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ON SOME
DISEASES OF WOMEN

Admitting of Surgical Treatment.

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ON SOME

DISEASES OF WOMEN

Avmitting of Surgical Creatment.

BY

ISAAC BAKER BROWN, F.R.C.S. (sy exam.)

SURGEON-ACCOUCHEUR TO ST, MARY’S HOSPITAL,
VICE-PRESIDENT OF THE MEDICAL SOCIETY OF LONDON,
FELLOW OF THE EPIDEMIOLOGICAL SOCIETY,
CORRESPONDING FELLOW OF THE OBSTETRIC SOCIETY, BERLIN,
ETC, ETC,

Gllustrated by Coloured Plates and Wood Engrabings.

 

LONDON:
JOHN CHURCHILL, NEW BURLINGTON STREET.
(Established in Princes Street, Soho, 1784.)

MDCCCLIV.
Y

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TO

CHARLES LOCOCK, M.D.

FIRST PHYSICIAN-ACCOUCHEUR TO THE QUEEN,

THE FOLLOWING PAGES
ARE INSCRIBED,

AS A TRIBUTE OF RESPECT TO HIS HIGH PROFESSIONAL STANDING,
AND AS A GRATEFUL ACKNOWLEDGMENT OF THE
MANY ACTS OF KINDNESS AND ASSISTANCE SHOWN BY HIM
DURING NEARLY TWENTY YEARS,
TO HIS FAITHFUL AND OBLIGED FRIEND,

THE AUTHOR.

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e
CONTENTS.
PAGE
LIST OF ILLUSTRATIONS «6 1. ee ee ee ee eK
PREPAOQE 4: 445 ai Sue eh Oe wa ES ee BOG Oe ak BO
PRELIMINARY OBSERVATIONS. ©. 2 6-1 1 ee ee ee ee ee OD
CHAPTER I.
RUPTURED PERINEUM . 2 2 1 ee ee ee ee ee ee ee
CHAPTER II.
PROLAPSE OF THE VAGINA | ne hn D2 On em es a AR Ee, 2 ree ce kd
CHAPTER III.
PROLAPSE OF THE UTERUS . . . - ee ee ee ee ee ew ee 85
CHAPTER IV.
VESICO-VAGINAL FISTULA. 6 eee ee ee ee ee ee ee 89
OHAPTER V.
REOTO-VAGINAL FISTULA . . 112
CHAPTER VI.
~ LACERATED VAGINA . 116
CHAPTER VII.
POLYPUS OF THE UTERUS . 118
CHAPTER VIII.
. 130

STONE IN THE FEMALE BLADDER .

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viii CONTENTS.

CHAPTER IX.

PAGE

VASCULAR TUMOUR OF THE MEATUS URINARIUS . . . . . . . . . » . 187
CHAPTER X.

IMPERPORATE HUMEN ¢ 4 3 yy 8 4 HB * e ee ee 4 & & % 3
CHAPTER XI.

ENCYSTED TUMOUR OF THE LABIA . . . . . «7. ee ee ee ee 144
CHAPTER XII.

DISEASES OF THE RECTUM RESULTING FROM CERTAIN CONDITIONS OF THE UTERUS. 147

CHAPTER XIII.

ON OVARIAN DROPSY, OR ENCYSTED DROPSY OF THE OVARY. . . . . . . 159
APPENDIX?S <4) @ # eo @ @ & 6 6 8 4 ¢ oS Oe # wig aoe a 2 278
INDEX) &@ 2 2 Ro 4 8 egw Se ooh KR @ 2 BOR Se Oe a we 1g BBS

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PLATES

I.

II.
III.
Iv.
V.
VI.
Vil.
VIII.
TX.

FIGURES
1 & 2.
3&4.
5 & 6.
7.

8.
9.

10.

11.

12.

13 & 14.

15.

LIST OF ILLUSTRATIONS.

E
The extent of the surfaces denuded in the operation for Ruptured Peri- kc
MOOUI ) ge Re ay, a, ee, Bee gy So ee. BB
Position of the parts on the fourth day after ditto . . . . 86
Position of the parts in a case of Cystocele before operation . . . . 72
Extent of the surfaces denuded in operation for ditto . . . . . . 74
State of the parts after the operation ©. . . . . . . . . . . 95
Normal condition of the Pelvic Viscera . . . . . . 2... 149
Slight retroversion of the Uterus . . . . . . 2... id
Entire retroversion ditto ditto . . . . . io ar, a ee ad.
Post-mortem appearance of an ovarian Cyst, nae some ithe pre-
viously by artificial oviduct. . . . . . 1. . . . . . 280
Needles for the deep sutures in Ruptured Perineum . . . . . . 34
Mr. Brown’s Perinzal Bandage . .. de sy ele es BT
Mr. Sims’ operation for Vesico- Vaginal Fistula . Be fas » 94
Mr. Brown’s knife for denuding the edges in Vesico-Vaginal Fistula « 9¢
Mr. Brown’s forceps for ditto . . . vet, Wome te, BO
Needle made at the suggestion of Dr. Wilkes for ditto Ps & Ag lio 98
Mr. Moullin’s improvement on Jobert’s Porte-Aiguille for ditto. . . 98
Needle by Mr. Blaize for ditto. 2. 2. . . 1. we. ee ew 9D
Dr. Druitt’s form of needle for ditto . . . 99
The appearance under the microscope of the eed pall: sii para
found in Ovarian fluid . . . . . 189
The large-sized trocar and canula used by Mr. Resid in chaning Ovaciaa
Cysts: Se Be hale ore eae, eo eae we we 209

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PREFACE.

TuHeEReE is no branch of Surgery more open to improvement
than that which relates to those accidents and diseases incident
to the female sex, which admit of no relief except from the hand
of the surgeon. In the standard works on Midwifery and the
Diseases of Females, these surgical diseases are for the most
part but imperfectly discussed, and their treatment is often
described in few words, and without any suggestions to direct
the surgeon through the difficulties and dangers of the more
important operations proposed for their relief. Nor has there
yet been published in this country any work specially devoted
to the consideration of these difficult, and, for the most part,
exceedingly distressing cases.

On some of the diseases in question, it is true, we have not
only admirable articles, scattered over the pages of our periodical
literature, but also full and well-written treatises; and to the
authors of these I gladly acknowledge my obligations. With
regard to other diseases, however, of not less urgency and import-
ance, I have sought in vain for any useful information in books,
and have been thrown, of necessity, on my own resources. It
is to the diagnosis and treatment of the latter class of cases, that
the bulk of this volume is devoted ; although the former are
not passed over with neglect, especially where I felt able to add

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Xi PREFACE.

any details of practical importance to what is already known
concerning them. ‘The treatise makes no pretensions to com-
pleteness. The subject is by no means exhausted. I have,
however, endeavoured to present a clear and practical, descrip-
tion of all the more recent improvements in this branch of
Surgery ; and I take leave of the subject, not without the hope
that much greater advances will soon be made by abler hands

than mine.

I. B. B.

16, Connaught Square, Hyde Park,
1854.

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DISEASES OF WOMEN

ADMITTING OF SURGICAL TREATMENT.

PRELIMINARY OBSERVATIONS.

THE subjects treated of in the following pages, I divide into
two sections. I.—Diseases or accidents which result directly
or indirectly from parturition. II.—Diseases or accidents of
the female organs occurring independently of pregnancy.

I.—Under the first section are classed operations for

1. Rupture of the Perinzeum.

2. Prolapsus Vaginee.

3. Prolapsus and Procidentia Uteri.
4. Vesico-Vaginal Fistula.

5. Recto-Vaginal Fistula.

6. Lacerated Vagina.

II.—Under the second section are classed operations for

1. Polypus Uteri.
2. Stone in the Female Bladder.
3. Vascular Tumour of the Meatus Urinarius.
4. Imperforate Hymen.
5. Encysted Tumours of the Labia.
-6. Diseases of the Rectum resulting from certain
conditions of the Uterus.
7. Ovarian Tumours.
With regard to the first class, the lamentable results of
B

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2 PRELIMINARY OBSERVATIONS.

difficult labours, so appalling to the hapless victim, so injurious
to her health and spirits, so obstructive to conjugal intercourse,
driving the sufferer from the society of her friends, and rendering
life all but intolerable,—I trust that the cases and suggestions
which will be found under this section will be of essential service
in removing this fertile source of human affliction, and may
be the means of relieving many females who have hitherto
kept their sufferings secret, without even the alleviation of hope.
In regard to one of these afflictive conditions—viz., ruptured
perineum, I have not confined myself to the limits of a mere
practical essay on the surgery of the case, but have endeavoured
to give a full history of all the various methods of treatment
recommended by surgeons of this and other countries; and I
trust the chapter will be found useful to my medical brethren
for reference. I have been induced to present an elaborate
treatise on this subject, even at the risk of tediousness, because
the notices of it to be found in works of British surgery and
obstetricy are very meagre.

With regard to the second class of ailments;—much has been
written, and well written, on the methods adopted for removing
polypi of the uterus; I have, however, offered some suggestions
which I hope may be found improvements in the mode of opera-
ting. The chapter on affections of the rectum will, it is hoped,
be serviceable in calling attention to their uterine complications.
In the chapter devoted to ovarian tumours (a subject which
has occupied my anxious attention since 1830), I have endea-
voured to expound and elucidate, step by step, in as comprehen-
sive and practical a manner as possible, the real and comparative
value of the various expedients which, in modern times, have
been adopted for the destruction of a distressing, and ultimately
fatal disease, formerly considered beyond the reach of surgical
skill; and I take this opportunity of explaining my views, and
of briefly recapitulating what I have published on the subject
during the last ten years.

In the year 1830, I read a paper at the Physical Society of
Guy’s Hospital, on “ Extirpation of Ovarian Cysts.” This
paper was a translation (by Mr. Hilton) of a paper sent to that
society from Wilna, in Poland. Since that period I have been

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PRELIMINARY OBSERVATIONS. 3

endeavouring to devise means by which this disease might be
destroyed without an operation dangerous to life. Most of these
expedients have been, to a certain extent, successful; but as
there are cases in which the most simple means are the most
eligible and valuable, so there are others in which the operation
for ovariotomy is requisite and justifiable.

In the year 1844, I published in “'The Lancet” my first
paper “On the Successful treatment of Ovarian Dropsy, without
the Abdominal Section.” In discoursing on the various plans
for extirpation of the tumour, in the introduction to this paper,
I expressed the opinion, that I did not think any of these
severe operations were justifiable till this, or a similar plan
of treatment, had been tried. It will, therefore, be seen that
I have never condemned extirpation, partial or entire, but have
only endeavoured to draw attention to other plans less hazardous
before resorting to that extreme procedure.

In the same year I published further remarks on the same
‘subject, in reply to objections which had been brought against
my views.

In the year 1848-9, I wrote a series of four papers, in which
I took a review of all the cases, successful and unsuccessful,
which had occurred in my practice; and, as I think, completely
refuted certain misstatements which had been made in order to
depreciate the value of my cases by discrediting the facts; an
attempt as weak as it was uncandid, for it happened that one or
more of my professional brethren whom I met in consultation
on the cases, were eye-witnesses of every fact which I had pub-
lished. Attempts, not less disingenuous and discreditable, were
likewise made to throw doubts on the correctness of my
diagnosis, which proved equally abortive.

The next two papers (published in 1850) were “ On the
Diagnosis of Ovarian Dropsy ;” and, in November of the same
year, I published a paper “On the Treatment of Ovarian Dropsy,
by the production of an Artificial Oviduct ;” and, in 1852, some
papers “On the Treatment of Ovarian Dropsy, by excising a
portion of the Cyst.”

It will be seen that in the following pages I have endeavoured
to institute an impartial examination of the comparative merits

B 2

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4 PRELIMINARY OBSERVATIONS.

of these methods of treatment, and the conditions of disease
which may render each, or any of them, specially applicable. I
have also added a practical account, with cases, of the operation
of extirpating the whole tumour; and have endeavoured to
show in what cases, and under what circumstances, this formid-
able operation is justifiable.

Several of the lesions considered in the following pages have
been so thoroughly treated of by others, that I have deemed it
unnecessary to enter into detail respecting them; and have
accordingly restricted myself to the practical suggestions I have
to offer as to their causes, diagnosis, and treatment. This will,
for instance, account for the apparently superficial description of
the varieties of prolapsed uterus, polypus uteri, &c., lesions
which are considered mainly with reference to the peculiar plans
of operation I propose for their cure.

