proportioned to the intensity of the action and the state of the
constitution; they seldom, if ever, require to be at all severe.
Turpentines, and other internal remedies, which may prove beneficial in
the gonorrhœa of males, are of little use. The external means are to be
chiefly trusted to, consisting of astringent and stimulating washes;
when the vagina is affected, the solutions must be thrown up by means
of a syringe. In leucorrhœa, the same external treatment is required,
and the use of a syringe is always necessary. The washes most commonly
employed are—solution of the sulphate of zinc, of alum, and of the
nitrate of silver, or a decoction of oak bark or galls. In leucorrhœa
the internal exhibition of preparations of iron and of tinct. lyttæ in
pretty large doses may be considered as almost a specific, stimulating
the whole system, and correcting that state of morbid debility, both
general and local, on which the vitiated secretion depends; and the
injection for the vagina, which is perhaps most efficacious, is the
solution of the nitrate of silver. The solid caustic may often be
rubbed over the surface of the vagina affected by bad leucorrhœa or
gonorrhœa, when exposed and brought into view by the speculum, with
the best effects. When the menstruation is irregular, blisters and
sinapisms may be applied to the loins, with cold bathing, general and
local. In gonorrhœa, when only the external parts are inflamed and
furnish discharge, the application of a solution of the sulphate or of
the acetate of zinc to the parts, by means of lint, effects a cure in a
few days—along with strict attention to cleanliness, the observance of
rest, regulation of diet, and occasional doses of gentle physic.
_Gonorrhœal Lichen_ not unfrequently follows suppression of the
discharge both in males and females. It is preceded by smart fever,
headache, and violent pains in the limbs. Inflammation of the fauces
is generally present, with superficial ulceration or excoriation; and
sometimes the abraded portions of the mucous lining are covered with
a whitish exudation. The symptoms subside on the appearance of the
eruption, which is papular. It generally appears first on the breast
and arms, and then extends over the whole body, accompanied with slight
itching. If the case proceeds favourably, the red papulæ disappear
in a few days, leaving blains in their stead. Desquamation of the
cuticle generally follows. This affection must not be confounded with
a cutaneous eruption which sometimes follows the use of copaiba, and
which is a species of urticaria.
When the fever is violent, bleeding must be had recourse to, but not
to a great extent, and only when it cannot with safety be avoided.
Gentle laxatives are to be given. Diaphoretics are very beneficial,
and the patient should not be exposed to cold or wet, but kept rather
warm, otherwise the eruption may be repelled, the affection thereby
prolonged, and the constitutional disturbance augmented. The fauces
soon recover under the use of simple gargles. Mercury is hurtful.
_Retention of Urine in females_ arises from tumours, natural or morbid,
of the uterus, or of the vagina and appendages, from displacement
of these parts, or from foreign bodies lodged in them. But the
consideration of such affections belongs to the accoucheur.
Retention takes place in females from paralysis of the bladder, and
the same treatment is necessary as in the case of the male. Hysterical
women often take it into their heads that they are unable to empty the
bladder, and will not attempt it; and though it may be difficult to
convince them of their mistake, yet when they are left to themselves
for a little, and begin to feel some of the torments which attend
retention, they contrive to get rid of their burden, and that without
any very great exertion. Sometimes they omit attempting to empty the
bladder when they could, and then they cannot effect it when they would
do so. Others are still more whimsical, and will push into the viscus
needle-cases, bodkins, portions of tobacco-pipes, and such like. The
surgeon should be aware of such whims and fancies.
