Part 71

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.

Aneurism of the branches of the _internal iliac_, whether spontaneous or the result of wound, is rare. When it does exist, its signs are sufficiently distinct. The old operation—opening the tumour by direct incision, and tying the vessel close to the cyst—has been performed successfully in one remarkable case on record. But this is attended with much risk, there being no means of commanding the bleeding during the incisions, nor until the ligature is placed and secured. The preferable proceeding is to tie the internal iliac near its origin, as has been put in practice successfully in a few cases. The same incisions are made as for reaching the common iliac, and then the sacro-iliac junction is felt for; with the nail of the forefinger the cellular tissue is cautiously and gently separated, and a needle and ligature placed under the vessel. In a corpulent adult, a needle, with a moveable point, may perhaps be useful, as also the copper spatulæ, to keep the parts aside; and a serrenœud may assist in the securing of the noose. It was the fashion once, and perhaps is so still, for every young and aspiring surgeon, when he was about to attempt lithotomy for the first time, to invent or alter some strange crooked tool, for smoothing, as he thought, his way into the bladder. The rage now, more especially on the other side of the Atlantic, is all for curious aneurism needles and tonsil shavers. It ought never to be forgotten, that the simplicity of any proceeding and of every machine is the measure of their perfection. I have had by me a lot of needles, all very ingenious, at the various operations for aneurism which I have had occasion to perform—many of them of the most difficult nature—and the simple needle has always been found to answer the purpose most perfectly.

Aneurism in the groin is not uncommon, and is very easily recognised. The old operation has been attempted, and unsuccessfully. Ligature has been placed on the distal side of the tumour, with no favourable result. One horrid example of the latter operation is on record, in which the femoral artery had been completely obliterated spontaneously, and nerves, vein, and portions of the muscles, were all included in ligature, by one random thrust of a large sharp needle. The _external iliac_ is to be tied—a proceeding now regarded as one of the regular operations of surgery, and likely to insure a favourable result. It was first undertaken in a case of secondary bleeding after ligature of the femoral, and since, has often been performed for the cure of inguinal aneurism, with almost uniform success. It has also been practised successfully, on account of hemorrhage after amputation. I was under the necessity lately of putting a ligature round the external iliac, on account of profuse bleeding from an opening in the groin, made five weeks previously, to secure the common femoral, on account of hemorrhage from a stump of the thigh. This operation should have been had recourse to in the first instance, the deligation of the common femoral being an operation not likely to be followed by permanent closure of the vessel, in consequence of its shortness, and the branches given off from it both above and below. The patient ultimately recovered from these three capital operations. The incisions are made in the same direction as recommended for ligature of the common and internal iliacs, but not nearly so extensive. This is preferable to incision, either in the direction of the vessel, or of a semilunar form with one of the corners pointing upwards; the abdominal muscles are less weakened, less injury being inflicted on them, and no troublesome bloodvessels are encountered. The artery is well circumstanced for the application of ligature, affording a considerable extent without the giving off of any branches. It is easily exposed by cautious separation of the cellular tissue, and the ligature is secured either towards its middle, or at its upper part, according to the size and situation of the aneurism.

Popliteal aneurism is of more frequent occurrence than any of the preceding; and in regard to it, also, the old operation has deservedly fallen into disuse. It seems in most cases to be occasioned by partial laceration of the coats of the vessel; a sudden pain, and a feeling as of the receipt of an injury on the part, are generally felt, during some violent or unusual exertion; the pain continues, and an unwonted beating is soon perceived in the ham, along with inconsiderable swelling; the tumour with pulsation increases, and may ultimately attain a large size, causing pain, general uneasiness in the limb, and lameness, sometimes œdema. In cases of long duration, and when the patient is cachectic, the bones become diseased, absorption being caused by the pressure of the tumour, and deep extensive abscess may form in the soft parts.