I would here acknowledge the great advantage I have derived
from the able work of Dr. Fleetwood Churchill on “ Diseases
of Women,” and would refer my readers to it for those particu-
lars which the peculiar character of my present work excludes.

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CHAPTER I.

LACERATION OR RUPTURE OF THE PERINAUM.

Tus is doubtless one of the most distressing accidents of labour,
and needs not the aid of many words to recommend itself
to our best attention; and although, thanks to the skill and
science of modern accoucheurs, it is an accident of comparatively
infrequent occurrence, yet I presume, few, if any medical men
fail to meet with it, in greater or less severity, in the course of
their practice.

The frequency of the accident—What is its relative frequency
among parturient females I have no data to show. The slighter
degrees, which demand no particular treatment, are certainly
common, especially in primipare; and I apprehend that the
severer forms are more frequent than is generally supposed,
often being, from the natural modesty of women and from
despair of obtaining. relief, kept secret with the sufferers. Of the
twenty-four instances of the severer forms of ruptured perineum,
given in the following pages, twenty-one happened in the first, two
in the second, and one in the eighth labour. Though the number
of examples are limited, no doubt can be entertamed of the parti-
cular proclivity of primipare to the accident; and this is what
might naturally have been predicted: at the same time it is
seen to be not strictly peculiar to them.

The frequency of the lesion relative to the age of the patients
cannot be safely predicated from so small a number of cases.
However, the mean of the reported ages of that number is about
twenty-eight; an age, in an obstetrical point of view, at which
an increased difficulty would attend parturition in first confine-
ments, which the great majority of the number in question
were.

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6 LACERATION OR RUPTURE OF THE PERINEUM.

However this may be, rupture of the perineum is a suffi-
ciently common lesion, and its consequences so grievous. as to
make it imperative on every practitioner to thoroughly acquaint
himself with it, and to study the best means for its relief.

Structure of the Perineum.—Without entering into anato-
mical details, it is as well to describe briefly the general struc-
ture of the perineum. This extends from the fourchette of the
vagina to the anus, and varies in length, from an inch to an
inch and a half, in the quiescent state; but it will measure from
four to five inches when put on the stretch during labour, so
extensible are its tissues. It consists of skin, fascia, and muscular
fibre; the last made up of the constrictor vaginee, transversalis
perinei and sphincter ani muscles, all of which meet at, and, in
fact, have their common insertion at the centre of the perineum.
By this arrangement it follows that, when divided in the line of
their common centre, as is the rule, they must by their contrac-
tion draw asunder the sides of the fissure. More deeply seated
are the deep fascize and the levator ani muscle. From their
attachments the fibres of this muscle will evidently also assist in
separating the edges of a perineal laceration. The firmness of
the perineum depends on the tonicity of the muscles, the
elasticity of the skin, and particularly on the strength of the
fascia.

Varieties of the Ruptured Perineum.—According as the peri-
nzum alone, or one or both of the mucous canals in relation
with it are involved, we are presented with the several varieties,
or: degrees of laceration. I make four varieties:—l. That in
which the permeum is torn to the extent of an inch or
less from the fourchette. This degree of injury is of no
great moment, is little marked when the parts return to their
quiescent or normal state, and requires no special treatment ;—
2. Where the permzum is torn between the constrictor vagine
and sphincter ani, those muscles remaining intact. This is
actually a perforation of the perinzeum, and, in some rare cases,
has given passage to the child;—3. Where the laceration occu-
pies the entire length of the perineum but does not penetrate
the sphincter ani; and 4. Where it extends so as to divide the
sphincter ani, and even the recto-vaginal septum. It is this

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LACERATION OR RUPTURE OF THE PERINEUM. 7

last form which constitutes so heavy a calamity to the patient,
and has hitherto been found so little amenable to treatment.

M. Velpeau remarks,* that two different lesions are generally
confounded together under the title of rupture of the perineum—
viz., perforations and fissures; the former (perforations centrales)
existing where the circumference—the sphincters of the anus
and vagina—is unbroken; the latter ( fentes vulvaires) where the
sphincters are involved and the fissure invades more or less the
rectum. Laceration of the perineum is peculiarly an accident
of childbirth; yet it may possibly occur from external violence,
but then its treatment will be the same. Some may imagine
that such an accident at parturition ought not to occur in the
hands of a careful practitioner, an inference, however, not coun-
tenanced by the records of obstetric medicine. It has occurred.
in the practice of the best accoucheurs, and some of its causes
we can neither obviate nor remove.

The causes of laceration may be divided into exciting and
predisposing. 'The former comprise:—l. Sudden and violent
expulsive action of the uterus before the os externum is properly

dilated; 2. Moderate or natural pressure with an abnormal con- .

dition of the perinzeum, or a very large child; 3. Improper or
injudicious employment of instruments, manual force, clumsy
manipulation in aiding the passage of the shoulders, or the want of
assistance. Of these three divisions of exciting causes the last is
the most fruitful of the accident. In twelve of the twenty-four
cases hereafter described, the use of instruments was the cause—
viz., in five the forceps, in one the vectis; in one (Case IIT.), ac-
cording to the patient’s statement a boot-hook was used, it is to
be supposed in the absence of a proper instrument; in the other
five the particular instrument employed was not ascertained.
In Cases II. and XIV. the accident was due to the sudden
onset of active uterine contractions during the application of
instruments, forcing forward the head and instrument \together.

In two of the three cases of M. Verhaeghe,t manual violence in —

* De Art des Accouchements. ; eg
+ Mémoire sur un nouveau procédé opératoire pour la guérison des
Ruptures completes du Perinée. Bruxelles. 1852.

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8 LACERATION OR RUPTURE OF THE PERINEUM.

rude attempts to facilitate the delivery of the head or shoulders
was the immediate cause.

Predisposing Causes of Rupture—The predisposing causes of
rupture, or those conditions of the parts concerned in delivery
which concur with, or favour the action of the exciting, are:—l.
An undilated state of the os externum when the child is driven
forwards by the active contractions of the uterus, as happens in
precipitate labour, instanced in Case XII. 2. An unnatural
rigidity of the perineum, which is dry, hot, thin, and unyielding,
as occurred in Case XIV. 3. A structural peculiarity, in which
the perineum is thick, undilatable, and readily torn, the mus-
cular tissue of the patient generally being flabby, as seen in
Case X. 4. A peculiar conformation of the perinzeum, which,
in some women, is so lengthy, that is, extending so far forward,
that it is distended by the advancing head like a bag, the os
externum meanwhile rémaining nearly quiescent; in other words,
the propulsive efforts of the womb drive the child’s head against
the broad surface of the perinzeum instead of towards the external
outlet. ‘ 5. Other malformations of the pelvis may, in particular
cases, conduce to the accident, so also may a misplaced uterus.
6. Parturition at an early age, will, from the state of the
tissues, favour the occurrence of rupture. Again, predisposing
causes may be found im conditions affecting the child, such
as an abnormal position or presentation, or any state involving
an increased bulk; as, for instance, hydrocephalus, twins, as in
Case XV., &e.

As the question has been mooted how far ergot of rye is a
cause of laceration of the perineum, I may reply that that drug,
injudiciously administered, may certainly be an indirect or re-
mote cause of the accident, by inducing violent uterine contrac-
tions, and a too rapid expulsion of the child. In a like manner
other medicinal or physical agents, or the age, or various con-
ditions of health of the mother, may interfere with parturition,
and act as remote causes of rupture; the description of such,
however, would involve details unsuitable to the present trea-
' tise, and are, moreover, well given in the works of various
accoucheurs.

Prevention of Rupture——It happens that there is considerable

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LACERATION OR RUPTURE OF THE PERINEUM. 9

difference of opinion amongst accoucheurs with respect to the
management of the perineum during the last stage of delivery.
The old authors on midwifery all recommend supporting the
perineum with the hand alone, or with a napkin; others, and
especially my accomplished colleague, Dr. Tyler Smith, in his
excellent work on the “ Physiology of Parturition,” object to
this plan, as causing a reflex nervous action from the perineum
to the uterus, whereby the latter is excited to greater expulsive
efforts, and, consequently, to the exertion of greater tension on
the perineum. This objection, no doubt, in a great measure,
holds good; for it is certain that frequent interference to sup-
port or press against the perineum, or to examine per vaginam,
does keep up an injurious excitement of the uterus, and increase
its expulsive efforts. Yet it is equally true that, where the head
is pressing downward and backward, i. e., on the rectum and
perineum, the hand should be steadily applied, so as to guide
the head forwards under the arch of the pubes through the
external parts.

Where rigidity of the perinzeum opposes the advance of the

child, various remedies have been proposed to overcome it, as,

bloodletting, tartar emetic, warm fomentations, and greasy sub-
stances ; but since the introduction of chloroform into practice,
I have never resorted to any of them, because I have found
that in ten minutes, in the very worst cases, the parts have
become dilatable when that agent is administered by inhala-
tion.

In those instances of elongated perinzeum in which the head
distends that structure like a bag, and cannot be driven forward,
it is necessary not only to support the permeum with the
greatest care, but also to introduce the thumb and fore-finger
of the right hand as far as the vertex, so as to be able to give a
forward direction to the head, and to guide it through the ex-
ternal parts, whilst at the same time the fourchette, where rup-
ture is most apt to occur, is thereby defended from the excess
of pressure. ;

Where, lastly, the contractions of the uterus are so violent as
to threaten precipitate delivery, the passages being unprepared,
the uterine action must be restrained by the inhalation of chloro-

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10 LACERATION OR RUPTURE OF THE PERINEUM.

form, or, where this is contraindicated, by the administration of
opium. Having these resources at hand, I would consider blood-
letting inadmissible, and tartar emetic a means of reducing
uterine power not to be recommended.

In cases where rupture seems inevitable during delivery, Dr.
Blundell recommended and practised the plan of relieving the
tension of the perineum by a slight lateral or oblique incision
during a pain, thus actually producing a laceration, but one of
no moment, if it serve, as intended, to prevent the tear along
the median line, where it naturally takes place, and proves of
serious consequence. This plan I concur with, and would practice
where indicated.

M. Chailly-Honoré places particular stress on duly supporting
the perineum during the delivery of the shoulders; stating, as
his belief, that most lacerations occur at that time from the neg-
lect of such support. In Cases VII. and XI., the exit of the
shoulders caused the rent; and so again it was the rough attempt
to deliver the shoulders which, in M. Verhaeghe’s third case,
did the mischief. This.reference to facts does not, indeed, con-
firm Chailly-Honoré’s opimion, but it demonstrates the import-
ance of giving due assistance at this stage of delivery, by showing
the escape of the shoulders to be not an unusual cause. It is
again an obvious rule to induce women to moderate their
efforts at expulsion during the passage of the head of the
child.

I need not extend my observations on the means of obviating
the causes of laceration, since they are well treated of in all
books on the art of midwifery.

Consequences of Rupture—The consequences entailed by a
laceration of the perineum will depend on its extent: they may
be slight and temporary, or so severe as to render life miser-
able ; the latter only require to be detailed, and to any one who
attentively considers the relative anatomy and functions of the
parts, they will seem very obvious. The triangular chasm of
which the perineum forms the floor, has the rectum tending
downwards and backwards as its posterior wall, and the vagina,
passing downwards and forwards, as its anterior; consequently,
when the two lips of a ruptured perinzeum are drawn asunder,

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LACERATION OR RUPTURE OF THE PERINEUM. il

the prominent convexity of the posterior wall of the vagina is
brought into view with its transverse ruge; and when the injury
is of old date, all this is much hypertrophied and hardened.
Again, the laceration may have penetrated so as to lay open
the vagina, tearing asunder the sphincter ani and recto-vaginal
septum, thus converting the opening of the two canals into
one.

Acting as the perinzeum does in the way of a counterpoise
to the downward pressure of the diaphragm on the abdominal
and pelvic viscera, its laceration deprives the latter of their
natural support; hence the proclivity to prolapse of the uterus,
of the bladder, and of the rectum, and their attendant
symptoms,—dragging pains from the loins, interference with
the functions of the bladder, leucorrhceal discharges, incapability
of exertion, even of ordinary exercise, inability to go up or
down stairs. Again, when the sphincters are torn their func-
tions are lost, the feces and intestinal gases pass uncontrolled.
Hardened feces may certainly be in a measure retained, but
when at all fluid, they will escape quite involuntarily, entering
the vagina and adjoining parts. Such circumstances necessarily
confine the afflicted person to her house or room, exclude from
all society, and render existence miserable. They may even
induce disgust on the part of the husband towards his unfortu-
nate wife, and render her companionship odious. No patients,
indeed, ought to be more the objects of our profound commisera-
tion, and of our liveliest sympathy. If any condition could
incite us to devise remedies, it surely would be this, in which
the patient may have all the bodily and mental functions m
health and vigour, but be by this accident so cut off from all
the pleasures and comforts of existence, that death seems pre-
ferable to life, and any means appear justifiable and are sought
for, which promise temporary quiet or oblivion.