There is, in general, no difficulty in passing the catheter. A short
one is preferable, there being less chance of giving pain; and the
operation must, of course, be proceeded in with the utmost regard to
delicacy. The forefinger is placed in the upper part of the orifice
of the vagina, and the point of the instrument, when placed a little
above this mark, readily slips into the urethra. It is recommended to
use the clitoris as the guide, placing the finger on this, and moving
the point of the instrument thence downwards; but when this method is
pursued, the catheter is apt to enter the more patent passage. The
instrument is to be carried gently onwards, in a horizontal direction,
till the urine flows. In some cases of enlargement and displacement
of the neighbouring parts, the urethra is elongated, and its course
irregular; in such, a long elastic catheter is required. If objections
are made to the use of the catheter, at an early period of retention,
nitrous ether may be given internally, fomentations applied to the
hypogastrium, and a turpentine enema administered. Puncture of the
bladder can seldom, if ever, be necessary in the female; if it should
be required, the opening may be made either above the pubes or
through the vagina. From the latter method there is a risk of fistula
remaining; but this, as will afterwards be noticed, can in some cases
be ultimately made to close. The operation above the pubes has, in some
instances, been necessary during parturition, when instruments could
not be passed by the urethra, nor through the coats of the vagina and
bladder.
False communication betwixt the vagina and bladder, termed
_Vesico-vaginal fistula_, is usually the result of mismanagement during
parturition. The bladder has been allowed to become over-distended, and
in this state to be pressed upon and bruised by the child’s head; or it
may have been compressed and bruised by instruments employed in tedious
delivery. The consequence is inflammation, violent, and followed by
sloughing. On the separation of the sloughs, the urine escapes, perhaps
six or eight days after delivery; or the anterior surface of the
vagina, and the coats of the posterior and lower part of the bladder,
have been lacerated by the imprudent use of the crotchet, or some such
crooked and awkward tool; then the escape of urine is immediate. The
unnatural flow continues, diminishing after a time, and if the opening
be at first not large, and have gradually contracted, ultimately it may
escape in but small quantities, at least during the recumbent posture.
Of course, the size and site of the opening are very various. I have
been consulted in some dreadful cases, incurable and loathsome—the
consequence of most culpable neglect and ignorant rudeness on the part
of the accoucheur;—the bladder, without any part of its posterior
fundus, has been rent so as to admit the fingers; the rectum also
torn extensively—in some, merely a shred of the sphincter remaining;
feces and urine constantly mixing in one vast offensive cavity. But
in general the opening is in the neck of the bladder immediately
behind the commencement of the urethra, and nearly in the mesial line;
sometimes it is considerably further back. It can be felt by the
finger, and is readily brought into view by means of a proper speculum,
a copper spatula being at the same time used to prevent the folds of
the vagina from interrupting the view; the speculum opened by handles
attached to the blades, and prevented from shutting by a serrated
semicircular plate interposed, is the most convenient and suitable.
Attempts 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. The speculum is introduced into the vagina,
so as to expose the aperture, and guard the neighbouring parts from
the cautery; and should the opening not appear distinct, a flexible
wire is passed by the urethra, and insinuated through it. A small
heated cautery is then slid cautiously along the speculum, and applied
lightly to the margins, with the view of producing a superficial
slough; this separates, and during the consequent cicatrisation the
opening contracts. When the edges have again become smooth, the cautery
is applied as before, and by several repetitions complete closure
may ultimately be obtained. The interval between the applications
is necessarily considerable; each must be allowed to have its full
effect. Once I attempted to combine the cautery with the suture; first
applying the heated wire, and after separation of the slough, and when
the margins were tumefied, excited, and apparently prone to adhere
by the formation of new matter, then approximating them by a species
of twisted suture. At first, matters proceeded favourably, but the
ultimate result was not very successful—it was such, however, as to
render the plan worthy of being again tried; if fortunate it would very
much abridge the cure. By the cautery I have succeeded in relieving
many, and in curing a few perfectly. I cannot quit the subject without
expressing regret at the frequent occurrence of such cases. I have
had three or four cases in the hospital at one time, and they are
constantly being presented for relief.
_Imperfections_ of the female genital organs are sometimes met with.
