only a single page. The senior surgeon to Guy's Hospital, Mr. Bransby B. Cooper, it seems, has no experience at all with its treatment. He speaks of it as being most difficult of cure: " My colleage, Dr. Dever," he says, '' has had several cases of recto-vaginal and vesico-vaginal fistule, which he has attempted to obliterate by plastic operations and sutures, caustics, and the actual cautery. The result of his experience proves, however, that very few cases are ever permanently cured, although by means of the actual cautery, he has fre- quently reduced the abnormal opening to the size of a pin's head; but I believe that only in one or two cases has he succeeded in producing a permanent cure."t Mr. Erichsen says, that urethro-vaginal fistule, when small, may sometimes be closed by applying the electric cautery or red-hot wire to its edges, once a fortnight or three weeks; but he further remarks "when the fistule is large, and especially when vesical, its cure can be accomplished only by paring the edges, and bringing them together with sutures, and thus attempting to procure union by the first intention. In effect- ing this, however, two difficulties present themselves—the sutures either cutting their way out too soon, or the trickling of urine between the freshly-pared edges interfering with adhesion." Of the various contrivances employed to over- come these difficulties, he recommends the bead sutures of Mr. * Elements of Surgery, t Lectures on Surgery. VESICO-VAGINAL FISTULE. 9 Brooks, and the clamp suture of Dr. J. Marion Sims. " The treatment recommended by Dr. Sims," he observes, "leaves little to be desired in the management of these cases."* Prof. Pirrie, in his recent work on surgery, does not even mention the disease or its treatment. Mr. Brown, surgeon accoucheur to St. Mary's Hospital, has, within the last few years, gone far ahead of any of his cotemporaries, in the management of those diseases of the female requiring surgical interference. His recent work shows that he has devoted much time and attention to the subject. Although his treat- ment of the disease under consideration has not been very successful, yet it has been conducted upon enlightened prin- ciples. As an illustration of the difficulties to be met with in any operative procedure, he gives the details of four cases treated by himself. Two of these were permanently cured; one, by the actual cautery and incision; and the other, by the quill suture. The remaining two were only partially re- lieved by the actual cautery and suture combined. Mr. B. employs the clamp as well as the quill suture. Having thus briefly glanced at the state of surgical science, in reference to the disease in question, in Germany, France and Great Britain, let us turn to our own country, and see what has been done. And here I may state, without the least fear of contradiction, and with no little national pride, that the surgeons of the United States have so far out- stripped their European brethren as to place this horrible complaint, which the latter have declared incurable, upon a par, as regards the probabilities of successful treatment, with accidents of like severity affecting other parts of the body. Drs. Mettauer, of Yirginia; Hayward, of Boston; Pan- coast, of Philadelphia, and J. Marion Sims, late of Mont- gomery, Alabama, but now of New York, are the only surgeons in this country, as far as I am informed, who have paid special attention to the subject of vesico-vaginal fistule; and, in noticing their respective operations, it will suit my purpose to speak somewhat fn detail concerning the different modes of closing the fistulous opening, as herein lies the superior advantages of one operation over another, as I shall presently endeavor to show. * System of Surgery. 10 VESICO-VAGINAL FISTULE. Dr. Mettauer operated for the relief of this malady as early as 1830* His method consisted in paring the edges of the fistulous opening, and maintaining them in contact with inter- rupted sutures made of lead wire. These he carried entirely through the vesico-vaginal septum, at a distance of an inch from the denuded borders. A sufficient number of them having been introduced, the ends of each wire were separately twisted together until firm coaptation of the edges was effected. The twisted extremities were afterwards cut off a short distance exterior to the vulva. On the third day the sutures were tightened by twisting them again ; and about the tenth day they were removed. Such was the original method employed by Dr. Mettauer, and, with but little if any alteration, is the one he still practices. He has performed it quite a number of times, and claims considerable success. Dr. Hayward, without any knowledge of what had been done by Dr. Mettauer. performed his first operation in 1839, and published it the same year.f He has the credit, I believe, of having been the first to operate successfully in this country; but there is no doubt that Dr. Mettauer pre- ceded him by several years, although the latter did not publish his operation until 1847. The peculiarity of Dr. Hayward's procedure consists in the mode of getting at the parts. He first introduces into the bladder, through the uretha, a whalebone bougie, with which, as a lever, the sym- physis pubis serving as a fulcrum, he next brings down the base of the bladder to the vulva, and thereby exposes the fistule fully to view. He then pares the edges of the open- ing, and brings them together by the ordinary interrupted sutures, which, in their introduction, are not allowed to pene- trate the mucous coat of the bladder. The operation being thus completed, and the bougie removed, the bladder is permitted to return to its proper place, and the sutures are allowed to remain until they become detached by ulceration. This is the method now recommended by Dr. Hayward, although formerly he was in the habit of splitting the edges of the fistule, so as to present a more extensive surface for agglutination, and at the same time lessen the chances of piercing the mucous membrane of the bladder in introducing * Virginia Medical and Surgical Journal, f Am. Journal Med. Soiences, VESICO-VAGINAL FISTULE. 11 the sutures. He also directed the bladder to be again depressed after a certain number of days, and the sutures removed. Dr. Hayward has performed his operation twenty times, but with no very great success, having cured, I under- stand, but three cases permanently.