Difficulties of treatment—The difficulties to be overcome in
the treatment: of laceration of the perinaum, have hitherto
been generally regarded as almost insurmountable. This im-
pression led to the common practice of leaving the injury to
nature; whilst the frequent failure of operative proceedings
induced many eminent surgeons to oppose altogether their

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12 LACERATION OR RUPTURE OF THE PERINAZUM.

adoption; nay more, as Dr. Barnes writes,* “An eminent
obstetric author has sought to console his brethren under the
disappointment of baffled art, by assuring them that it is better
not to cure the whole laceration.”

The situation of the wound, its nature, the structure of the
parts involved, and their relations; the time which may have
elapsed since its occurrence; the retraction that usually occurs;
the difficulty of effecting apposition for a sufficient length of
time to ensure union; the irritation, inflammation, and even
sloughing apt to occur in some constitutions; the greater
tendency to the growth of mucous membrane than to union by
the first intention, or even by granulation; and the difficulty
of the management of the bowels and bladder during the
healing process, present so many and great obstacles in the way
of success in the endeavour to restore the integrity of the parts
by any surgical operation; that the most skilful attempts have
often been frustrated, and many bad cases abandoned as hopeless.
T hope however, in the ensuing pages, to show that these several
impediments to successful treatment, may be met and overcome
by a simple operation, so that laceration of the perineum
may no longer be reckoned among the opprobia of obstetric

surgery.

SURGICAL HISTORY OF THE SUBJECT.

Before proceeding to detail my own plans, I will offer an
outline of what has been done by others; but, at the same
time, will not profess it to be perfect, as the want of literary
leisure for a diligent search after writers has, not improbably,
kept me in ignorance of some useful contributions on the
subject.

So far as my researches have extended, ancient medical
authorities appear to have regarded the injury as irremediable;
by many of them no mention of it is made. Celsus speaks of
lacerations about the vulva, and of recto-vaginal fistula, but
does not describe the severe form of ruptured perineum. For the

* Lancet, Vol. IL, 1849.

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LACERATION OR RUPTURE OF THE PERINEUM. 13

relief of those injuries which he mentions, he recommends absolute
rest, the tying of the legs together, and other general measures
to favour the natural disposition to heal. And with reference
to all but comparatively recent days, it may be stated generally
that no operation was attempted to bring about union of the
torn parts.

German Writers—Excepting Dieffenbach, German surgeons
appear to have studied the subject but little. It has certainly been ©
often enough the theme of dissertations or theses of students pro-
ceeding to their degrees; but, so far as I can discover, has been
rarely a matter of practical research by those so situated as to be
able to contribute to our knowledge. Indeed,—and the remark
applies not to Germany only, but also to France and England,
—neither the anatomy nor physiology of the perineum has
been sufficiently attended to in its bearings on the accident in
question; how accurately soever it may have been studied by
surgeons with reference to the operation of lithotomy.

Dieffenbach’s Rules of Practice.—It is not till 1829,when Dief-
fenbach directed his attention to the matter, that, in Germany,
we meet with any originality in the treatises on, or in the treat-
ment of rupture of the perineum. This eminent surgeon, from
his position at the Charité of Berlin, and an extensive private
practice, enjoyed ample opportunities of observation. After a
most deliberate and careful investigation, Dieffenbach concluded
that suture alone would not supply any certain mode of
remedying perineal laceration ; and, among others, he laid down
the following rules of practice :—1. That prior to the operation
the bowels should be well cleared by purgatives and enemata.
2. That despite the swollen state of the torn parts, the presence
of discharges, and the debility of the patient after delivery, the
operation should be performed as immediately as possible after
the accident, since those evils would be more than counter-
balanced by those consequent on delay, as suppuration, slough-
ing and loss of substance, and the yet later results—displace-
ment of the uterus and associated organs. 3. That no rupture,
however slight, should be left to nature, for the healing would
be superficial, and the vulva enlarged, proportionably to the ex-
tent of laceration, by the retraction of the labia towards the

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14 LACERATION OR RUPTURE OF THE PERINEUM.

anus, the support of the pelvic viscera being also thereby dimi-
nished. 4. That three to five sutures are necessary, according
to the severity of the accident; the insertion of the sutures
commencing at the anus, and, where the sphincter is torn, the
first being applied at its angle. 5. That where the perineum
is lax, either the twisted or the interrupted suture may be used ;
and when the vagina is implicated, its fissure should be first
brought together; also that where the permmeeum is tense and
rigid, an elliptic incision should be made on either side the
median line, and equidistant from it. 6. That in those cases
where there has been a considerable loss of substance, the
transplantation of an adjoining piece of integument may be
resorted to—i. e., a plastic operation may be attempted. 7. That
in cases of old standing, the edges of the fissure require to be
pared before being brought into apposition by sutures. 8. That
after the operation, the bowels should be bound by the admi-
nistration of opium, in doses of one third of a grain twice a
day; and that the urine should be regularly withdrawn by the
catheter.

~ Such are the maxims of Dieffenbach. Of these the most
original is the making incisions where the tension of the
perineum is considerable: among them, too, is one which I have
much insisted on, and which, moreover, is opposed to ordinary
practice—viz., confining the bowels by opium after the comple-
tion of the operation. With respect to the incisions advised
by Dieffenbach, they are spoken of as penetrating only the in-
tegument and superficial fascia on either side the wound, in
order to obviate the pull upon the sutures by any movements.
Thus he seems to have overlooked the divergent action of the
sphincter ani, and did not attempt to remove it by a division of
the fibres of that muscle. Moreover, it was only latterly that
this eminent surgeon recognised and advocated recourse to opera-
tion immediately on the occurrence of the accident.

Chelius gives a brief exposition of the operative proceed-
ings pursued in the treatment of ruptured perineum, but
offers nothing original. He and also Zung, advocate the
common practice of keeping up a looseness of the bowels during
the process of healing. Professor Roser, in a recent paper

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LACERATION OR RUPTURE OF THE PERINAZUM. 15

in Schmidt's “Jahrbucher” for the year, 1853, recommends
hair-lip (twisted) sutures to bring together the edges, and
the leaving them undisturbed for three or four weeks, not-
withstanding any suppuration. Other writers in Germany,
whose works I am personally unacquainted with, have written
on rupture of the perinzeum, among them Menzel, Osiander,
Wutzer and Langenheck.. The plan of the last named surgeon
it is the object of M. Verhaeghe’s (of Ostend) Memoir* to make
known; but I shall defer describing the method at present.
To that memoir I am indebted for the following notice of
German opinions. The interrupted suture is that generally re-
commended as the chief, and the twisted suture as accessory to
keep the integument and subjacent areolar tissue in accurate
apposition by preventing its inversion or eversion. M. Wutzer
employs long curved needles, about 33 inches in length, which
he runs through the entire thickness of the lips of the wound.
These needles, M. Verhaeghe tells us he has himself employed
with great advantage. Wutzer and others postpone operating
till the cessation of lactation ; but Dieffenbach, Jungmann, and
Langenbeck, advise immediate operation.

French Writers—The French literature of the subject is
more extensive than the German. Ambrose Paré, the father of
modern surgery, pointed out the applicability of sutures to the
accident. Mauriceau likewise wrote in its favour. But the
first authentic instance we have of the suture being actually
employed, is related by Guillemeau, a pupil of Ambrose Paré ;
he used the interrupted suture, and met with success. It did
not, however, become a recognised mode of treatment until the
time of Saucerotte and La Motte, at the close of the last cen-
tury. Noél and Saucerotte used the twisted suture, and each
succeeded in a single case.

Although admitted by the majority to be the most effective
and certain means of securing union in perineal rupture, yet
the suture has been condemned as useless, and even as mis-
chievous, by not a few French surgeons and accoucheurs.

* Mémoire sur un nouveau procédé opératoire pour la guérison des
Ruptures complétes du Perinée, par L. Verhaeghe. Bruxelles. 1852.

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16 LACERATION OR RUPTURE OF THE PERINEUM.

Deuleurye* says, such solutions of continuity are to be healed
without sutures ;—Puzos agrees with him ; likewise Outrepont
and others. Boyer even condemns attempts to heal the lace-
ration. Still more recently (1836), M. Duparcque,t who has
devoted an entire treatise to ruptures of the female genera-
tive organs and perineum, concludes that sutures are unneces-
sary and undesirable, and expresses his reliance on the old
general rules of position, absolute quiet, &c.

On the other side, as advocates of operation by suture,
we have Saucerotte, La Motte, the MM. Dubois, and that most
successful and talented surgeon, M. Roux. This last named
gentleman succeeded in curing four out of the first five cases
he attempted. He employed the quill-suture with an accessory
twisted suture at one or two points. In one instance, he kept
the bowels confined for twenty-two days, but he does not pomt
out such a proceeding as a rule of practice; not generally, in-
deed, resorting to it himself. He also practised Dieffenbach’s
incisions, but does not appear to have recognised the utility of
dividing the sphincter ani to obviate retraction of the edges of
the wound. Moreover, M. Roux thinks it best to defer
operating till suckling is given up. In this opinion he is sup-
ported by Danyan. Madame Boivint is silent on the subject.

M. Velpeau§ has a chapter on rupture of the perineum,
and supplies a good review of its literature, but presents no
original matter. He appears to recommend sutures, and,
where tension is great, Dieffenbach’s incisions.

In a patient with rupture of the perineum, involving also
the vagina, Saucerotte, upon repeating an operation, divided
the sphincter ani. No reason, however, is assigned for so
doing, nor is the direction of the incisions mentioned. In fact,
he evidently did not recognise the proceeding as an essential
part of the operation.

MM. Paul Dubois and Chailly-Honoré advocate an ob-

* Traité des Accouchements.

+ Histoire compléte des Ruptures et des Déchirures de l'Uterus,
du Vagin et du Perinée. Paris. 1836.

£ Mémoire de Art des Accouchements. Paris. 1836.

§ L’Art des Accouchements.

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LACERATION OR RUPTURE OF THE PERINEUM. 17

lique incision, about the third of an inch long, of the vulva,
towards the perineum, either to altogether prevent the rupture
of that region when much distended, or, when the laceration is
inevitable, to favour it at a spot where it can produce the least
mischief. The writers support their views by the history of
successful cases.*

English Writers.—With English surgeons and accoucheurs
rupture of the perineum has engaged but little attention. We
have no English treatise on the subject; and it is, moreover,
strange to observe how often a lesion, so important in itself and
in its consequences, and not so uncommon in its occurrence,
has been almost or altogether passed by unnoticed in works on
midwifery and surgery, and even in those of standard reputa-
tion. For example, I find no mention of it in S. Cooper’s
elaborate Surgical Dictionary, none in Pirrie’s Treatise on
Surgery, just published ; no article upon it in Dr. F. Churchill’s
Operative Midwifery, nor in Burns.t Again, where not alto-
gether omitted, it has been very superficially treated of; so
much so, that no sufficient instruction is conveyed to the
practitioner having the treatment of a case, and with no
experienced surgeon at hand to advise with.

In my search after recorded cases of ruptured perineum,
and for opinions respecting its treatment, I have met with
several instructive accounts scattered in the medical journals,
which, that a conception may be had of what has been done in
_the matter, or left undone, in this country, I will briefly advert to.

Smellie, in his book On Midwifery,t relates several cases
of laceration; but all the severe ones were either left to nature
or treated unsuccessfully. Dr. Aitken§ is a determined oppo-
nent to operation, especially by suture, and would trust to the
expedients practised of old, such as tying the legs together,
attention to cleanliness, perfect rest, the withdrawal of the
urine, the use of enemata, &c. Dr. Blundell (Lectures on

* Lancet, Vol. I, 1861. This plan is also proposed by Dr. Blundell.
See p. 10.
+ Principles of Midwifery. Dr. Burns. ;
+ A Treatise on the Theory and Practice of Midwifery.
§ Principles of Midwifery, 1785.
c

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18 LACERATION OR RUPTURE OF THE PERINAUM.