The external parts may be well formed, while the vagina is short, and
the uterus and its appendages are wanting; or these may be perfect, and
the vagina closed at its external orifice, either by a thin and dense
membrane, or by a thick and fleshy substance. Young children are not
unfrequently presented with the latter kind of imperfection, but in
them there is no need for interference; the urine is not obstructed,
and it is only towards puberty that a necessity arises for removal of
the deficiency. At this period, the menstrual discharges are retained,
if the vagina continue closed, and accumulate in great quantity,
producing much distention of the canal, pain in the hypogastrium,
general uneasiness in the parts, and sometimes swelling of them to a
great extent. On division of the membrane, there is sometimes an escape
of many pounds of dark, thick, putrid fluid, and all the symptoms
quickly subside. A cautious incision is made in the mesial line, until
the obstruction be completely divided; if an opening be found, a probe,
or director, is introduced, and by this the knife is guided. There is
seldom any risk of the parts again coalescing; when the obstruction,
however, is unusually thick, the insertion of dressing between the
edges during granulation may be necessary to prevent contraction.
Unnatural adhesions of the external labia occasionally take place,
occurring in early life from the healing of excoriation and ulceration
caused by neglect of cleanliness. Perhaps the closure is not to such
an extent as to prevent escape of the discharges, but still it is
inconvenient and requires attention. The parts must be divided in the
proper direction and to the necessary extent, and, by the interposition
of dressing, reclosure is prevented.
_Contraction_ of the vagina at a distance from the orifice sometimes
occurs. On one occasion I was requested by an accoucheur to examine
and divide a very tight, firm stricture, scarcely admitting the finger.
Labour had commenced, and the expulsion of the fœtus was prevented
by the stricture; it was attributed to injury inflicted in a former
delivery. By a probe-pointed bistoury, guided on the finger, it
was notched pretty deeply at many points—a proceeding which I have
frequently followed with advantage in simple stricture of the rectum.
Everything proceeded happily.
Occasionally the contraction of the vagina is to a great extent; the
uterine discharges are not permitted to escape at all, and great
uneasiness is thereby occasioned. In one case, in which the canal may
be said to have been wholly obliterated, from what cause or at what
period it did not distinctly appear, I ascertained the position of the
uterus by the finger passed into the bowel, pushed a curved trocar
on to it through a considerable thickness of parts, and afterwards
dilated this artificial passage by bougies gradually increased in size.
The vagina was thus reëstablished, and menstruation again occurred,
and without interruption. A case, in which the vagina was obliterated
to the extent of from two to three inches, occurred some months ago
at the North London Hospital. It took place, it appears, after an
accouchement, the genital organs being raw and sore, with considerable
loss of substance from phagedænic ulceration. A large tumour could be
felt betwixt the hand placed on the hypogastric region and the finger
in the rectum. The patient was exceedingly urgent in her entreaties
to have the canal restored, and the attempt was made. The contiguous
viscera being emptied, a trocar, guided by the finger in the bowel,
was pushed in the course of the vagina as far as was thought safe; the
canula was retained, and, some days after its withdrawal, the part was
farther dilated by gentian root. It was intended to have carried the
pointed instrument farther, but symptoms of peritoneal inflammation
supervened about the tenth day, and in spite of active treatment proved
fatal. The uterus, os uteri, and from an inch and a half to two inches
of the upper part of the vagina, were enormously distended with dark,
putrid, grumous, and bloody fluid, of the consistence of tar; the
trocar had reached the parietes of the cavity, and, if pushed forward
another line, must have entered the vagina, and allowed the fluid to
escape. There was a quantity of putrid and dark-coloured serosity in
the cellular tissue of the pelvis and behind the peritoneum. It is to
be regretted that I did not feel warranted in the first instance in
pushing the instrument forward more boldly. Had the fluid been allowed
to drain off, the probability is, that the future infiltration and
peritonitis would not have occurred. The intention was, being foiled
in the first attempt, to dilate the canal sufficiently to admit the
finger, and by the direct guidance of that to carry the perforation
farther.