* Dr. Pancoast's method consists in adapting the edges of the fistule to each other on the principle of the tongue and groove. The posterior border he splits to the extent of half an inch, and pares the anterior to the shape of a wedge. The former is then made to receive the latter. In this way four raw surfaces are brought in contact, and held in this relation by his plastic suture. How much success Dr. Pancoast has had by this method I am not prepared to state. He reports, in the Medical Examiner, for May, 1847, two cases cured in this manner by himself. Lastly, we come to consider the method of Dr. Sims, a description of which I deem altogether unnecessary ; for, being generally approved by the profession, it is well under- stood by every one interested in such matters. Suffice it to say that the peculiarity, as well as the great advantages of Dr. Sims' method, are to be found in his clamp suture. Considering the comparatively small measure of success obtained by Drs. Mettauer, Hayward and Pancoast, it would be useless to enter into a discussion of their relative merits, as I suppose that no one, in this country at least, will be likely to adopt the method of any one of these gentlemen, with the great advantages of Dr. Sims' method staring them in the face. But it is to the latter that I invite attention, and, however bold or fool-hardy the attempt may appear, I hope to be able to show that the clamp suture has serious objections that may be entirely obviated by the procedure presently to be described. In saying this, however, I do not wish to be understood as attempting to detract from the great credit due from the profession and the public to Dr. Sims for his untiring perseverance in bringing his method to its present high state of perfection. I consider that this gentleman is fully entitled to more than all the praise that has been bestowed upon him, both in America and Europe. To the honor of his professional brethren in this country, it may be * Surgical Reports. 12 VESICO-VAGINAL FISTULE. ' stated that no one has been found who has not gladly accorded to him the high distinction that he at present occupies. I am sorry that the same cannot be said of European surgeons in general, for, with the exception of Mr. Erichsen, Mr. Brown and Mr. Druitt, of London, no one on the other side of the Atlantic has, to my knowledge, proved sufficiently frank to do full justice to Dr. Sims' claims. Fully impressed, therefore, with the importance of the position I assume in attempting to show that the clamp suture is objectionable, I proceed to the task, actuated, as every inquirer after truth should be, by no other motives than a desire to make facts and principles subservient to the great ends of science. In the first place, then, Dr. Sims states that the " clamp suture lies embedded in the tissues for an indefinite period without danger of cutting its way out as do silk ligatures."* This proposition is doubtless true, so far as it implies that the clamp suture is much less liable to cut out than silk ligatures ;: but the question is, does not the clamp suture itself irritate and very often cut out ? Dr. Sims says not. My experience with it, however, has led me to a different conclusion. I have several times seen it ulcerate out, and that, too, within five or six days, thus entirely defeating the object of its appli- cation. When there is much dragging of the parts, this is almost sure to occur. The liability to this accident I have found greatly increased by an indurated condition of the tis- sues, which very often exists on one or both sides of the fistu- lous opening. The ill consequences of the ulceration occa- sioned by one or both clamps are sufficiently evident. Other fistules are in this way liable to be formed, as occurred in a case alluded to by Dr. Mcttauer,t and even if this does not take place, the morbid action may extend to the raw edges of the opening, and thus interfere with the healing process. Gangrene and sloughing of the included parts may take place also when the clamps are applied with too much force. Another objection to the clamp suture consists in the fact that to apply it properly requires more experience than most practitioners of surgery can be supposed to possess. The operator must be able to judge of the condition of the tissues, * Am. Journal Med. Sciences for January, 1652. f Op. Cit. VESICO-VAGINAL FISTULE. 13 whether indurated or not, and whether this condition is con- fined to one or both sides of the fistulous opening. If indu- ration exists, he must know what precautions are to be observed in the arrangement of the clamps, and the dangers resulting from a neglect of these precautions. Many failures, I have no doubt, can be referred to a want of familiar acquaintance with these matters, which, as just stated, is to be gained only by much experience. Another, and the greatest objection to Dr. Sims' method, is the frequent impossibility, in cases of double fistule, of applying two sets of clamps at the same time. This I regard as a consideration of the utmost importance. If two fistu- lous openings are found to exist, and circumstances will allow of but one being closed, failure is almost sure to follow, owing to the escape of urine through the other into the vagina, and its contact with the denuded edges. Still another objection is the impossibility of making the sutures act only in one direction. They have all to be intro- duced exactly alike ; each wire must be entered on the same line, at a proper distance from the edge of the fistule, and brought out in a similar manner, so that when the shot are secured in their places, the same amount of traction, and in the same direction, shall be exerted upon each suture. Unless these precautions be observed, the clamp will not lie easy, and is liable to do injury. Such I conceive to be the most important objections to the clamp suture. There are others of a minor consideration, but they need not be mentioned here. Yery soon after I began to employ this suture in the treat- ment of visico-vaginal fistule, I discovered these faults ; but it was a long time before I could believe but that it was the best and surest plan of procedure that could be adopted. Failure upon failure occurred, when from the favorable nature of the cases such results were not to be expected. Finally a case of double fistule came under my care. The two open- ings were in close