Midwifery) says: ‘“ With the greatest care and nicest manage-
ment these cases are seldom remedied by operation.” He
mentions cases of old and partial laceration operated on
successfully by Mr. Rowley, which, says he, “did great credit
to his surgery.” Denman (Practice of Midwifery) presents a
good description of rupture of the perineum, its causes and
prevention, but points out no plan for its cure. Dr. David
Davis, (Principles and Practice of Midwifery,) im his chapter on
ruptured perineum, appears averse to operative proceedings,
because “they much more frequently fail, . . . leaving the
intermediate gap in a worse state than before,” and remarks,
“that it is a damage seldom benefited by any of the modes
of treatment hitherto resorted to for that purpose.”

Mr. South, in his translation of Chelius (System of Surgery),
appends to the tolerably good account of the subject by the
German author, some valuable notes, and quotes a successful
operation by Mr. Davidson, reported in The Lancet (Vol. II.,
1838-39, p.225,) in which the quill suture was employed, and
constipation kept up for seventeen days. Mr. South, however,
favours the common plan of keeping the bowels loose after the
operation.

Dr. Ramsbotham (Principles of Midwifery) speaks of lacera-
tion of the perinzeum as an accident of labour, but mentions no
remedy for it. Miller (Principles of Surgery) devotes only ten
lines to the subject, and advises any operation being delayed for
some time after parturition.

Dr. Cockle, in a recent pamphlet,* advises a chance
being given of natural union by the first intention; and remarks
that, “as a general rule, sutures are to be considered as in-
admissible, at all events in the early stage.”

Thus, on the whole, the prevalent opinion in England appears
to have been that, from the uncertain, and most frequently, un-
successful results of the operations devised, and from the
apparently insuperable difficulties to be contended with, it was
better merely to aid the efforts of nature in narrowing the
wound, and in lessening the evils attendant on it.

* On Laceration of the Perineum during labour. 1853.

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LACERATION OR RUPTURE OF THE PERINEUM. 19

CASES ON RECORD.

Of the instances of operation narrated in the medical journals,
I will refer first to that described by Mr. Joseph Rogers,
(Lancet, Vol 1., 1849, p. 555). The laceration did not in his
case involve the sphincter, but extended round the extremity of
the rectum quite to the posterior part. The edges of the wound
had nearly cicatrized throughout. In his first attempt, Mr.
Rogers used two stitches (interrupted sutures); but these having
ulcerated through, the operation was repeated, and the edges
placed in perfect apposition by hare-lip pins, secured by the
twisted suture. After the operation, the patient was interdicted
nearly all food for six days, and had her bowels kept bound by
opiates. At the end of seventeen days complete union had
taken place; the period, however, having been prolonged by
obstinacy on the part of the patient.

On this case Dr. Robert Barnes has offered some remarks
(Lancet, Vol IL., 1849). He writes, “I believe that no amount
of skill and precautions will justify the surgeon in the majority
of cases, in looking for perfect union by means of any of the
sutures in common use.” He then proceeds to recommend the .
bead-suture, devised by Mr. Charles Brooke, as obviating all the
objections raised against operation by suture. He supports his
recommendation by reference to a case operated on by Mr.
Brooke, under very unfavourable circumstances, yet with com-
plete success.

Mr. Higginbottom, of Nottingham, briefly relates (Lancet,
Vol. II., 1849, p. 661) a case of laceration of the permeum,
extending through the sphincter ani, which was “directly
united by the interrupted suture in two places, and the nitrate
of silver applied to the skin on each side, close to the line of
the wound, and left without any other dressing.” At the end
of the second day the bowels were opened by castor-oil, and on
the third day the sutures were removed. “The wound united
by the first intention; the eschar surrounding the laceration
made by the caustic had the power of fixing the parts as if
adhesive plaster had been applied.” This treatment was carried
out thirteen years prior to the published account; and during

c2

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20 LACERATION OR RUPTURE OF THE PERINEUM.

that lapse of time the patient had suffered no inconvenience,
and had borne nine children without any recurrence of the
laceration.

In the same volume of the Lancet (p. 672) is the report of a
case treated by Mr. Holt at the Westminster Hospital. The
rupture was of two months’ standing, deep and ragged, “ extend-
ing fron the lower portion of the vagina to the upper part of
the anus.’ The edges having been pared, their contact was
secured by “three double sutures passed through the whole
thickness, at about half an inch from the edge. A piece of
small gum-elastic bougie was then placed on either side; one
piece through the loop formed by the double thread, and the
ends of the ligature tied over the other.” Hight days after, the
sutures were removed, and the bowels, hitherto confined, relieved
by castor oil. In about four weeks union was complete.

In the Lancet (Vol. II., 1850, p. 93), two cases occurring at
King’s College Hospital, under the care of Mr. Fergusson, are
briefly recorded. In some preliminary remarks, it is said
(apparently on the authority of Mr. Fergusson), that “it is
better to wait before any surgical means be attempted, until
_ the primary inflammation has subsided.” In both cases, the
interrupted suture was employed; the distinguished operator
stating his opinion to be that the objections to it are remove-
able by precautionary measures, of which the most important,
as illustrated in the cases cited, are the parallel incisions in the
long diameter of the perinzeum, as proposed by Dieffenbach.

In the first patient, Mr. Fergusson inserted three sutures,
and then made an incision on each side the closed fissure, filling
it with dry lint. The bowels were kept regularly open by
enemata. In about eleven days the sutures were removed, and
at the end of a month both the original rent and the lateral
wounds were entirely healed.

The same plan was pursued with the second case, except that
the bowels were kept confined six days after the completion of
the operation. The perineal wound was entirely and accurately
closed within twenty-seven days after the insertion of the
sutures, but a very small communication existed between the

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LACERATION OR RUPTURE OF THE PERINEUM. 21

vagina and rectum, so unimportant however, that Mr. Fergusson
declined resorting even to cauterization.

Both Mr. Arnott, of the Middlesex, and Mr. Lane, of St.
Mary’s Hospital, have operated successfully for laceration of
the perineum, but have published no detail of their cases; and
without doubt many successful operations remain unrecorded,
or are at least unknown to me. ,

Dr, Lever and Mr. Hilton’s Operation—Quite recently a
volume of the Guy’s Hospital Reports* has appeared, containing
a brochure by Dr. Lever on Laceration of the Perineum, with
two cases operated on in a peculiar manner: viz., by dividing,
by a subcutaneous incision, the coccygeal attachments of the ex-
ternal sphincter and levatores ani.

In the first case the sphincter, during delivery by forceps,
three months previously, had been ruptured, “the laceration
extending through the perineum, so that the feces passed in-
voluntarily.” The operation took place on the 26th August; on
the 1st September, the patient is reported to have then had
“command of the rectum; but she felt a bearing-down pain
after standing or sitting;” and on the 7th “there was a con-
tinuous surface of mucous membrane from the sphincter to the
vagina.”

“This patient, when last seen, two and a half years after the
operation, had lost the pain and bearing-down, and had full
command of the bowels, except occasionally when the feeces were
very fluid.”

The second case, of nine years’ standing, was complicated with
procidentia uteri and leucorrhcea, whilst a considerable portion
of the rectum protruded through the anal opening, the mucous
membrane being intensely injected with blood, and very tender.

“She complained of constant burning pain in the rectum,
with inability to retain the feces if the stools were fluid.....
This woman was seen more than three years after she left the
hospital, and stated that there was no descent either of the
uterus or rectum, but she was compelled to be attentive to the
state of her bowels.”

* Vol. VIIL, Part ii, 1853., p. 401.

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22 LACERATION OR RUPTURE OF THE PERINEUM.

Mr. Hilton operated in each instance, and thus details his
reasons :—“ Remembering that the levatores ani have one firm and
fixed attachment to bone near the arch of the pubes, and
another at the coccyx, and that the external sphincter ani might
be regarded anatomically nearly in the same light in relation to
its effects upon the injury to the perineum, and bearing in
mind that all muscles contract towards their more fixed point, it
occurred to me,—that by disengaging the coccygeal attachments
of the levatores ani, I might allow them to retract the anal
aperture and adjacent structures in a direction towards the
pubes, as it were, to bury the perineal injury deeply in the
pelvis, thus enabling the lower fibres of those muscles to assume
the office of a sphincter to the lacerated opening, by approxi-
mating the edges of it, and drawing it upwards towards the
pubic arch.” Also, “that by separating the coccygeal fixed
point of the sphincter ani, I should necessarily change the
direction of its contractile power from the coccyx towards the
vagina, and thence to the pubes; this I hoped would help to
occlude the lacerated opening between the vagina and rectum.
Whether I had reasoned rightly or not, the results were as
satisfactory, and indeed more so, than I had anticipated. It
seemed to myself, that two ulterior purposes might be held in
view by such an operation; the first was to ascertain how much
of complete relief could be afforded by an operation which pro-
mised to be altogether free from both danger and the severity
of the ordinary operation for such cases; and secondly, should
no important immediate benefit be derived, it would certainly
tend to the advantage of the patient, by putting the parts into
a better state (by relaxing them) for the easy and perfect accom-
plishment of the usual but more formidable operation of paring
the edges of the lacerated wound, and maimtaimmg them in
contact for a time by sutures.”

From the last clause especially, but also from the general
line of argument, Mr. Hilton seems to have apprehended the
importance of annihilating traction of the fissure by severance
of the muscles ; yet I cannot commend the utility of the opera-
tive measures his anatomical reasonings suggested. At the best
those measures answered very indifferently;—the fissure re-

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mained (uot so widely gaping it may be) a source of annoyance
and discomfort ; and the control over the dejections continued
imperfect and a necessary cause of misery. The operation may
indeed be less “ formidable” than that of paring and stitching
the edges together, but the end gained is trifling, and not to be
weighed against complete cure, which the plan I follow promises
almost certainly, and which cannot be rightly called formidable.
T cannot believe Mr. Hilton will have many imitators, nor that
he and Dr. Lever are themselves much in love with the opera-
tion, as they appear to have allowed some six years to elapse
without repeating it im any case.

M. Verhaeghe’s Memoir.—l have reserved the account of
M. Verhaeghe’s Memoir to the-close of this sketch of what has
been done by others, because it has been published since the
appearance (in 1852) of my first Essay on the Treatment of
Rupture of the Perineum, which is referred to in its pages,
and in many points, indeed, the author expresses opinions
coincident with my own. It is curious, however, to note that
in those very points of practice in which we agree, M. Verhaeghe
claims them as peculiar to his operative system, and in contrast
to that adopted in England, although he has at the same time
quoted my pamphlet as one known to him.

I should observe that M. Verhaeghe, who is surgeon to the
Civil Hospital of Ostend, puts himself forward as the expounder
of the system and views of M. Langenbeck, the inventor of the
operation, but who has not himself described it.. It may,
therefore, be rightly called Langenbeck’s operation. It has
been designated perineo-synthesis. Operation immediately after
the accident is advocated ; but the description given of the pro-
ceeding applies to old cases, “ since in recent lacerations it is
only necessary to bring into apposition the divided tissues to
restore the perineum.”

The operation may be divided into several stages, viz,
1. Vivisection of the free border or spur (éperon) of the recto-
vaginal septum. 2. The undoubling (dédoublement) of the
septum, and the formation of a flap destined to form, in the
new perineum, the anterior side of the triangular space (formed.
by the two canals, vagina and rectum, with the perineum as the

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24 LACERATION, OR RUPTURE OF THE PERINEUM.

base). 8. The vivisection of the two lips of the laceration.
4. The insertion of the sutures. 5. The two semi-lunar in-
cisions advised by Dieffenbach.

“In order to pare the free edge of the septum, two fingers
of the left hand are introduced into the rectum so as to stretch
the parts transversely ; then, by means of scissors, a very thin
lamina is removed from the entire thickness of the spur.”
This done, the second stage of the operation, doubtless the
most difficult, comes next. The two fingers in the rectum
keeping up tension of the septum, a nearly semicircular incision
is made on the anterior surface of the latter, and two or three
lines from its inferior border. A convex and very sharp scalpel
should be here used, in order to avoid removing aught but
the mucous membrane, and, above all, wounding the rectum.
The upper lip of this incision is next to be seized by
forceps and separated by careful dissection from the deep layer
for the space in length of six lines, and in the entire breadth of
the septum. Thus two lamin are formed, one anterior or
vaginal, the other, posterior or rectal; the latter destined to
continue in situ to close the rectum, the former to be drawn
forward and fixed by its angles at the anterior part of the new
perineum on each side. It will thus form an inclined plane,
directed from behind forwards, as a sort of valve, which will act
with reference to the new perineum as the epiglottis does to
the glottis; that is to say, it will prevent the fluids of the
vagina coming in contact with the newly united parts.”