Violent and deep _inflammation_ of the external parts of generation
is not uncommon,—the result of bruise or wound. It is generally met
with in the lower class of prostitutes. The inflammation often attacks
the vagina and neighbouring parts, followed by great swelling; and,
if not allayed, extensive abscess forms, with much fever and pain;
pointing takes place betwixt the external and internal labia. The parts
must be copiously leeched, and afterwards fomented; strict rest and
antiphlogistic regimen must be observed, and when matter has formed,
a free opening should be made early, to prevent deep and extensive
mischief. A sinus sometimes, though rarely, results; generally the
cavity fills up, and the discharge ceases in a very few days. These
parts are much more vascular than the lower part of the bowel, and when
in a diseased condition, are not of necessity so frequently put in
action; hence extensive incision and division of the sphincter is here
very seldom necessary.
_Tumours_ of various kinds are met with about the external female
organs; more rarely, internally. Encysted tumours of the labia are not
uncommon, and sometimes solid swellings, varying in size and structure,
grow from these parts. I had occasion to remove one of the latter
description, which weighed many pounds, and had been productive of
great and long inconvenience. The general rules for the extirpation of
tumours apply to them. Considerable hemorrhage may be expected. The
operation must be done so as to deform and impair the functions of the
parts as little as possible.
New and unnatural growths, or enlargements of the natural parts, as
of the prepuce, of the clitoris, or of the internal labia, sometimes
occur, and may require curtailment.
The external parts of elderly females may be the seat of warty
excrescences, degenerating into malignant ulcer, and demanding free
removal by incision.
Tumours of a medullary nature sometimes proceed from the interior
of the pelvis, and displace and interfere with the functions of the
vagina, bladder, and the neighbouring parts; such cases are of course
hopeless, and the treatment must be merely palliative.
Polypous tumours, of various size, structure, and consistence,
sometimes grow from the cavity of the uterus, or from its orifice,
or from the parietes of the vagina. They are generally attached by a
narrow pedicle, except when of a truly malignant nature—occasioning
discharge, mucous and vitiated, sometimes bloody, often profuse.
Bearing-down pains are complained of, and the health declines in
consequence of the discharge. Most of such tumours are benign,
troublesome only from their bulk and situation, and from the irritation
which they produce in the surrounding membrane. They very frequently
have their origin in the substance of the uterus, and are extruded from
it, covered by the mucous lining. Removal by ligature is generally
the most advisable method of extirpation. The site and nature of
the attachment are ascertained, and a strong wire of fine silver,
or a piece of whipcord, is noosed round the base by the finger, and
pushed down close to the origin, care being taken not to include the
healthy parts beyond the growth. The ligature is tightened by passing
it through a canula, or along a strong probe, with a ring at each
extremity, to the lower of which it is secured. It is drawn more
tightly from time to time, till the tumour drop away. A double canula,
the portions of which can be separated, is often used for the purpose.
By practice only can dexterity in such manipulation be acquired; the
object being understood, it must be attained by perseverance.
_Malignant disease of the uterus_ is common. Various morbid alterations
are here met with; soft, or hard, or bloody masses, earthy deposits,
&c. The disease generally commences in the neck, with fulness and
thickening; in many females it is attributable to faulty menstruation,
to leucorrhœa, or to other irritations in the neighbourhood. Ulceration
sometimes occurs, not of a malignant nature, from similar causes;
but in old females this is either of a bad kind from the first, or
degenerates, presenting all the usual characters of malignant sore on
a mucous surface. The surrounding induration is usually great, and
quickly spreads to the neck and body of the organ, contaminating also
the neighbouring tissues and the lymphatics.
Some bloodthirsty accoucheurs and operators have attacked the uterus
unrelentingly; more than one appears to have been seized with the
monomania of cutting out part or the whole of the organ. Numerous
females, at a period of life when malignant diseases rarely show
themselves, have been subjected to excision of the os and cervix uteri.
