Part 70

The _recto-vesical_ method should never be resorted to in preference to the lateral; in other words, it is unwarrantable, in my opinion, in those cases to which lateral operation is applicable. It consists in exposing the neck of the bladder by division upwards of the sphincter ani and lower part of the rectum, and then either making a section of the prostate in the usual way, or dividing also the coats of the bladder in the posterior fundus, when the concretion is large. The cure is tedious and harassing: the urine and feces are discharged together, and hardened feculent matter may accumulate within the bladder; the wound is long in contracting, and often cannot be made to close completely without much trouble, and after a long time; often a fistulous opening remains, communicating with the bladder and rectum, and through this the urine continues to be in part discharged. It has been argued, that the recto-vesical method is advisable, with the view of obtaining more room for extraction of the stone; but to me it appears that the divided rectum will occupy just as much space in the outlet as when entire and empty. Circumstances may, however, occur, rendering this operation, or a modification of it, absolutely necessary, as in the following case—the only instance in which I have encountered an encysted stone. The patient, aged 64, of a spare habit of body, was seized with symptoms of stone in the bladder about twenty-four years previously to my seeing him; at that time he was sounded, but no stone could be discovered. The symptoms gradually subsided, and ultimately disappeared, and he remained for considerably more than twelve years totally free from any affection of the urinary organs. But, about three years previous to the operation, the symptoms returned, and again attentive examination of the bladder was made, without detecting any stone; on introducing the finger into the rectum, however, as high as possible, a firm substance was felt, globular, of considerable size, and very slightly moveable. From this time the symptoms gradually increased in severity, ultimately becoming almost intolerable. At length the presence of a stone was distinctly ascertained by sounding, and the instrument was passed beneath as well as over the calculus; from simultaneous examination by the rectum, it was evident that the hard bulging body was connected with the foreign matter struck by the sound. The lateral operation was performed, and, expecting to meet with a large stone, both sides of the prostate were divided. The forceps were introduced, but the stone, though easily laid hold of, could not be moved. Attempts with the instrument were accordingly abandoned, and further examination made by the finger, when it was found that the stone lay fixed in the lower and anterior part of the viscus, that it was firmly enveloped by a cyst situated between the rectum and posterior part of the prostate, and that only a part, small in proportion to its body, projected into the cavity of the bladder. Of this unusual and untoward circumstance, the medical gentlemen present were also satisfied by manual examination. It was quite apparent that it would be impossible to divide the cyst sufficiently without wounding the rectum, and I therefore determined to lay the bowel, the cyst, and the track of the wound into one cavity. This was effected by cutting the upper and anterior part of the cyst, passing a blunt-pointed and curved bistoury behind the remainder of the cyst, insinuating it through the coats of the gut at that part, meeting the point with the forefinger of the left hand passed per anum, and then carrying the instrument forwards to the surface. A strong scoop, much curved, was passed behind the stone, and without much difficulty extraction was thereby completed. Not above a few tablespoonfuls of blood were lost during the operation, in which not much time was occupied, and no bleeding took place after reaction was established. The cure proceeded favourably, though necessarily slow and tedious, the more so since the patient had been very much reduced by the previous suffering. Some superficial sloughing took place in the wound, but the sloughs soon separated, and healthy discharge and granulation followed. By keeping the bowels gently open, the annoyance from feculent evacuation by the wound was in some measure diminished. The patient was daily out of bed, and took food in good quantity and with relish. At the end of the fifth week, however, he was seized with a severe bowel attack—vomiting, purging, cold extremities, &c.—and the effects of this were never surmounted. The real Asiatic cholera was at that time prevalent, and the patient was under great apprehension of an attack. The weak state in which it left him continued and increased: he was soon confined entirely to bed, the wound made no progress in closing, sloughing of the back took place, and he sank about the end of the eighth week from the operation.

Calculi sometimes lodge in the urethra, obstructing the flow of urine, becoming firmly impacted, and increasing in size. If in the perineal portion of the canal, they are to be fixed and made prominent by being grasped with the fingers, and then exposed by an incision made in the raphe: they are turned out, either with the finger, or by means of a small scoop. If situated in the part covered by the scrotum, the opening should be made, if possible, behind, not anterior to it, for a wound in the latter site will be closed with difficulty. When in the posterior part of the canal, they are reached by incision on the left side of the perineum and opening of the membranous portion. After such operations, the wound, if not anterior to the scrotum, usually closes in a few days.