“ The vivisection of the two sides of the laceration is the
next object. To do this a quadrilateral space, rather elongated
antero-posteriorly is to be circumscribed by the scalpel, from the
vulva towards the anus, avoiding the mucous membrane of
the vagina above, and the skin below. In front the incision
must not pass beyond, nor yet stop short of the poimt where
the posterior commissure of the vulva naturally exists; behind,
it should connect itself with the corresponding side of the pared
edges of the spur; no portion not pared should exist between
them. In general this quadrilateral space should be an inch
and a half long, by three quarters of an inch wide.

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This space having been very accurately pared, and bleeding
having ceased, the next business is the introduction of the
sutures. The suture intended to close the rectum is the first
introduced, by a curved needle carrying a double thread. The
needle should pierce the skin to the left of the anterior margin
of the anus, and from four to five lines from the edge of the
wound, so that it may come out on the denuded border of the
spur of the septum, at the distance of about two lines to the
left of the central line; it is then to be plunged into the same
border, at an equal distance from the median line, and to be
brought out at a point corresponding to that at which it was
first inserted on the opposite side. By drawing this thread,
the opposite pared edges are found to approach in the
median line, and thus to close the rectum. This ligature
thus drawn, being intrusted to an assistant, the other sutures
to effect specially the reunion of the perineum are to be
introduced. For this object three or four sutures are
needed. M. Wutzer’s needles serve well for this part of
the operation. The posterior suture is the first inserted ;
and about four lines should be left between any two. The
needles should penetrate the flesh four to six lines from the
margin of the wound, and emerge at a corresponding point on
the opposite side, being kept clear from wounding the mucous
membrane of the vagina. Those very long needles possess the
advantage of being able to traverse the entire thickness of the
tissues, from left to right.

The next step is to fix the lamina derived from the septum,
left until the present at the anterior part. For this object
small curved needles with a single thread suffice; and two or
three sutures on each side are enough. This flap beg fixed,
its purpose becomes evident. It acts as a vaulted roof to the
essential parts of the operation, obliging all the original secre-
tions to flow towards the vulva without infiltrating in the
interstices of the united fissure. In other words, it reconsti-
tutes the anterior wall of the triangular space seen in the
normal perinzum.

The sutures of the perineum are now drawn tight. It is

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26 LACERATION OR RUPTURE OF THE PERINZUM.

as well, perhaps, to introduce a needle between the first and
second sutures from the vulva, and form a twisted suture.
Lastly, the incisions of Dieffenbach may be made, as they serve
materially to obviate dragging on the united parts by movements.

Water-dressing is advised, and a (Hooper’s) water-cushion,
of a horse-shoe shape, for the patient to lie upon.

In the way of after-treatment are recommended the con-
stant application of compresses dipped in water; frequent
injections of infusion of camomile into the vagina, and cathe-
terism whenever a desire to pass water is felt. This last
attention is most important, and requires to be continued until
union is perfect.

Low diet is ordered; constipation by the administration
of opium to be secured. After three days the sutures may,
one or other, be withdrawn, and the lint, dipped in goulard-
water, be applied. It is most desirable to avoid any action of
the bowels for a day or two at least after the removal of the
last suture. After the first stool enemata may be used, and
from this date a more substantial and plentiful diet be allowed.

Such is a condensed account of Langenbeck’s method of
treatment, as propounded by M. Verhaeghe. It evidences great
attention to the subject, and in some particulars, especially in
the production of constipation after the operation, by opium,
resembles the plan advocated by myself. However, the writer
tells us that this very point of practice, constipating the bowels,
has not been thought of in England.

Langenbeck’s operation differs from mine primarily and
essentially, in omitting the division of the sphincter ani; and
in a second and inferior degree, by forming a flap from the
septum or spur of the vagina, to prevent infiltration of vaginal
-discharges in the conjoined parts. Of the latter proceeding, I
may here remark that I have not found such necessary, and
that it seems to complicate, and to add difficulty to the ope-
ration. As it may seem desirable, I will here add an analysis
of the three cases, illustrating M. Langenbeck’s plan.

Cases of M. Verhaeghe—The first case was that of a woman,
aged 24. The accident had occurred in her first and only

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LACERATION OR RUPTURE OF THE PERINEUM. 27

labour, two years and a half previously. The laceration was
complete, extending to the anus, and for about four lines into the
recto-vaginal septum. Her labour was long and painful, and
the midwife used much force with her hands to deliver the
head of the child. Intestinal gases escaped involuntarily at
all times, and also the feeces when soft. The bodily health was
good, and menstruation regular. This had occurred ten days
previously.

Prior to the operation, hip-baths, simple vaginal injections,
purgatives, and enemata were used, and the bladder emptied.
The patient was brought under the influence of chloroform ;
and the edges having been pared, four interrupted sutures were
introduced, and one twisted suture between the first and second
of the preceding. The incisions of Dieffenbach were made
about an inch on each side the restored perineum. The
operation lasted an hour and a half, having been interrupted by
the patient, the chloroform failing to produce complete insen-
sibility. Immediately after, a dose of opium was given, and
this was repeated twice before night. The general after treat-
ment above described was pursued.

The next day (September 22nd) three doses of opium were
administered. The patient’s state was satisfactory. On the
24th, a tolerably abundant, blackish, sanguineous vaginal dis-
charge occurred, like a return of the menses. The pin of the
twisted suture was removed this day. 26th: Removed one of
the central sutures, and on the 28th two others. The central
portion, four or five lines in length, was open, and there was
suppuration. Pledgets of lint soaked in goulard-water were
applied. ‘The opium and low diet continued. 29th: The poste-
rior and only remaining suture, which united the rectum,
came away. Granulations were closing up the central fissure.
30th: The menstrual flow ceased. The granulations were
touched with nitrate of silver. October 2nd: The first desire of
. defecation occurred (i. e. twelve days from the date of ope-
ration.) Three enemata of infusion of linseed were injected.
The patient felt able to control the evacuation both of fecal
matters and of wind. From this day the nourishment was

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28 LACERATION OK RUPTURE OF THE PERINEUM.

increased, and improved in character. October 4th: She got
up for the first time and walked gently. The lateral incisions
were now healed. She quitted the hospital cured at the end of
the month.

Casz II. A young woman, et. 24, suffered from complete
rupture of the perineum caused by the application of the forceps
in her first confinement; the sphincter ani was entirely divided;
the inferior border of the recto-vaginal septum, forming a sort
of spur, (éperon,) was the only separation between the vagina
and rectum. Even when the feces were hard they could be
retained but a short while. The lesion had existed five months.
The operation was performed on the 21st December, eight days
after a menstrual period. Besides the suture to close the rectal
fissure, four other deep interrupted sutures were introduced;
each suture consisting of four threads, waxed. By means of
‘Wutzer’s needles,—the parts being lightly drawn together by
traction of the rectal suture, the threads were passed by one
effort, traversing the entire thickness of the two lips to the
bottom of the wound. Three other sutures made fast the flap
of the septum on each side; and one twisted suture was placed
between the first and second of the interrupted. The incisions
of Dieffenbach terminated the operation, which had lasted three-
quarters of an hour, the patient during that time having been
kept insensible by chloroform. A half-grain of opium was
given at once, and twice repeated before night. The catheter
was introduced twice daily, and frequent vaginal injections made.
The most restricted diet was ordered—ouly barley-water and
lemonade.

From the close of the operation till night, the patient com-
plained of cold, and distinct rigors. She vomited once, and the
pulse was small and frequent.

The next morning the skin was warm; the pulse 80, and
stronger. All the night she had suffered much from flatulency. .
On the 28rd, there was febrile reaction. Still much flatus,
but now the patient could control its escape. 24th: The needle
was removed. 25th: Two middle sutures were withdrawn.

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LACERATION OR RUPTURE OF THE PERINEUM. 29

Union seemed perfect. 27th: The remaining threads re-
moved.

On the 30th, the first desire to evacuate the bowels occurred—
z.é., ten days after the operation. Two injections were given,
and much hardened fecal matter discharged. Notwithstanding
every care the wound opened about half an inch, posteriorly ;
fortunately, the anterior half held good. Jan. Ist: After a
laxative by the mouth, a loose evacuation followed, which the
patient was enabled to retain some time. Granulation in the
re-opened portion proceeded slowly; to stimulate it nitrate of
silver was frequently applied. This closure by granulation,
however, and the consequent contraction of tissue had the
effect of shortening the perineum. On the 27th she quitted
the hospital quite cured.

Case III. A woman, et. 22, employed in field labour, suf-
fered laceration of the perineum in her second labour, six
months ago. The injury resulted from the efforts of the mid-
wife to disengage the shoulders by introducing her hand into
the vagina. The rupture was complete; the delivery was fol-
lowed by puerperal fever, and an abundant suppuration of the
lips of the laceration. The recto-vaginal septum is laid open
for about three lines, and the sphincter ani involved; the incon-
tinence of fecal matters complete. The bodily health good.

After the preliminary baths, injections, and aperients, the
operation was performed on the 17th March. The parts were
highly vascular, and bled largely, so retarding the operation,
and requiring torsion of the small vessels. Four sutures were
placed; one to close the rectum, and the other three to form
the new perineum. ‘The flap taken from the septum had been
previously fixed by two sutures on each side. The Dieffenbach
incisions that had been made on each side bled in an unusual
manner.

Cold-water dressing was used, and cold injections of infusion
of camomile every three hours. The knees were kept together
by a bandage. The oozing of blood, chiefly from the lateral
incisions, did not cease till near evening. March 18th: Pro-.

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30 LACERATION OR RUPTURE OF THE PERINEUM.

gressing favourably. Pulse 75; no heat of skin. Vaginal in-
jections as yesterday, but warm. Two doses of opium; nourish-
ment, thickened rice water, lemonade. 19th: The patient finds
she can control the escape of flatus. To-day allowed broth,
a wing of fowl, and the yelk of an egg. The suture nearest
the anus has slightly cut the tissues. 20th: The twisted suture,
and one other withdrawn. 2lst: Condition very satisfactory.
An abundant muco-purulent discharge has taken place from the
vagina. Injections, diet, and opium continued. 22nd: The
vaginal discharge augmenting, an injection of sulphate of zinc
was adopted, and the pledgets of lint externally were soaked in
the same liquid. Only one suture, besides that closing the
anus, was now left. 28rd: The appetite is very great, and the
patient can hardly restrain herself from indulging it. The two
remaining sutures removed. Union seems complete. 24th:
The vaginal secretion less. The same regimen continued. 25th:
Whilst administering an injection yesterday, a sanguineous flow
from the vagina was observed, probably a premature return of
the catamenia. To-day this discharge is copious. Astringent
and cold injections therefore stopped, and the tepid camomile
one repeated. Catheterism and opium continued. Diet: broth,
and rice milk. March 26th: Menstruation still abundant. Ca-
theterism omitted from this day; but patient made to pass the
urine placed resting on her hands and knees, and the parts
carefully washed afterwards. Opium discontinued. 27th:
Catamenia ceased. Having a desire to empty the bowels, two
linseed injections were given without effect, but the third
brought away a scanty stool, of nodular portions. This is ten
days after the operation. The diet still to consist of liquids,
but now in larger quantity. 28th: A copious, formed, not hard
evacuation followed an enema to-day. The perineum was sup-
ported by a cushion of lint smeared well with cerate. The diet
was improved. An enema to be given every morning; the
vaginal injections but twice a day. 30th: The small sutures
confining the flap of the septum were not removed till to-day.
A first attempt has been made to walk. The new perineum is
a good inch long, and very firm.

In concluding, M. Verhaeghe calls attention to the great

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LACERATION OR RUPTURE OF THE PERINEUM. 31

importance of minute attention to the details of the after-treat-

ment, upon which, he truly observes, the success of the operation
will depend.

Such is a summary of what has been said and written by
others respecting the treatment of ruptured perineum. It now
remains for me to state my views, and to detail those operative
proceedings which reflection on the deficiencies of other plans
led me to adopt, and which an ample experience has convinced
me to be the best. Further, as the results of operations are the
best test of their efficiency and value, I shall hereafter detail
those cases in which I have been concerned, and also any others
which have been communicated to me by those who have pur-
sued my plan.

Some few words are due to the consideration of the cases of
a less formidable character than those of the complete rupture,
and which constitute the three first cases I have enumerated
(p. 6.)

The first variety, in which the rent extends to only an inch
or less, requires, as already stated, no special treatment, at least
of an operative description. Such a laceration needs only quiet
and an attention to cleanliness to heal it.