proximity, and the long axis of one was at right angles to that of the other, thus precluding the possi- bility of using two sets of clamps at once. Thus circum- stanced, I adopted the only alternative, which was to close one and leave the other for a future operation. Accordingly 14 VESICO-VAGINAL FISTULE. I applied the clamps to the superior aperture, as the peculiar nature of the parts required that this one should be closed in order that a resting place might be formed for one of the clamps in the next operation. On the tenth day, I found upon examination that the apparatus had cut out entirely. The failure I decided to be due to the injurious effects of the urine upon the denuded borders of the fistule, and upon the raw surfaces produced by the pressure of the clamps ; and I became furthermore satisfied that I should never be able to cure the case, unless I could invent some contrivance by which either to close both openings at one operation, or to afford complete protection to the denuded edges of one during the healing process. The thin and raw edges of the fistule when brought together by the clamp suture under such circumstances, are necessarily acted upon by the poisonous urine on both the vesical and vaginal surfaces, union by the first intention being thereby rendered very improbable, even under auspices otherwise most favorable, and in the majority of instances almost clearly impossible. To contrive an appa- ratus that would fulfill one or the other of these indications required, I supposed, much more inventive talent than I pos- sessed; and after a little thought, I abandoned all hope of providing anything that would answer the purpose. Some- time afterwards, however, while buttoning my vest, it occur- red to me that a somewhat similar process might be applied to such cases as the one above cited, and after turning the matter over in my mind, I determined to put the idea in practice. Accordingly I made a contrivance on the button principle, and applied it in a case where the clamp suture had failed three times. The result was, as it has been in every trial since, as satisfactory as could^be desired. With such flattering results in its favor, I propose now to offer the operation to the profession for what it is worth. It will be found to be simple and easy in its performance, appli- cable to the great majority of cases, and devoid of any inconvenience to the patient. From its construction, mode of action, and the circumstances which led to its adoption, I shall call it the Button Suture. It is, however, only a modi- fication of the twisted, as the clamp is a modification of the quill suture. After a brief description of the apparatus/.and VESICO-VAGINAL FISTULE. 15 the mode of applying it, I shall add the details of four suc- cessive cases requiring seven operations in which I have employed it without a single failure. The essential parts of the apparatus consist of wire for the sutures, a metallic button or plate, and perforated shot to retain the latter in'place. The wire should be made of pure silver, about the size usually marked No. 93, and properly annealed. A length of about eighteen inches should be allowed for each suture. The button possesses several peculiarities. It may be made of either lead or silver. The former, hammered out to the thickness of l-16th of an inch, answers the purpose tol- erably well. The latter can be made still thinner, and does better on several accounts ; it is lighter, less likely to yield under pressure, admits of a higher polish, and allows the wires to be drawn through the small holes, without dragging. Fig. 1. Full Size. End View. The object of the button is to cover the fistulous opening after the introduction of the sutures, and its size and shape will therefore vary somewhat according to circumstances. The shape of those that I usually employ is oval (fig. 1,) but they may be circular, simi-circular, L or T shaped, to suit individual cases. The size will also necessarily vary, but it is seldom that one larger than the largest here represented, say 1 1-4 inches in length and 5-8ths of an inch in breadth, is required.* But whatever the shape or size, it is a matter of great importance that the under surface should be slightly concave, and the edge turned up. Along the middle of the button are arranged perforations for the passage of the sutures, which should be sufficiently large to admit two thick- nesses of the wire freely. The number of these openings will depend of course upon the number of the sutures, which are usually placed about 3-16ths of an inch apart. * Recently I employed a semi-circular one, which was nearly two inches in length and con- tained eight perforations. 16 VESICO-VAGINAL FISTULE. The shot are No. 3 in size, and perforated for the passage of the wires. Operation.—In remarking upon the different operations which have been performed in this country, I stated that I should confine myself mainly to a consideration of the sev- eral modes of suterization, and, singling out that of Dr. Sims as the only one deserving of notice, I have attempted to show wherein it is deficient. It is not necessary, nor is it my purpose, to enter into a detailed account of the earlier steps of the operation ; for in regard to these matters Dr. Sims has left little or nothing to be desired. I must mention, however, that I generally bevel the edges of the fistule upon the vaginal aspect to a greater extent than is recommended for the clamp suture. The object of this is to obtain large surfaces for agglutination, and at the same time to admit of a sufficiently firm degree of approximation to prevent if pos- sible the least passage of urine through the part. The edges of the fistule having been pared, the wire sutures are to be lodged in their respective places in the usual way, by attaching them to the ends of silk ligatures previously carried by means of a needle through the septum from one side of the fistule to the other. But in connection with this step of the operation, there is some difference between Dr. Sims' procedure and my own. In the first place, I do not usually take so firm a hold of the tissues, the space between the entrance of the needle and the edge of the fistule rarely if ever exceeding half an inch, and it matters not whether the parts be indurated or not, the wire is not likely to cut out very soon. Secondly, it is not necessary to observe the same scrupulous care in entering and bringing out the sutures upon an exact line with each other ; for, as will be hereafter understood, each one is in its action entirely independent of the others. Thirdly, instead of being obliged always to place the sutures parallel with each other, I have it in my power, if the peculiar nature of the case indicate, to insert them in any direction, and am thus enabled to bring within the sphere of successful treatment a large class of cases, which, owing to the irregular shape of the fistule, and the scarcity of tis- sue not admitting of extensive paring, cannot be subjected to the clamp suture. VESICO-VAGINAL FISTULE. 