The _superficial femoral_ is to be tied, and the preferable point is where it is crossed by the sartorius muscle. This is always a better practice than removal of the limb, which has not unfrequently been resorted to in cases of large aneurism; there is great risk in such a proceeding, the anastomosing vessels in the thigh are all much enlarged, profuse hemorrhage takes place during the incisions, not completely arrested by any pressure, and probably twenty arteries or more require ligature, as I have witnessed; after all, the occurrence of secondary bleeding is not unlikely. I have tied the femoral artery, with a favourable result, in some cases of very large aneurismal tumour, and in one instance after the cyst had been imprudently punctured. An incision is made from three to four inches in length, and in an oblique direction in regard to the thigh, tracing the inner border of the sartorius muscle, and so placed that its middle may correspond with that part of the artery on which the ligature is to be put. In order to insure the wound being thus situated, there is no need for measurements; these are but a clumsy substitute for anatomical knowledge. The surgeon, well acquainted with the relative situation of the parts, finds it sufficient to ascertain the exact course of the muscle by manipulation, whilst the thigh is slightly bent, and then guides his knife by the eye, unfettered with mathematical diagrams. The muscle is exposed almost by the first incision; the dissection is then continued through the cellular tissue on its inner border, until the sheath of the bloodvessels is reached, the branches of the crural nerve on the fore part being carefully placed aside uninjured; the sheath is cautiously opened immediately above where the muscle conceals it, and the artery separated from its connections to a very slight extent; the needle is then passed, and the ligature applied. The operation, when thus conducted, is exceedingly simple. But embarrassment and delay have often been experienced from following an opposite method, cutting down on the outside of the sartorius; the muscle must either be dissected from its attachments and turned over, or cut across; or the artery cannot be found, and an additional external wound is necessary.

The artery may require ligature at a higher point, either in consequence of wound, or for the cure of femoral aneurism. This disease, however, is very unfrequent. When it does exist, it is usually so situated as not to admit of the favourable application of a ligature below the origin of the profunda; and it may be considered necessary to tie the _common femoral_. The course of this artery being superficial, is easily ascertained; an incision of convenient extent is made in the same line, penetrating the skin and fatty matter; the cellular tissue is carefully separated, and the sheath exposed; a limited opening is made, with corresponding detachment of the vessel, and the ligature applied, close to the lower edge of the ligament of Poupart. But ligature of the external iliac is in all cases to be preferred, for the reasons already given. This has proved successful in more than one case of double aneurism, one in the groin, the other in the ham.

In ligature of the common and of the superficial femoral, the vein is in more danger than the nerve, and the utmost caution is required lest it be punctured. It has been wounded—I witnessed one instance of it; the opening was drawn together and closed by ligature, inflammation of the vein supervened and proved fatal.

When secondary bleeding occurs, on the separation of the ligature, either after this operation or after that for popliteal aneurism, compression is not to be trusted to, nor should the vessel be tied higher in the thigh. From imprudent reliance on the former method I have known patients perish. An incision must be made in the same line as the former, and a ligature placed on the vessel both above and below the bleeding point, as may be necessary.

The arteries of the leg very seldom require ligature, except for wound. In such cases, the source of the bleeding must be the guide to the incisions, and these should be placed so as to interfere with the muscles as little as possible, always in the direction of their fibres. When the bleeding point is arrived at, the vessel is exposed to a short distance, and tied above and below the wound. During the dissection, it will in most cases be necessary to arrest the bleeding by pressure in the ham, either by the fingers of an assistant, or by means of a tourniquet.

The thigh may be the seat of _aneurismal varix_, the result of wound, as in the following case. Fourteen years ago, a young man wounded the lower part of his thigh deeply by the accidental thrust of a narrow chisel. The puncture was in the direction of the femoral artery; violent hemorrhage was the immediate consequence, and after he had fainted the wound was stuffed and compression applied. In eight days the parts had healed, and he returned to work as usual. But about twelve months afterwards, troublesome pulsation was perceived in the part, at the same time the veins of the leg became varicose, and a succession of ulcers formed on the lower and anterior portion of the limb. The affection attracted but little of his notice till about six months since, when he observed a considerable swelling in the site of the wound, beating strongly, and the pulsations accompanied with a peculiar thrilling sound and feel—not confined to the tumour, though strongest there, but extending to the groin along the course of the femoral vein, which was evidently much dilated throughout its whole course. At present the tumour is nearly equal to the fist in size, of regular surface and globular form, pulsating very strongly, and imparting to the hand the peculiar sensation of aneurismal varix, remarkably distinct and powerful. The pulsation and thrilling are continued, in a less degree, to Poupart’s ligament, and down to the calf of the leg. On applying the ear close to the tumour, or listening through the stethoscope, the peculiar noise is not only felt, but heard of almost startling intensity—somewhat resembling the noise of complicated and powerful machinery, softened and confused by distance. By making firm pressure on the tumour, the thrill is lost, and the regular pulsation alone perceived; at the same time, the turgescence of the femoral vein disappears, and on compressing the femoral artery in the middle of the thigh, both pulsation and thrilling are arrested, and the swelling much diminished,—but only temporarily, for the collateral circulation is free and complete. He feels little pain, but exercise and exertion of every kind are seriously impeded; constant and firm pressure on the swelling, with uniform compression of the whole limb, has been employed, with the effect of relieving all the symptoms, and rendering the limb much more useful, and by its continuance it is to be hoped that the disease will at least be considerably palliated.