The second form is rare, and demands special treatment.
Mostly, in order to secure the closure of the perforation, it is
necessary to divide the anterior band at the fourchette, and then
to bring together the edges by quill and interrupted sutures. It
almost seems unnecessary to point out that, where the accident
has existed some time, and the edges have become covered by
mucous membrane or otherwise cicatrized, the latter must be
pared before sutured.

The third variety, in which the perinzeum is lacerated but the
sphincter remains ‘entire, is still more an object for treatment.
Although the functions of the rectum are not disturbed, yet
a rupture of this sort, left to itself, entails many evils; for,
besides those immediately attendant on the enlarged vulva, there
are others due to the want of support to the pelvic viscera;

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32 LACERATION OR RUPTURE OF THE PERINAUM.

hence, prolapsus uteri, displacement of the bladder (cystocele),
or of the rectum (rectocele), and symptomatic disorders conse-
quent on such dragging down. Wherefore, every instance of
this degree of laceration requires operative treatment. For when
left to nature, even if closure of the fissure occurs, adhesion is
apt to be superficial, and the contraction ensuing upon the pro-
cess of reparation, is such as to draw backwards the parts towards
the anus, enlarging the vulva, and so predisposing to pelvic dis-
placements.

In examples of this form of ruptured perinzeum, the treatment
is pretty much the same as for the next and severest form, and
most of the steps of the operation to be presently detailed belong
to this degree of the accident, and, to avoid repetition, will not
be here described. (See Case XVI.) However, it will not
always be necessary to divide the sphincter ani, and all the
sutures used will be introduced in advance of the rectum. Both
quill and interrupted sutures are desirable.

In my second “Essay on Rupture of the Perineum,” I
introduced it as a proposition, “that those forms of rupture,
where the sphincter is not torn through, should be cured, to pre-
vent prolapsus uteri, &c.,” and I illustrated it by two cases, which
appear as the sixteenth and seventeenth in the subsequent series.
In those cases I thought it desirable to divide the sphincter ani.
They were both of long standing, and great stretching of the
parts had followed the displacements. In Case XVI., indeed,
the pressure of the prolapsed uterus had been so great as to
rupture the rectum. Case XVIII. is an additional example of
this variety of lacerated perineeum, where I operated on the
occurrence of. the accident, one interrupted suture introduced
answered the purpose, without any further measures. In this
last case, I should state, necessity—from the want of instru-
ments—was the chief reason of this considerable departure from
the practice generally pursued. Indeed, in deciding on the
operation in any particular case, we must be guided by its special
circumstances.

Other instances of rupture of the perinzeum, not involving the
sphincter ani, occur in the chapters on vaginal cystocele and
rectocele, in which, however, the usual operation was modified

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LACERATION OR RUPTURE OF THE PERINEUM. 33

to adapt it to the cure of the complication, which in those cases
was the leading feature.

Contra-indications to Operating. —Before deciding on an
operation, certain circumstances are to be taken into account. ~
For instance, if pregnancy has advanced beyond the fourth
month, if suppuration and inflammation exist, then the opera-
tion must be delayed; in the former case till after parturition,
in the latter, until the arrest of these processes. The presence
of leucorrhcea need not deter from operating, when it cannot be
removed by simple measures: a postponement, however, is
desirable until after a menstrual period. Cough, if present,
should.be relieved, on account of the straining it causes.

It seems almost unnecessary to add that, if the patient’s
health be impaired, an endeavour should be made to improve it
before surgical means are resorted to, for the condition of the
patient has much influence over the success of the operation.

Time of Operating —The operation may be performed imme-
diately after the completion of labour. The surfaces of the
wound are then fresh, and in a condition favourable to union by
the first intention, and consequently the paring of the edges
required in old cases is not here necessary. Should, however, -
surgical means not be resorted to.on the day of delivery, the
advantages accruing from the recent nature of the wound will
be lost; the mischievous effects of the vaginal discharges will
have placed the edges in a disadvantageous position for healing,
and it will therefore not be desirable to attempt an operation
until after the third month, by which time the parts will have
recovered themselves, be capable of undergoing the necessary
denudation, and be sufficiently strong to carry the sutures.

As immediately preparatory measures, the bowels should be
well cleared out by aperients—such as ox-gall, castor oil, and
by injections of salt-and-water. Warm baths are not ob-
jectionable, but generally sponging with warm water is sufficient.
The diet for some days prior to the operation should be
unstimulating, plain, and nutritious. Asa last point, the bladder
should be emptied.

Instruments required—The instruments required are, a
common straight scalpel; a blunt-pointed straight bistoury, to

D :

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34 LACERATION OR RUPTURE OF THE PERINEUM.

divide the sphincter; a pair of long dissecting forceps; three
large needles for deep sutures; small ones for the superficial
interrupted sutures; a tenaculum; pieces of gum-elastic catheter
or bougie, with twine well waxed; sponges, &c.

The needles used for deep sutures are fixed in handles, and
more or less curved to adapt them to different cases; the width
of perineum and the thickness of the tissues varying consider-
ably in different persons. See figs. 1 and 2.

Fig. 1. | ‘Fig. 2.

 

*,* These figs. 1 & 2 represent one-half the size of the
instruments actually used.

Chloroform.—The operator will require at least two assistants.
Unless contra-indicated, or opposed by the patient or her
friends, it is desirable to place the patient under the influence
of chloroform; for not only will she be thereby saved pain, but

opposition and straining are avoided, and a favourable relaxation
of the parts obtained.

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LACERATION OR RUPTURE OF THE PERINEUM. 35

MODE OF OPERATING.

The patient should be placed in the position for lithotomy,
the knees well bent back upon the abdomen, and all hair closely
shaved off about the parts. The sides of the fissure should be
held by an assistant so as to insure sufficient tension for the
operator; a clean incision is now to be made about an inch
external to the edges of and equal to the fissure in length, and
sufficiently deep to reflect inwards the mucous membrane, and
so to lay bare the surface as far as another incision on the inner
margin (see plate 1). The denudation of the opposite side of
the fissure is then to be practised in a similar manner, and the
mucous membrane from any intermediate portion of the recto-
vaginal septum to be also pared away.

This denudation must be perfect, for the slightest remnant of
mucous membrane will most certainly establish a fistulous
opening when the rest of the surfaces have united.

Some operators, especially the continental, remove the mucous
membrane by scissors, but this is a clumsy and unsafe method,
and the knife will be found to effect the purpose quicker and
better. ,

Division of the Sphincter.—So soon as this stage of the opera-
tion is completed, the sphincter ani is to be divided on both
sides, about a quarter of an inch in front of its attachment to
the os coccygis, by an incision carried outwards and backwards.
The incision should be made by a blunt-pointed straight bistoury,
which, having been introduced within the margin of the anus,
guided by the forefinger of the left hand, is quickly and firmly
carried through the fibres of the muscle and through the skin
and subcutaneous areolar tissue to the extent of an inch, or
even two, external to the anal orifice.

The degree of relaxation to be sought must be regulated by
the extent and character of the laceration; it bemg remembered
that the freer the incision the greater will be the amount of
relaxation obtained. In every case, muscular traction must be
destroyed, for so long as it exists it will oppose the union of the
parts.

Insertion of the Quill Sutures—The sphincter having been

D2

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36 LACERATION OR RUPTURE OF THE PERINEUM.

divided in the manner just stated, the thighs are to be approxi-
mated, and then the quill sutures introduced. The left denuded
surface and tissues external to it being firmly grasped between
the forefinger and thumb of the left hand, a strong needle
carrying a double thread is plunged, with the right hand,
through the skin and subjacent tissue an inch external to
the pared surface, and thrust downwards and inwards beneath it
until its point reappears on the edge of that surface ; it is then
introduced at the corresponding margin of the denuded space of
the opposite side, and made to traverse beneath it in a direction
upwards and outwards until it escapes at a point equi-distant
from the external margin with that at which it entered on the
left side. Each of the three sutures is to be introduced in the
same way, the one nearest the rectum first.

The sutures are double, to allow them to enclose the quills,
or (as actually used) the pieces of elastic catheter or bougie,
around which they loop on one side, and are tied over, by their
free ends, on the other. For sutures I prefer stout twine, well
waxed, to silk, as I believe it to be less irritating and productive
of less suppuration.

Insertion of Interrupted Sutures—Having firmly secured the
three sutures upon the bougies, the sides of the fissure become
approximated,—the denuded surfaces in apposition. To bring
together the outer margins, along the line of the skin, it is
advisable to pass three or four interrupted sutures. If this be
carefully done, union of the skin will speedily take. place, and
that of the deeper parts be materially facilitated (see plate 2).
As an accessory or superficial suture, the twisted form is used
on the Continent ; but I think the interrupted more simple, and
have found it answer completely.

I should recommend, previously to bringing the operation to
a close, that the forefinger of the right hand should be passed
into the vagina, and that of the left into the rectum, so as to
ascertain that apposition is complete throughout.

Lastly, the parts having been well cleansed by sponging with
cold water, a piece of lint steeped in cold water is applied, and
over it a napkin kept in situ by a T bandage.

Operation in Recent Cases.—The operation has been detailed

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LACERATION OR RUPTURE OF THE PERINEUM. 37

with reference to cases of some standing, where cicatrization has
occurred 3 with respect to recent cases of the accident, the only
variation of the plan is in the omission of the otherwise neces-
sary denudation of the margins of the fissure.

Afier-Treatment.—The patient having been removed to her
bed, should be placed on her left side on a water-cushion, with
the thighs and knees close together, and flexed on the abdomen.
Perfect quiet enjoined, and cold-water dressing to be continued.
Ice given to suck for twenty-four hours is refreshing, and allays
febrile reaction and nausea. Two grains of opium should be
given at once, and one grain repeated every four or six hours.
Beef-tea and arrowroot may be given within the first twenty-
four hours, but not wine, unless there are signs of flagging:
the wine I give is port. After the first day, four ounces of
wine may be allowed; and a generous diet, chops, strong beef
tea, &c., after the second or third day. This is supposing no
symptoms occur to contra-indicate such regimen.

- It is of great importance to draw off the urine by the catheter
every four or six hours for three or four or more days, after
the operation. As the patient lies im the common obstetric
position, this is best done by introducing the catheter between
the thighs from behind; and in withdrawing the instrument, the
thumb should be kept on its end, in order to prevent any urine
remaining in it from escaping into the vagina, whereby it might
cause such irritation about the wound as to render our attempts
to close it abortive.

_ After some days, as on the eighth or ninth day, if the healing
go on satisfactorily, and the strength of the patient be equal to
it, she may be allowed to pass water, resting on the hands and
knees, so as to prevent, as far as possible, its contact with the
lower or sutured surface of the vagina.

‘The deep sutures should be removed on the third or fourth
day in hospital patients; in private cases on the fifth or sixth.
I have found their retention after the periods named, of no
service, but rather mischievous by their tendency to suppurate
and slough, results of more rapid occurrence in hospitals than
elsewhere; hence the earlier date proposed for their removal in
hospital cases. On the sixth or seventh day the external sutures

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38 LACERATION OR RUPTURE OF THE PERINEUM.

may be taken away. In withdrawing the sutures care must be
taken not to separate the thighs, for it is necessary to keep up
their apposition for some time. The time for the removal of
sutures above stated, does not correspond with my practice in
the first cases J published; increased experience has led to the
alteration.

If, after the operation, there should be any considerable
bleeding, not controlled by the simple water-dressing, pieces of
ice may be introduced, or ice-water injected into the vagina:
other measures, as ligature or torsion, are scarcely ever required.
For removing secretions, and keeping the parts clean, injections
of tepid water may be used two or three times daily, especially
after the employment of the catheter. By such, and by frequent
sponging, perfect cleanliness must be attained. Should there
be an offensive discharge, chloride of soda may be added. The
opium should be persevered with, so as to keep the bowels con-
stipated for two to three weeks after the parts have united;
when union has become firm and complete, the bowels may
be relieved by injections of warm water with castor oil, and by
the latter given by the mouth. Attention should be paid
during the passage of the first evacuation, and support given to
the restored perineum if any hardened masses should cause
stretching.

The precise time for opening the bowels must be regulated
by the strength of adhesion set up, and by the amount of repa-
ration of lost tissue which has been attempted.

For some few days after the first evacuation, an enema had
better be continued.

Should adhesion, unfortunately, from any accident, not be
complete throughout, and a fistulous opening persist, the actual
cautery is the quickest and surest means of closing it; but the
application of a caustic or stimulating substance may be tried.

CRITICISMS AND SUGGESTIONS.