17 Fu In regard to the needle for passing the ligature, there is great diversity of opinion. Nearly every operator hasone to suit his own peculiar fancy, and probably uses it, after some little experience, to better advantage than he could any other. M. Jobert recommends the spear-pointed spring canula of Lewziski. Dr. Druitt prefers the fish hook needle, and some surgeons employ the ordinary short curved variety. I am myself in the habit of using one that is short, straight and spear-pointed, as repre- sented in fig. 2, a, b, c, d, the length varying from a half to three-fourths of an inch. The needle-holder or clasp may be straight (fig. 2, e) as recommended by Dr. . Sims, Mr. Brown, of London, and others, or it may be made of the shape represented at f. The latter was made at my own suggestion, and I have found it to answer a better purpose than the straight vari- ety where the fistule is situated far to one side or the other. It consists simply of the ordi- nary steel clasp (h) having a long substantial shaft and a flexible metallic canula (k) for the purpose of approximating the branches of the clasp. The latterJare furrowed in various directions for [the purpose of holding thefneedle firmly, and allowing it to be][placed at any angle that may be desired. (At l may be seen a needle clasped and ready for use.) The introduction of the needle in reference to the struc- A B C D 2 18 VESICO-VAGINAL FISTULE. tures to be penetrated, is justly considered a matter of no little importance. Dr. Mettauer and some others advise that the instrument be carried entirely through the vesico-vaginal septum. Drs. Sims and Hayward strongly disapprove of this practice on the ground that other fistules may thus be produced; and I fully agree with them. Indeed, I consider that too much care cannot be taken to avoid piercing the mucous coat of the bladder j and the needle, instead there-. fore of being carried through the septum, should be brought out at the edge of the opening in the vesical sub-mucous areolar tissue. As heretofore mentioned, the wire for each suture should be about eighteen inches in length, and the sutures ] should be placed usually not more than 3-16ths of an inch apart, although if the tissue be sufficiently abundant to admit of easy approximation without dragging, an interval of l-4th of an inch may be left. Fig. 3. Figure 3 is a representation of the fistule of the most com- mon shape, with its edges pared in the bevelled manner heretofore mentioned, and the silver wires drawn through. The next step in the opera- tion is to draw the raw edges closely in contact, by bringing the opposite ends of each wire together. This may be readily accomplished with an instru- ment which I have invented for the purpose, and call the suture adjuster. It consists simply of a steel rod, fixed in an ordinary handle, its distal extremity flattened, perforated, and raised upon one side into a kind of knob as represented at A, figure 4. The opposite ends of each suture are to be passed through the aperture in the end of the adjuster^from the convex toward the flat surface, and while the former are held firmly between the forefinger and thumb of the left hand, the latter is carefully slipped down upon the wires until it comes closely in contact with the tissues. In. this way the edges of the fistule are gently forced together, and, for the time being, the stiffness of the wire prevents their ^%^ VESICO-VAGINAL FISTULE. 19 Fig- .4- separation. Should it be found, however, that B—UH-.....i-A accurate coaptation does not take place, owing to the imperfect manner in which the edges have been pared, the sutures may be readily loosened, and the defect remedied without the neceessity of withdrawing the wires. The appearance of the parts, after all the sutures have been adjusted, Fig. 5. is faithfully repre- sented in figure 5. A button of suita- ble shape V and size having been previously provided,Fis]now,ito,)be placed upon the wires, (fig. 6) its concave sur- face corresponding to the vesico-vaginal sep- tum, and carried down in contact with the septum. The wires being again held in the left hand, the button should be pressed^gently against and adapted to the surface of, the parts (fig. 7). This may be accomplished by an in- strument which I call the button adjuster, repre- sented at figure 8,*consisting of a stiff iron rod, bent at a right angle within half an inch of its distal extremity, and inserted into an ordinary woodenlhandle. The shot are to be now passed down over the approximated ends of each suture (fig. 9) to Fig. 6. the convex surface of the but- ton, and here each one is to be successively grasped with a pair of strong forceps, (such as'is represented at figure 10,) and held against the button, while traction is made upon the corresponding suture, in order to bring the vaginal sur- face of the septum in close contact with the concave sur- face of the button, and insure 20 Vesico-vaginal fistule- close coaptation of the edges of the fistule. This having been satisfactorily accomplished, sufficient force is exerted upon the forceps to compress the shot, and thus prevent its slipping. The opera- tion is then concluded by clipping off the wires close to the shot, as seen at figure 11. The appa- ratus is allowed to remain on, generally, not more than ten days. Remarks.—After the foregoing description of the construction and application of the button suture, it is unnecessary that I should add any thing by way of explaining its modus operandi. Its principle, as heretofore stated, is founded upon and is analagous to that by which the vest or other clothing is or- Fig. 9. dinarily fastened.