Some forty and fifty were operated on within a very few months; in
almost all of these cases the proceeding was, without a doubt, cruel,
reckless, and unnecessary. Attention to the general health, with local
applications, would, in all probability, have restored the parts to a
healthy condition in the greater number.
Malignant disease affecting the uterus may be removed, at an early
stage, by incision, with propriety and safety, and I have done so
successfully. The part is examined by means of a hollow tube of tin,
polished inside, gently and cautiously introduced. A dilator as well
as a speculum is required in the operative proceedings for removal
of the parts; and for this purpose the instrument mentioned, when
treating of vesico-vaginal fistula, is to be employed. When this
has been introduced, the os uteri is laid hold of by one or more
vulsella, and pulled down; the diseased portion is then removed by
a blunt-pointed knife, the incisions being carried beyond the hard
and altered part. There is not much loss of blood, and it is easily
arrested by stuffing the vagina. Afterwards bland fluids are injected,
and, after a time, those of a gently stimulating nature, to wash away
the superfluous discharge, and promote healing. The state of the sore
can be occasionally examined by means of the speculum, and nitrate of
silver or other applications employed when necessary.
When the disease is in an advanced stage, the neck of the uterus
is involved completely, and there is an uncertainty as to how far
the morbid alteration extends. Only palliative treatment can be
adopted,—soothing applications, and internal remedies according to the
symptoms. The practice of some, however, is more bold and decisive.
The uterus has been cut out by incision of the abdominal parietes. It
has also been removed through the outlet of the pelvis. As was to be
expected, the patients have perished from loss of blood, and the shock
of such barbarous proceedings; one or two, perhaps, survived, only to
die from extension of the disease to the internal parts, within a very
few months. Such doings are not justifiable; and, if repeated, should
be punished by the execration of all professional men of sound sense
and principle.
The _Common Iliac_ artery may require ligature, on account of extensive
aneurism, involving the internal iliac, or its branches at their
origin, or encroaching on the external iliac to near the bifurcation.
It may also be necessary, in consequence of wound of the artery, or in
cases of secondary hemorrhage from branches of either the external or
the internal iliac.
An incision is made through the abdominal parietes, commenced over
the passage of the cord through the transverse fascia, and extending
upwards, and a little outwards, for five or six inches; its extent
depending on the size of the patient, the thickness of the parts to
be divided, and the consequent depth of the vessel. By this first
incision, the skin and superficial fascia of the abdomen are divided,
and then the muscles are penetrated, the line of the preliminary
wound admitting of their being cut in the direction of the fibres.
After the external oblique has been passed, the proceedings require
to be conducted with great caution. The fibres are cut by the hand
unsupported, and then the transverse fascia is scratched through,
slightly and with great precaution, cutting upon the finger or a
director introduced at the lower angle of the wound. By means of the
finger, the opening is dilated, and the fascia separated from the
peritoneum. This membrane and the parts within it are then, with
the utmost gentleness, pushed inwards and upwards, by the hands of
an assistant, so as to expose the bottom of the wound. The course
of the vessel is now felt for, and by separating the edges of the
wound, either by the fingers, or by broad and thin copper spatulæ, its
bifurcation may be seen. About an inch or so above this point, the
artery is slightly detached from its connections by the point of the
knife, separating it from the vein on its posterior and inner surface,
and a blunt-pointed needle, armed with a firm ligature, is pushed
beneath, without force, and close to the coats of the vessel. The
deligation is made firmly, and both ends of the ligature are brought
out at the wound; this is then approximated by a sufficient number of
stitches, and a compress and bandage applied.
This operation is not often required. I had recourse to it once in
bleeding, after very high amputation of the thigh, occurring some days
after the operation. The hemorrhage was effectually arrested, but the
patient did not recover from the effects of the previous loss of blood,
and continued to sink.