The history already given has sufficiently detailed the propo-
sitions made, and the plans of treatment pursued by others;

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LACERATION OR RUPTURE OF THE PERINEUM. 39

but it remains for me to respond to the criticisms or objections
raised against my mode of operation and of treatment since its
first publication. This I shall attempt to do very briefly, as a
practical response is at once offered by the greater success of the
cases recorded, than that following any other plan yet brought
forward. Hypothetical, 4 priori, objections are not worth
discussing; for it is experience alone that can prove the fitness
or unfitness, the safety or danger of any operation. It is absurd
to descant on the necessary danger of a measure, when
experience, sufficiently ample, proves that if such peril be not
altogether imaginary, it is so small as not to be taken into
account with the benefit to be gained by incurring it. Give
importance to such an objection and what operation would be
attempted.

On Immediate Operation—Supposed danger of vaginitis
is an objection of a cognate character to immediate operation
after the accident. It has been said that an immense danger
will then attend the suturing of the parts, from the inflam-
mation set up in the vagina, and its tendency to extend to the
uterus and neighbouring parts, which after delivery require to
be carefully preserved from any such morbid action. But,
omitting for the present, reference to the teachings of experience,
we may observe, it is a mucous canal that is dealt with, not
very delicate, and not prone, like a serous tissue, to so rapid
propagation of a morbid process; for within it severe inflamma-
tion may be very limited in its extent. Moreover by immediate
operation, the otherwise necessary denudation of surface is
avoided; only the sutures have to be introduced, and the
sphincter divided; the torn edges are thus placed in contact,
and only that amount of inflammation necessary to union
required; whilst the accurate apposition of surfaces guards
against the noxious irritation from secretions. But, supposing
the case left, will not the chances of extended inflamma-
tion be even greater? will not the inflammation, unavoidable,
indeed even necessary to the healing of the lacerated surfaces,
be greater, and its duration longer, seeing that the torn parts
are exposed to every source of irritation? The reply ‘must
surely be in the affirmative.

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The noxious influence of the lochia on the wound, chiefly in
preventing or retarding the healing process, has been urged
against immediate operation. The danger therefrom is, how-
ever, obviated by the close and accurate apposition of the sur-
faces when sutured, and when, too, the action of the sphincter
fibres in drawing them asunder is annihilated. The ill effects
of this discharge are further provided against by the constant
attention to cleanliness, and by the use of injections as recom-
mended.

A reason for deferring a surgical operation until some time
has elapsed after delivery appears, to many practitioners, in the
fact of the successful issue of some cases which have been left
to themselves. For my part, I cannot admit this as a sufficient
argument for delay. The maxim that “delay is dangerous,”
here holds good in all its force. The chances are greatly
against spontaneous cure, even in milder cases; in severe, it is
vain to hope for it. Surgical operations would be few indeed,
if extraordinary instances of natural cure were allowed generally
to contra-indicate resort to them.

On the other hand, the operation for ruptured perineum,
and more particularly in recent cases, is not of that formidable
character to alarm the patient, or to peril her life; whereas,
by it a complete restoration may confidently be anticipated,—a
result hardly ever to be reckoned on when the injury is left to
repair itself with all the advantages obtainable from general
attention to quiet, position, and such like expedients.

That this laissez faire doctrine has so extensively prevailed,
is readily accounted for, when we consider how very frequently
unfavourable have been the results of operative proceedings
heretofore devised and put into practice. Too often has the
operator not only failed in procuring union of the fissure, but
has also rendered the mischief worse by his interference. This
sore discouragement will, I believe, no longer attend the surgeon,
if the principles of treatment laid down in these pages be
followed out; and then what has prevailed so often to deter
from immediate operation will have ceased to influence.

Lastly, it is to be remembered that resort to operative
means may in slighter cases secure an adhesion of the lacera-

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LACERATION OR RUPTURE OF THE PERINE[EUM. 41

tion in three days; and, at all events, will always effect a cure
in a much briefer period than can the natural unaided process.

Supposed Rigidity of Restored Perineum.—Another general ob-
jection to the operation—indeed, to any similar operation—is that
the restored perineum must be, from its nature as a cicatrix, so
unyielding as to almost necessarily rupture from the stretching
of a future labour. This is another of those vain hypotheses
which vanish when tested by experience. The closed fissure
certainly presents a cicatrix, but the natural yielding tissues per-
sist on each side, and admit of the needed extension.

Suggestions, &c.—The cutaneous elliptic incision on each side
the sutured part, proposed by Dieffenbach, and practised by Mr.
Fergusson and by most continental surgeons, is of no service when
division of the sphincter is resorted to. Again, I cannot appre-
ciate the supposed utility of the central flap (dédoublement) from
the recto-vaginal septum, adopted by M. Verhaeghe; perfect
closure is attainable without, and the reflected portion can have
little vitality, and is very apt to perish.

On Incision of Sphincter—A_ subcutaneous incision of the
sphincter has been suggested, but it will not furnish the results
aimed at. The muscular fibres of the sphincter must be com-
pletely severed, and also the investing integument, to annihilate
all traction. The utility of dividing the skin and subcutaneous
tissue is undoubted, and particularly recognised in the generally
approved incisions of Dieffenbach.

On Sutures-—The Bead Suture—tThe bead suture, invented
by Mr. Brooke, has been suggested as preferable to the quill
suture, and as sufficient in itself to keep up the required appo-'
sition of the edges of the wound, and so render division of the
sphincter unnecessary. In its mechanical operation as a suture
it may be very excellent, but I have had no experience of it, for
having been very successful with the quill suture, I have tried
no other. That, however, it would render section of the sphincter
unnecessary I cannot admit, until repeated trials have proved it;
for, according to my views, the division of that muscle is the
peculiarly important and essential feature of the operation to
restore the perineum.

As the history given shows, each kind of suture has had its

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own advocates, and each has frequently failed. Dieffenbach
thought the quill suture did not approximate and keep so closely
together the edges of the wound as did the interrupted suture.
I can account for this notion only by supposing he gave the
quill suture but little trial, or that he failed to take up sufficient
tissue with it.

MM. Langenbeck and Verhaeghe employ the twisted as the
supplementary suture; but I think the interrupted, as used by
myself, more simple and effectual in bringing about union of the
integument.

The spring clasps invented in France, to keep the edges of a
wound in contact, have not sufficient power and stability to be
of any use in so serious an accident as a severe perinzal
rupture.

On Diet—The after-treatment- proposed has had various
arguments brought against it. The dietary has been thought
ill adapted to the circumstances of the patient, after a severe
operation, and the customary low diet of gruel, toast-water, and
such like, been preferred. This low or fever diet has, in
my opinion, been far too much persevered with in disease
generally. In women after delivery, I believe its adoption is
a mistake in most stances; and in the majority of women
with ruptured perineum, there are more or less exhaustion—
nervous and other, and weakness, demanding support. More-
over, I believe a more generous diet, with wine, is favourable
to the healing process, and a safeguard against erysipelas.
This opiion is a reiteration of what was advanced by me
in my paper read before the Medical Society of London
in 1851, and subsequently published; and it is with peculiar
pride and satisfaction that I am now able to support it by the
able advocacy of Mr. Skey. I cannot forbear making an appo-
site quotation from that eminent surgeon’s recently published
Lectures.* “Why do we invariably subject patients after a
long and severe operation, to abstinent diet? Why do we anti-
cipate inflammation? and, still more, why do we encourage it ?
We anticipate inflammation, because our experience teaches us

* On the Prevalent Treatment of Disease. By Frederick Skey,
F.R.S., &e. London. 1853.

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that it is ready at hand, that our patient is now predisposed to
it, but do we not refer it to the wrong cause? We attribute it
to the irritation caused by the knife, and not to the debility
and to the shock produced on the system by the operation, with
attendant loss of blood. I believe that such persons should
always be supported by moderate stimuli, from the hour of the
operation until their inclination for food is re-established. By
such treatment, generally, if not uniformly adopted, many lives,
particularly after operations of severity, would, I believe, be
rescued from the grave; that, and—‘odium chirurgicum,’ or
rather ‘odium medicum’—the lancet and scarificator, with all
their concomitants of purgatives, laxatives, and diaphoretics,
which tend to rob the body of its richest juices, constituting the
essence of its life itself, may be largely restricted in their
application.”

On Opium.—Constipating the bowels by means of opium has
been thought reprehensible. The practice has almost universally
been to keep up a looseness of the bowels, and to use repeated in-
jections, from the date of the operation. On the contrary, I obtain’
union of the wound first, and afterwards open the bowels. In
this plan I have the support of Dieffenbach, and more recently
of Langenbeck and Verhaeghe. In my own practice, I have
never seen any ill effects from the prolonged constipation and
use of the opiate. The reverse, indeed, I hold to be true—viz.,
that the opium proves actually beneficial by allaying irritation,
by controlling inflammation, and thus by generally favouring
the healing process.

When I published my first paper on Ruptured Perineum,
my colleague at St. Mary’s Hospital, Dr. Handfield Jones,
kindly furnished me with some interesting and valuable obser-
vations on the use of opium, from which I extract the following
as applicable in this place:—

“Dr. Pereira notices the efficacy of small doses of opium (ten
drops of laudanum three times a day), in such instances as the
chronic or callous ulcer, the so-called varicose ulcer, in recent
ulcers from wounds, in which granulation proceeds slowly, and
especially in elderly persons, and in those whose constitutions
have been debilitated by disease, labour, spirituous liquors, &c,

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‘It appears,’ he says, ‘to promote the most genial warmth, to
give energy to the extreme arteries, and thereby maintain an
equal balance of the circulation through every part of the body,
and to animate the dormant energies of healthy action.’

“In the cases recorded in this paper, opium was given, not
chiefly for the purpose of directly promoting the healing process,
but of preventing its disturbance by mechanical and forcible
disruption of the coalescing parts. For this it was freely given ;
and this most important end it well accomplished. But had
not this end been all-important, I own I should have feared
before trial, that the quantity of opium administered—three or
four grains sometimes in a day—would have had the effect of
disturbing, by its influence on the organic functions, that
reparative healing process, which issued in so beneficial and
happy a result. For in these cases there does not appear to
have been any marked asthenia, or undue irritability of the
system. The terrors of surgical operations of earlier days,
when the anesthetic spell was unrevealed, may well have
inflicted on the system a disturbing shock that opium alone
could calm; but now there cannot be the same need for this
potent agent.

“It is, however, clear that if in these cases opium did not
promote the vital healing process, at least it did not retard it:
or such obstacles, as the first case presented, would not have
been overcome, and the second would not have progressed so
steadily and favourably. This circumstance in itself is, I think,
novel and instructive.

“ Perhaps, however, if we consider the matter more closely,
it may appear not difficult to understand why no unfavourable,
but, on the contrary, a beneficial result was produced by the
opium. The condition of an ulcer, healing by granulations,
may first be referred to as an extreme instance, illustrating the
great waste of plasmatic material which occurs in such cases,
and more or less in all that approach to it. Much of the
effused plasma—effused too rapidly to be organised—is cast off
as effete matter, having taken the form of pus; much is
organized into the low type of the granulation structure
destined to future re-absorption. This waste is needless, nay,

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injurious, as a drain to the system, and if it can be prevented,
as sometimes it may, by applications that exclude the air, or
restrained and limited, as is done by the common water-
dressing, the reparative process goes on much better, and with
less constitutional disturbance.

“Again, if, as in the case before us, two fresh incised
surfaces are brought together, and the aim is to induce them to
unite by the first intention, what can be more prejudicial to
this than the effusion of much plasma, or any, the least,
approach to the above-mentioned condition? To form a
connecting medium across which capillaries may anastomose
and fibres unite, the thinnest film of exudation is sufficient, and
the thinner the better; for the organizing process is of neces-
sity slow, far slower than the exudative, the capillary loops
must take many hours to unite, the opposed fibres some days
to blend by means of the connecting material, and the further
the old surfaces are separated the longer this must be delayed,
and the more of the exuded matter, which itself has produced
the separation, will pass into the form of effete and purulent
fluid. Now, this tendency to the excessive effusion of plasma,
opium very probably restrains, somewhat, it may be, as it
restrains a flux from a mucous surface; the hurried action is
‘stilled, the vascular excitement tending to inflammation
allayed, the sedative influence of the drug assisting Nature in
her work, by preventing that which would mar or delay it.
The imparting of energy to the extreme arteries, which Dr.
Pereira speaks of, we know from observation to be the restora-
tion of their tonicity, enabling distended, relaxed, and congested
vessels to resume their natural calibre, and thus to transmit a
due and not excessive quantity of blood in a current of proper
velocity to the parts they supply. The restoration of the proper
function of the arteries, ‘the conductors and disposers of the
blood, as John Hunter accurately defined them, will manifestly
tend greatly to prevent the excessive effusion of plasma, and
thus remove at least one obstacle to the progress of reparation.