— ^fffj^^ The only marked /~~Ei~!jJa~j^L difference is, that in X Wmlm the latter process m^^^^^^^^^^ the button is first ^^^^^^ secured to the vest, and then the two sides brought together; while in the former the process is reversed, the oppo- site edges of the opening to be closed being brought together, and then the button put on. One of the marked peculiarities of the button suture is the separate and independent action of each wire, as a conse- quence of which, as before stated, it is not necessary that the separate points should be parallel with each other, but may be placed in any direction, even at right angles, if the shape of the fistule should require it. The only precaution requi- site is to have the shape of the button made to correspond to that of the fistule, and its perforations to the arrangement of the points of suture. Another advantage derived from this circumstance consists in the fact that if too much force be applied to one suture in drawing the edges of the fistule together, no injury results in consequence to the others, and such an accident as sloughing is hardly to be thought of. By means of the button suture quietude and an accuracy of Fig. S. vesico-vaginal fistule. 21 approximation are secured Fi£- H- to a greater degree than by any apparatus that has ever before been invented, two circumstances upon which the cure of fistules oftentimes solely de- pends. Splints properly adapted to the arm in transverse fracture of the humerus do not hold the fractured ends of the one so accu- rately in apposition as does the button suture fhe edges of the fistule. But, unlike splints applied to the limbs, there is little or no outside pressure upon the approximated edges of the fistule, for, by the concave form of the under surface of the button, the pres- sure is thrown some distance off, and any injury that might result from this circum- stance is entirely obviated. But probably one of the most important advantages of the button suture is the protec- tion that it affords to the denuded edegsof the fistule. It is a fact well known to surgeons, that a simple incised wound will heal with much more rapidity when shielded from the atmosphere and all other extraneous influences, than, all other circumstances being equally favor- able, when there is no such protection. Yesico-vaginal fis- tule, after the edges have been pared, being truly an incised wound, is subject, of course, to the same general laws. The button fulfills this indication of protection with positive cer- tainty, if its application be properly attended to. It is true that in a deep cavity like the vagina, the opposite walls of which are nearly always in contact, the atmosphere can have little or no effect upon the affected parts. But there are oth- er and far more obnoxious influences to shutout; and of these the urine, in cases of double fistule, is most hurtful, for, as it is not commonly the case that both openings are closed at the same operation, the one first operated on, without some pro- tection, is continually bathed in this poisonous fluid. I say poisonous, for few will deny to urine such an influence upon 22 VESICO-VAGINAL fistule. raw surfaces, and the consequence is that failure from this cir- cumstance alone oftentimes occurs. Leucorrhceal discharges are also more or less harmful, a fact of which Chelius was aware, but I do not know that any other author has made mention of it. Summary.—My experience with the button suture, as de- tailed in the history of the seven operations appended to this paper, has, I think, established its superiority to the clamp su- ture in the following particulars : 1st. It is simpler in its construction, an^ applicable to a greater number of cases. 2d. It affords complete protection and > perfect rest to the approximated edges of the fistule. 3d. If two fistulous openings exist, one or both may be closed at the same sitting, according to the inclination of the opera- tor or patient, without reference to the condition of the parts. 4th. The introduction of the suture does not demand the same exactness in regard to the position of the points. 5th. The independent action of each suture renders paral- lelism unnecessary, and thus gives the operator the liberty of introducing them in whatever direction may best suit his pur- pose. 6th. If perfect coaptation be found wanting after the edges of the fistule have been brought together, it is not necessary to remove the sutures, but simply to loosen them in order to perfect the paring. 7th. The apparatus does not irritate, it matters not what the condition of the parts may be, provided they are not in a state of progressive ulceration or inflammation. 8th. The apparatus requires to remain in position seldom longer than ten days. Having thus completed an imperfect account of the con. struction of the button suture, and. attempted to establish for it the first place among similar contrivances for the treatment of vesico-vaginal fistule in the estimate of the profession, I shall conclude this paper by an account of all the cases in which it has been employed, subjoining a simple statement of its success in comparison with that of other procedures. VESICO-VAGINAL FISTULE. 23 Case I.— Vesico-Vaginal Fistule of nearly three years standing; failure of three operations with the Clamp Suture; one operation with the Button Suture entirely successful. The patient was a young colored girl of small stature and delicate con- stitution. She was confined with her first and only child, August, 1852, and states that she was in labor about forty hours ; the child, which was large, having to be eventually removed with instruments. Several days after delivery, dribbling of urine occurred from the vagina, which continuing, together with other indisposition, confined her to bed for five or six months The following spring she was operated upon according to the method of Dr. Sims', but was not relieved. She came under my charge a short time afterwards, and upon examination, I readily discovered a circular opening about the size of a No. G catheter, occupying the vesico-vaginal septum near the neck of the uterus and a little to the left side. On the right side the tissues were in a normal condition, but on the left very much indurated. After due preparation of the systam, I applied the clamp suture in the usual way. Oa the thirteenth day, I examined and found that the clamp on the left side had cnt entirely out, and the aperture considerably enlarged. Shortly after this unsuccessful operation, the patient's general health became verv much