On kolpokleisis and other allied procedures as means of treating vesico-vaginal fistule : being an answer to the article of the late prof. Gustave Simon, of Heidelberg, entitled A comparison of Bozeman's operation with that of the author

Front matter

ON KOLPOKLEISIS

AND OTHEK

ALLIED PROCEDURES

Part First

A, Historieal Sketch — B, Tabular Statement of our Operations at Heidelhurg — C, Our Correspondence. — Soon after the appearance of the paper in the "Wiener Medizinische Wochenschrift," 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.

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far with my work when the sad intelligence of the distinguished surgeon's death reached me at Paris. My first impulse 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 fistule, 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 contribute 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 publications 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, kolpokleisis, as a means of relieving incontinence of urine, supposed 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

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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 fistula, he said:

" The reason why I have proved the validity of my claims of priority at such length is simply this, that, in my opinion, kolpokleisis is the most important plastic operation which in the last decennia has originated from one single man. The operation 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 countryman, von Langenbach, could alone be placed by the side of kolpokleisis, as far as the safety of the performance and its immediate 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 obtained 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 defects of the bladder have been freed of the most intolerable suifering; viz., the incontinence of urine. I have myself in eighteen cases succeeded in efiecting 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 remained satisfied with that mode of operation, to which you still adhere. On the contrary, I have constantly labored to perfect

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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 " Beitrage zur Plastischen Chirurgie," Prag., 1868, p. 216). Moreover, whereas I used to consider kolpokleisis indicated only where very large defects existed, I have now limited this indication a good deal, having cured at later periods very considerable defects by uniting the borders of the wound by sutures like these (^, T, A> A); ^7 resorting to incisions along the sides and parallel with the sutures, and even by transplanting a flap from the vesico-vaginai 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-vaginai fistules in Germany, as much on this subject may still be unknown to you. My statements will uo doubt be for you — the most experienced operator on fistules in America — of the greatest interest, as you will thereby perceive that the operation 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 certainty of success which it has not attained in any other country, and that especially your American method and its modifications have been surpassed in every respect. Without fear of contradiction, I believe myself justified in considering that, of

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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 improved 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 (4J per cent.) died.

"With what safety the cures are efi'ected 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 previous 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 oomplieations 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 notwithstanding these troublesome circumstances all 14 patients

* The italics are mine.

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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 colleague, 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 entertained by him upon the extension of the principle, as found published in his justly popular work on Plastic Surgery ("Beitrage 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,

" 3. 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 procedures, he laid down (op. cit., p. 229) the following eight indications, 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 peritoneum.

"4. Haemorrhage into the bladder, where considerable, after operations.

"5. Confinement by adhesions of the stump of the cervix uteri, inside the bladder.

" 6. Atresias 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. lire tero- vaginal and uretero-uterine fistules."

The next year ("Deutsche Klinik," No. 15, 1869), in an article entitled "Efi'ects of Urine and Saliva upon Tissues deprived of Epithelium," Professor Simon recorded some fifteen experiments made upon man, dogs, and rabbits, with the view, as stated, of controverting a popular error, with regard to the injurious 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 necrosis. This view has been held not only with regard to decomposed and alkaline, but with regard to undecomposed 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 relating to operations on the generative and urinary organs of womeQ, 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. I am 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."

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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 leaving any trace of its eflfects, 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 together 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 ammoniacal urine, unfiltered and filtered. From their importance as relates to the operation of kolpokleisis, I will here copy in extenso :

" Experiment 6. From two to four drachms of alkaline urine, containing triple phosphates, mucus, and pus, were injected 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 produced, 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 circumstances 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 :

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" 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° G. 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'^-60° C. 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 experiments 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 surgeons 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 ol 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

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no precautions for the conveying away of the urine, most remarkable success has been attained. A good many years ago, Wutzer, in operations for vesico-vaginal fistula, used to puncture 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. H© was compelled, however, to repeat the operation ten or twenty times for the cure of the smallest fistulse, 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 fistulse, 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 operations 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 recognized as might be desired in the interests of the patients concerned. For American, English, and French surgeons after the operation for vesico-vaginal fistula or similar lesions about urinary 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 inconvenience 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 management, which I have followed for years with the best results; namely, to'provide for the cleansing of the external genital organs

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and the vagina, and to allow the urine to be passed at pleasure (see my article *0u 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 (extraction 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 irritation, 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 execution 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 perineum 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

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prevented, the urine "having a direct outle|i; 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 beat 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 hi.s experiments.

Here I may be permitted to tabulate my experience during a part only of ^^^^J^^c^d^'^ra^fect 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- vaginal fistule, and thus established the standard of my form of cure with preservation of the generative functions, to which I have ever since adhered without 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 compensating for loss of tissue, leaving vaginal atresias untreated, entirelj' 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, w^icA 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 Tvith his improved duck-bill speculum, with the foldof edges of the fistule, and sometimes the cervix uteri into the bladder, and with gradual preparatory treatment of vaginal atresias, sacrificing 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 (33J 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 principle 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 entirely new, claiming that his discovery of silver wire (adroitly purloined from the published experiments of the late Dr. Henry S. Levert, of Mobile, Alabama, "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, 18&S). <i^/

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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 performed. These were completely cured, with preservation of the generative functions, but relapsed, owing to the incompleteness 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 complete 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 " Louisville Eeview," May, 1856, the "North America Medico- Chirurgical Eeview," July and November, 1857, and the " New Orleans Medical and Surgical Journal," January, March, and May, 1860.