_Calculus of the female_ is exceedingly rare. Concretions are not so apt to be retained in the bladder as in males; they are passed by the urethra. The symptoms are similar to those which have been described as indicating stone in the other sex. Sounding is easy; it is performed with an instrument slightly bent at the farther extremity, and considerably shorter than those employed in the male. Even when the calculi are of considerable size, they can be removed, as well as other foreign matter, by dilatation of the urethra, effected gradually. Portions of gentian root, and sponge tents, were formerly used for this purpose; but of late years various dilators have been contrived. Some are really new, others have been published as such, though correctly represented in works some hundred years old. Their blades are made to separate in a parallel direction by peculiar adaption of the screw; and, by gradually and very slowly increasing their separation, uniform dilatation is effected. Very soon the opening is sufficient to admit the finger; then the size of the stone is ascertained, and, if necessary, the dilatation is continued to a sufficient extent. When thus the canal has been widened so as to admit of the passage of the stone, forceps are introduced, and extraction accomplished in a direction downwards, that is, towards the vagina. Incontinence of urine is apt to continue for some time after this operation, if the dilatation have been considerable, as well as after the removal of larger stones by incision.

Incision has been proposed in various directions—into the vagina, or by the side of it, upwards and outwards; and it has also been recommended to cut the bladder, on the fore and lateral part of its neck, without interfering with the urethra.

By the latter method the chance of incontinence remaining is diminished, but there is a risk of urinary infiltration, and this will require to be provided against by the use of a tube, as after the lateral operation in the male. A staff is introduced, and by it the urethra is depressed towards the vagina. An incision is then made by the side of the crus clitoridis, and through this the finger reaches the neck of the bladder, more by dilatation than by additional use of the knife.

In one case I removed a very large stone by incision. By a straight grooved staff the urethra was depressed; a straight blunt-pointed bistoury, being slid along the groove» was carried upwards and outwards, first on the left side, and then on the right—dividing the urethra and parts exterior, so as to form a track of wound, which, after dilatation, would admit of the ready passage of the stone. Extraction was easy. Incontinence continued for many months, but ultimately was in a great measure removed by promoting farther contraction of the opening by the cautery. The preferable plan, and one I have since then followed in a few instances, is dilatation to some extent, and by a proper instrument; then slight incision on each side upwards and outwards; then further dilatation; in a few minutes, without much pain, the finger is admitted, then the forceps. The stone is then extracted quickly, with but little pain, and no bad consequences follow.

_Gonorrhœa in females_ is often confounded with _Leucorrhœa_, which is a very common complaint both in married and unmarried women. Leucorrhœa sometimes occurs at a very early period of life, at the age of ten or sooner; and in such circumstances affections of the glandular and osseous systems often supervene. Frequently it precedes the accession of the coloured menstrual discharge, and in many instances is substituted for it; it is always most profuse after the menstrual period. In leucorrhœa there is generally neither heat nor pain during the passing of urine, and the colour of the discharge differs from that of gonorrhœa, though sometimes very slightly; the stain of gonorrhœal matter is yellow with a black border; leucorrhœal is white or yellowish, but does not possess the latter characteristic. The application of leucorrhœal matter will induce discharge from the urethra or from the external parts of some males, but the affection thus caused is, perhaps, not so violent, nor of so long duration, as that which arises from specific contagion. The effects of leucorrhœa on the system are very troublesome. There is general debility, disorder of the stomach, pains of the back, sides, and limbs, a sallow bloodless complexion, paleness of the lips. It is often a cause, at other times a consequence, of miscarriage. Sometimes it is accompanied with a prolapsus uteri, sometimes with thickening of the os uteri. The discharge which attends ulceration of the parts, from whatever cause, is generally bloody, sometimes it is thick, and of a laudable aspect, sometimes thin and fetid. More or less discharge attends polypus, and is often profuse and coloured.

In gonorrhœa the inflammation is usually limited to the external parts, but sometimes extends along the vagina. In neglected cases great tumefaction of the labia takes place, along with excoriation of the neighbouring parts, patchy ulceration around, and swelling of the absorbents and of the inguinal glands. Heat, pain, and scalding, are experienced in making water, but in comparison with the other sex, females suffer little or nothing from this disease. The parts are much less complicated; and bad effects seldom follow either the affection or the remedies employed, however strong.

The inflammatory stage must be subdued by antiphlogistic measures, 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.