impaired, and it was thought advisable to allow her to return home. I heard no more of the case until April of 1855, when she was again placed under my care, having, in the meantime, entirely regained her usual good health. I found on making an examination, that the fistule was somewhat smaller than when I last saw her, but the induration of the left border still existed. Aside from this latter circumstance, I considered the case altogether favorable and felt very confident that an operation would prove successful. Accordingly, on the 12th of April, I applied the clamp suture again. The edges of the iistule came together beautifully, but owing to the indurated condition on the left side, the corresponding clamp could not be made to embed itself, and consequently rested on a plane higher than the one on the opposite side. Notwithstanding this rather unfavorable feature, I was very sanguine of success. On the thirteenth day, I examined the parts, and, to my great mortification, saw that the left clamp had again cut out, and thus enlarged the opening. After two such signal failures with the only operation that I then consid- ered worthy of confidence, I was much discouraged, and had serious thoughts of abandoning the case altogether; but it was only a week or two subse- quently, that the principle of the button suture first suggested itself to me, and I immediately determined to subject the ease to an experimental trial. All things being ready, on the 12th of May I put the new method in opera- tion. Everything seemed to progress favorably. On the thirteenth day, I removed the apparatus, and to my great delight found the festulc completely closed, and not the slightest evidence of irritation except what might be naturally expected around each suture. Case II,—Two Vesico- Vaginal Fistides of seven months standing; two operations with the Button Suture; both entirely successful. Kitty, a colored girl of small stature, aged 18, was sent to me from a neigh- boring county, on the 24th of May, 1855. She stated to me that she always enjoyed good health until the birth of her second child, the preceding Octo- ber, with which she was in labor three days; the child was of large size, and bad to be mutilated before delivery oould be effected. She did not discover 24 VESICO-VAGINAL FISTULE. dribbling of urine until the second week ; during labor and for some time afterward, she had a numb of feeling in the lower extremities ; was not able to leave the bed for two months, and even then could not walk. From that time until she came to me, she sat the greater portion of her time upon a stool with a hole in it, to allow the urine to dribble into a vessel placed beneath. Owing probably to the constancy of that position, sciatica was induced and greatly augmented her sufferings. Her appearance, when I first saw her, was the most perfect picture of misery that I ever beheld ; emaciated to such a degree that her lower extremi- ties were not larger than chair posts; unable to walk or even to stand ; racked with pain ; writhing under the excoriating effect of the uncontrolled urine ; with the fatigue of traveling nearly two hundred miles added ; all taken together, rendered her an object of the most extreme commiseration. After allowing her to rest for a couple of days, I made an examination, found her thighs and buttocks extensively excoriated, the labia majora almost com- pletely encrusted by calcareous matter, and so sensitive, that the least effort to separate them caused excruciating pain. Before the vagina could be explored, this deposit had to be removed, and even then the suffering was considerable, owing to an extreme irritable condition of the organ, and a protrusion of the mucous coat of the bladder through the fistulous opening. When the speculum was introduced, I discovered that the posterior wall of the vagina could not be raised up with usual facilitj'. This I soon found resulted from a morbid attachment of its two walls. The adhesion extended obliquely across from the right side of the cervix to the left side of the vagina. thus concealing from view the os uteri, and rendering an exploration of the entire canal impossible. A fistulous opening, three-quarters of an inch in length, occupied the vesico-vaginal septum, and extended from near the beginning of the urethra obliquely upwards and to the left, terminating abruptly at the point of coarctation. Hero a careful examination revealed a small opening which allowed a probe to pass into the cut de sac above, and from thence into the bladder, showing clearly that another fistule existed in this situation. Having thus ascertained the true condition of things, I became satisfied that two operations would he required. The fistule first described was accessible, and demanded my first attention, owing to its larger size and the very irritable state of the mucous coat of the bladder which pro- truded through it. I thought it advisable, however, before attempting any operation, to improve the patient's general health. Accordingly she was put upon the use of Precipt. Carb. Iron three times a day, and confined to bed upon her back, with a catheter in the urethra, in order to divert the urine from the vagina and excoriated parts as much as possible. Under this course of treatment she very soon began to mend, and not long afterwards could walk about; which she had not attempted before for months. June 12th, I proceeded to apply the button suture to the lower opening Much difficulty was encountered in paring the edges, owing to the great resistance of the patient, and the herniated condition of the mucous coat of the bladder. Four sutures were required ; the button was 7-8ths of an inch in length, and about 5-8ths in width. For two or three days after the opera- tion there was considerable fever, and pain in the hypogastric region and I feared something serious might result; but things soon took a favorable turn, and the case seemed to do well until about the seventh day. At this time a VESICO-VAGINAL FISTULE. 25 great discharge of urine occurred from the vagina, and my first impression was that the sutures had given away ; but upon examining the parts carefully, I discovered the whole of the difficulty to depend upon tympanitic distension of the bowels, attended at times with powerful peristaltic action. When the latter would occur, I found that there was a sudden increase in the flow of urine, clearly resulting from downward pressure upon the bladder. To obviate the trouble, I gave several remedies, mostly carminatives ; but none of them seemed to be productive of any good. Finally, I resorted to the use of Turpentine, which answered the purpose to a very great extent, though not entirely. Feeling a little uneasiness as to the result, notwithstanding the' discovery of the source of trouble, I determined on the ninth day to remove the appa- ratus. Upon introducing the speculum into the vagina, the parts presented indeed a most unpromising appearance ; the mucous membrane was of a deep red color, and the button completely encrusted with earthy matter. I now had a firm presentiment that all was not right; but when the sutures were clipped, and the button raised, I found to my great satisfaction, that union of the parts was perfect. The catheter was worn a few days longer, and the patient then allowed to get up. Her general health now improved rapidly, and it was not long before her sciatica entirely disappeared. In a few weeks I made preparation for the other operation, by first breaking up the morbid adhesion between the two walls of the vagina, so as to expose the fistulous opening above. To prevent reunion of the parts, a bag, made of oil silk and stuffed with bits of sponge, was introduced into the vagina. This was removed daily, and injections of cold water used, by which means the upper extremity of the vagina was in a few weeks dilated to its normal size, and the fistule well exposed. August 23d, everything appearing as favorable as could be expected, I pro- ceeded to operate ; only three sutures were required; but as in the former operation, I had much difficulty, owing to the resistance of the patient. Tympanites supervened again several days after the operation, and caused the patient a good deal of suffering; but with this exception the case did well. On the ninth day I removed the apparatus, and had the satisfaction of finding an entirely successful result, and not the slightest irritation had been produced. The improvement of the patient, in every respect, was now rapid; and when I discharged her in September, she was as active and sprightly as though she had never had a sick day. Remarks.—The bad health of this patient, the existence of two fistulous openings, a herniated condition of the mucous coat of the bladder, a morbid attachment of the two walls of the vagina, and an exceedingly irritating quality of the urine, were all circumstances which strongly militated against the treatment. It is indeed one of the most remarkable cases that has ever come under my observation, and, I may add, that a better case for illustrating some of the advantages claimed for the button suture, and especially that of pro- tection to the denuded edges of the fistule from the poisonous effects of the urine, could not have been selected. After removing the button employed in the first operation, its very shape and size were found impressed upon the parts over which it rested during the healing process, and the pale red color of the mucous membrane here, contrasted beautifully with the deep red and 26 VESICO-VAGINAL FISTULE. fiery appearance of that which had been exposed to the urine escaping through the upper opening. Case IIL-Tico Vesko-Vaginal Fisiules of eighteen years standing; two successful operations with the Button Suture. Dinah, a colored woman, stout and heavily built, about 47 years of age, was placed under my charge on the 28th of June, 1855. She stated that the dis- ease under which she was laboring, was produced by the oirth of her fifth child in 1837. As well as she could recollect, she was in labor about a day and a half; was attended by a physician, but did not know whether instru- ments were employed to effect delivery or not. Dribbling of the urine commenced a few days afterwards, and in this condition the poor creature had dragged out eighteen years of miserable existence. During this period she miscarried quite a number of times ; only one child having gone to the full time. Upon examination, I found a fistule near the centre of the vesico-vaginal septem, circular in shape, and sufficiently large to admit the index finger into the bladder. Supposing this to be the only opening, on the 5th day of July I applied the button suture. On the tenth day it was removed, and the parts found to be perfectly united, not the slightest irritation having been pro- duced by the apparatus. In a few days afterwards the patient was allowed to get up, but, to my surprise, there was still dribbling of urine. I apprehended, therefore, that the newly formed cicatrix had given away, and there was a re- production of the fistule ; but making an examination, I discovered that such was not the case. I was now at a loss to account for the appearance of urine; but upon a more careful exploration of the vagina, I found another very small opening, situated far up on the right side, at least an inch from the one I had closed. The whole difficulty was now explained. Another operation was required : but, owing to the bad health of the patient, I was not able to perform it until the 10th of September. This fistule, although small, had a peculiarity I had never met with before. It was valvular, i. e. the opening through tne vaginal part of the septum did not correspond to that of the vesical! Two sutures were sufficient to bring the edges together. Things went on well, and on the tenth day, I removed the apparatus, and found union perfect. Remarks.—In this instance the fistulous openings were of eighteen years standing, the patient old, and her general health not very good ; yet the result was as prompt and decided as could have been desired. One of the great advantages claimed for the button suture, namely, protection to the denuded edges of the fistule, was again forcibly illustrated in this case. , Case IV.—Two Vesico- Vaginal Fistides of nine years standing; several failures with the Clamp Suture; Button Suture employed with entire success. The patient, a mulatto girl, aged about 25, of large size, came under my charge in September, 1855. She says that she always enjoyed good health until the birth of her first child in 1846, at which time she became the subject of her present difficulty. According to her account, the labor lasted three days, and during that time she passed little or no urine ; does not know whether instruments were employed or not; discovered very soon afterwards dribbling of urine. She also states that she was sent to New Orleans, and there treated VESICO-VAGINAL FISTULE. 27 for a long time, with but little if any benefit. Since then she has been operated upon several times according to the method of Dr. Sims, but the relief afforded was only partial. Upon examination, I found two fistulous openings, one about two inches from the cervix, and a little to the left side ; the other, a little larger, was, situated far to the right, at a point just where the anterior and posterior walls of the vagina become continuous. On the 10th of September, I proceeded to apply the button suture to the larger opening. It was my intention to close the other also at the same time, but the patient preferred to wait. Only two sutures were required, and on the tenth day I removed the apparatus, and found union perfect. October, the 18th, I operated upon the other fistule. This I found pre- sented the same peculiarity that was observed in the preceding case, in being of a valvular form. Only two sutures were required, and on the tenth day I removed the apparatus, and found adhesion perfect, without the slightest irritation in the surrounding parts. Remarks.—The result in this case was as satisfactory as could be desired ; it needs no comments. If it proves anything, it is that the button suture was better adapted to the case than the clamp suture, which latter had been long and perseveringly tried. Conclusion.—Having now finished a description of my mode of treating vesico-vaginal fistule, together with the narration of all the cases in which it has been employed, I propose, in conclusion, to compare its results with those obtained by oth. er methods. Since the 12th of May last, I have performed seven succes- sive operations without a single failure. This is the amount of my experience with the button suture. Now to form any- thing like a proper estimate of the several modes of treatment heretofore recommended, it is necessary first to ascertain what proportion of the operations according to each have been suc- cesssful when compared with the whole number performed. In this way only can their respective merits be properly set forth. To effect this object, I have examined, so far as my opportunities allowed, the records both of Europe and this country ; but as the data are imperfect, I have not been able to arrive at very satisfactory conclusions. Chelius speaks of Wutzer as having had the greatest sue cess. Of eighteen cases operated upon, three were radically cured. We are not informed how many operations were per- formed in all. Jobert, by the anaplastic process, cures, I am indnced to be- lieve, about one-half of his cases. What proportion of his op^ erations fails, I have not been able to learn. 28 VESICO-VAGINAL FISTULE. Mr. Henry Earleis said to have operated thirty times upon one case before succeeding. The failures here were as twen- ty-nine to one. Mr. Brown operated ten times upon three cases, and ob- tained one successful result. The-failures here were as nine to one. Dr. Hayward operated twenty times upon nine cases, and obtained three successful results. The failures here were as seventeen to three. I am not prepared to state positively what proportion of the whole number of operations performed according to the method of Dr. Sims has been successful. Judging from my own experience, and from what I have seen of it in the prac- tice of others, I am inclined to think that the average is not over one-half.* In regard to my own cases, it may be supposed by some that they were all peculiarly favorable, which accounts for my unprecedented success; but this was not the case : a re- ference to their individual histories will show that they were quite the reverse. The very fact of two of them having re- sisted the repeated application of the clamp suture, is proof sufficient upon this point. The other two were each double fistules, and therefore very unfavorable. One of them, case II, I consider the most unpromising I have ever seen, that was at all curable. * A few weeks since, there appeared in the New York Medical Gazette, a notice of the number of the Review containing the above article, in which the writer says that I am mis- taken in regard to Dr. Sims' success, and asserts that he (Dr. Sims) has cured, during his residence in New York, thirty cases without a failure. From this, it would seem that I had done Dr. Sims great injustice. While I here disclaim any such intention, I will simply add, that my language in reference to his and other opera- tions as compared with mine, is explicit, and I am surprised it should have been construed into a meaning so unjust. That Dr. Sims has done what is claimed for him, I have not the slightest doubt, but this fact has no bearing upon the statement made by me. The point which I endeavored to arrive at, was, what proportion of the operations performed according to different methods, had been successful. The opinion expressed as to the clamp suture, was principally based upon my own experience with it. This amounted to eight operations, six of which having been com- plete failures. If I am in error as to the average success of other operators, it remains to be determined by statistical facts, which are not before me, and so far as my knowledge extends, have never been published. As additional support to the advantages claimed for the but Ion suture in my paper, I will state that since it was prepared for the press, I have performed eight more operations, making in all fifteen. My jtwelfth operation was a partial failure. All of the others were entirely successful. July, 1856. VESICO-VAGINAL FISTULE. 29 In conclusion, I freely acknowledge that the results thus far obtained, by the use of the button suture, although so re- markably successful, do not amount to a sufficient number to justify an indisputable claim to superiority over all other pro- cedures ; and I do not, therefore, urge its adoption, by the profession, without farther trial. This is all I ask for it at present. My little experience with it has led me to believe that the principles upon which it acts are more nearly correct than any heretofore suggested ; but if, upon more careful ex- amination, this be found not true, it will only prove that the success of my seven operations was a most remarkable and heretofore unheard of coincidence. Montgomery, Jan. 1st, 1856. w '*-. *%> ■ * &J* • «a I