“Tt seems, therefore, reasonable to expect that opium, so
long as it does not manifestly disorder the nervous system or
the organic functions, would tend powerfully to promote the

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healing process, and this expectation is amply borne out by the
results of the cases recorded.”

The mode of treatment—operative and general—now set
forth, is, in my opimion and according to my experience,
applicable in all instances of rupture of the perineum ad-
vanced to the extreme degree. I will arrange my leading
views under three propositions:—1l. That the worst forms of
lacerated perinzeum, of however long standing, may be cured
by the operation. 2. That immediately on the occurrence of
the accident it should be resorted to. 3. That subsequent
parturition is possible without injury to the restored perinzeum.

CASES.

I am now enabled to bring forward such a number of cases
in which I have operated successfully, that I feel sure the value
of the plan advocated must be admitted. Some of these cases
have already been made public either in my printed Essay, or
in the paper which was read before the Medical Society in
London. I now collect together these, and others not previously
published, and am at the same time pleased to be able to adduce
instances of successful operation by friends who have followed
my method, and kindly furnished me with details.

The order in which I purpose to describe the cases of the
severest or fourth form, will be according as they illustrate the
first, or the second proposition. I commence, therefore, with
cases of long standing, and shall afterwards narrate those
operated on immediately after the accident; whilst examples of
the truth of the third proposition casually occur in both series.
After the preceding will come instances of the third variety of
lacerated perinzeum,—that, viz., where the sphincter ani is not
involved.

Moreover, I may observe that not a few of the recorded
cases of perineal rupture, by being complicated with displace-
ments of the pelvic viscera,—of which indeed the rupture itself
is a cause, serve also as examples of such pelvic diseases, and of
the treatment suitable to them.

Casz 1.—Complete Rupture of the Perineum, of fourteen years

standing.—Operation.—Delivery two and a quarter years subsequently.
Remarks.—A lady, (A—— T——), xt. 37, living in the country,

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came under my care in August, 1851, suffering from an extensive
laceration of the perineum, with prolapsus of the mucous membrane
of the bowel, and a small polypus uteri. She was unable to control
the contents of the rectum when at all relaxed, and had in other
respects no sphincter power. Any exertion would bring the uterus
down to the os externum; and, on one occasion, when she was
ascending a hill, the womb prolapsed, and inflammation succeeded,
requiring leeches, with rest in bed for some days, to subdue it. She
could not stand for any length of time without suffering severely ;
and riding in a carriage produced much uneasiness. Her health was
good. On examination, I found a rent extending through the
sphincter ani to the rectum ; and instead of taking the usual straight
direction, had either bifurcated from the fourchette, or, having
reached the rectum, had returned on itself, thereby isolating a
triangular portion from the front of the rectum and recto-vaginal
septum. The last indeed was gone, most probably by sloughing, and
hence a considerable chasm existed in the anterior part of the
rectum.

This mischief occurred in her first labour, which was difficult,
and protracted to nineteen hours; during the passage of the head,
instruments were used. Notwithstanding so extensive a lesion, and
the distressing consequences of it, this lady had never had the nature
_of her case recognised, or at least pointed out to her, during the
fourteen years which intervened between its production and the time
of her being submitted to my treatment. In this interval, moreover,
she had given birth to five other children.

On her first visit to London, I removed the protruding mucous
membrane and polypus, and advised an operation to restore the peri-
neum. After consulting Dr. Locock, she returned to the country
for two months, and then came to town to place herself under my
care.

On the 15th of August I proceeded to perform the following ope-
ration, assisted by Messrs. Coulson, Lane, and others; chloroform
being administered by Dr. Snow.

Having placed the patient in the position for lithotomy, I pared
the cicatrices on each side from mucous membrane to the extent of
an inch in width, and about two inches in length. The edges of the
bowel, which were drawn back (everted) by the absence of the
anterior portion of the sphincter, I also denuded, and after that
brought the whole together by three quill sutures in the manner
heretofore described. ‘

This done, the outer margins were stitched by small interrupted
sutures. Finally, on passing one finger into the vagina and another
in the rectum, I found a space not in apposition, and therefore,
to close this, introduced another suture through the vagina and
rectum, and thus effected an accurate contact of every portion of the
fissure.

The operation lasted an hour. After sponging the parts perfectly

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clean, and having placed the patient in bed, cold water dressing was
applied to the wound, to be renewed every three or four hours; two
grains of opium were given at once, and one grain ordered at
7 o'clock. At 10 p.m. the catheter was used.

16th. Introduced the catheter again at 2 a.m, and repeated this
every four or five hours during the day. At 4 a.m., gave her some
wine and water, after which she obtained four hours’ sleep. On each
occasion of employing the catheter the parts were carefully sponged
with cold water, and every portion of secretion cleansed away.
There was no undue swelling of the labia. She was allowed wine and
water, and coffee. One grain of opium was given every four hours.

17th. The urine drawn off at intervals, as yesterday. There was
no sleep to-day. A grain of opium was given at 9 a.m., and at 1 and
10 p.m. Besides wine-and-water, some mutton was taken.»

18th. Passed a bad night, having been disturbed early in the
night. At4am., two grains of opium were ordered. At 11am,
wine and brandy were freely given to overcome faintness. Catheter
introduced every five or six hours, day and night.

19th. Has passed a better night. Complains of an aching and
at times of a sharp pain within the vagina. There is a free discharge.
11 am: the pain continues. I removed the last external suture. In
the afternoon ordered warm fomentations and sponging. Two grains
of opium in two doses were taken during the past night ; one grain
ordered this evening. The urine was withdrawn by the catheter four
times in the twenty-four hours.

20th. When seen at midnight, she had great pain, especially
about the orifice of the urethra, of a darting and aching character.
The catheter was used, and the parts well sponged.. At 6 a.m, the
catheter repeated. On examining per vaginam, I found the now
purulent discharge escaped through an opening by the sphincter ani,
but still not without pressure from within. She now told me, for
the first time, that on the last two days wind had passed from the
bowel through the vagina. A bread-and-water poultice to be
applied. This day, on again examining, I found a recto-vaginal
opening. I removed all the sutures, and divided the sphincter ani at
the posterior part, and immediately the united portion of the peri-
neum was drawn towards the vagina, and the fissure throughout
closed more accurately. Half-past 1 p.m, a very free discharge of a
sanguineous character. The catheter re-introduced. She is much
more free from pain. Towards the evening the discharge became
more purulent. Catheter used again at 4 and at 10 p.m.

21st. The discharge free. Catheterism every five or six hours.

22nd. Half-past 2 a.m.: Great pain in the rectum from the matter
not escaping freely. During the day this was assuaged, and healthy
granulations were visible.

25th. On this, the tenth day, the patient was allowed to empty
her bladder, supporting herself on her hands and knees.

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26th. I consulted with Mr. Lane, and determined to pare the
edges where mucous membrane existed. To do this, I placed the
patient under the influence of chloroform.

27th. I injected some warm water into the rectum, first plugging
the vagina, to prevent any escape of feculent matter into it, when the
bowels were relieved for the first time since the operation twelve days
ago.

31st. Has gone on well. The granulations springing up freely.

Sept. lst—12th. ‘Going on the same. The catamenia have
appeared.

19th. The catamenia having subsided for twenty-four hours, I
examined carefully, and was pleased to find the fistulous opening by
the side of the anus much less than it was a week since. The mucous
membrane, however, had joined the skin on the left side of the
opening, thus arresting all granulations there, and so preventing
union. I therefore determined to pare the edges of the opening, and
then to bring them together by a good deep stitch with a double
silk suture. This I did to-day, and found afterwards, by passing one
finger into the rectum, and another into the vagina, that [ had com-
pletely closed the passage.

The new perineum produced was half an inch thick, and sound.
Two grains of opium were ordered at once, and one grain every two
hours, to prevent pain and to arrest the action of the bowels. At
8 p.m, I emptied the bladder by catheter, and watched all night.

20th. At 3 pm. she was very sick, and vomited freely; after
which she slept at intervals At 11 am, on again using the
catheter, several clots of blood came from the vagina. I directed her
to pass the urine herself next time, by kneeling on the bed. 6 P.m.:
Has voided urine as directed, and some more clots have come away.
There is no undue swelling of the sutured parts. She has taken some
solid nourishment and some wine.

24th. I removed the suture, and found that only partial and slight
adhesion had taken place close to the orifice of the anus, which is,
however, now quite complete, and of its usual circular form; but a
sinus exists, the size of a goose quill, between the vagina and
perinzeum.

25th. The bowels have acted by injections of warm water and a
_ seidlitz powder. She has now perfect control over the contents of
the rectum. TI painted the orifice of the sinus with acetwm lytte, to
stimulate the granulations, and ordered the bowels to be kept daily
gently relaxed. ;

29th. The sinus is diminishing, and the granulations filling up the
space in front of the anus. The acetum lyttee was again applied.

Oct. 5th. The process of granulation continuing very tardy,
although the acetum lytte had been brushed several times during the
last few days over the surface; and as the patient, feeling so nearly
well, was extremely anxious to get home, I determined to make use

E

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of the actual cautery to deprive the surface of the sinus of all mucous
membrane. This was done, and attended with success, and in a short
time the sinus closed, and my patient was able to return home on
the 7th October, to enjoy a degree of comfort she had not known
for years. There was a good strong perineum, and the sphincter
ani performed its functions accurately. :

Nov. Ist. I have heard from my patient since her arrival home.
She has greatly improved in health and strength,- takes horse-
exercise daily, and walks about with facility. Her bowels have acted
comfortably, and no prolapse of the uterus has appeared. The case,
therefore, must be deemed completely successful.

Remarks.—This case furnishes an illustration of my first propo-
sition. The necessity for the frequent use of the catheter was urged
upon me by my friend Dr. Locock, who told me that he had seen a
very bad case fail at the first operation from inattention to this point
of practice ; whereas, on the second operation, by attending to it, the
patient was cured. The greatest care also should be taken that none of
the urine escape into the vagina, and trickle down on the united
surfaces; for, if it does, the almost certain result will be sloughing
of the parts which we are endeavouring to unite by adhesive inflam-
mation, A second important practical point is to keep the bowels
perfectly quiet—to allow no action. In the preceding case I kept
them confined twelve days by repeated doses of opium. A third
practical detail is the constant personal watching and attention to
the wound. I was in constant attention on this patient for twelve suc-
cessive nights ; studiously keeping her on her side, on one of Hooper's
water-cushions placed under her hips.

It will be seen that I did not divide the sphincter ani on the day
of operation, but a few days subsequently. This was wrong. In my
subsequent cases I have recognised this section as a leading principle
in the operation, and have accordingly at once made it. Nothing
could prove the importance of this procedure more clearly than this
first case ; for although adhesion took place anteriorly very satisfac-
torily, still, prior to the division of the sphincter, the edges posteriorly
seemed drawn asunder after the removal of the sutures; whereas,
immediately on making the section, they were brought into contact and
steadily kept so. This matter is well illustrated by the following
cases. In my first essays at operating for ruptured perinzeum, I was of
opinion that an incision on one side only of the sphincter was necessary,
but subsequent experience has led me to prefer one on each side.

It was of much assistance to me that my patient was very quiet
and tractable, attending to every direction, especially that of passing
the urine by resting on her hands and knees, to prevent its contact
with the sutured parts.

Iam now able to add to the history of this my first published
case, the result of the test of delivery on the restored perineum.

Jan. 17th, 1854. At10 a.m. I was sent for to this lady, who

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was taken in labour at the full period of gestation. Its progress was
slow, On making an examination I found a natural head presenta-
tion. At 4 a.m, the membranes broke and the head proceeded to
descend on the perineum, which was strong, safe, and dilatable—be-
fore labour it was 13 inch in length, and now by the pressure of the
head, it elongated to 3 inches. Unfortunately, the head was un-
usually large, and continued to rest on the perineum for three hours,
the pains forcing strongly. Fomentations and lard were applied, and
the uterine contractions calmed by the administration of chloroform by
Mr. Moullin. At length a strong pain thrust the head through
the outlet, causing a laceration of the perineum, about an inch in
length, in the median line. Great care was used in the delivery of
the shoulders, but they were so large and broad that the rupture was
extended half an inch farther, not in the median line, however, but
to one side, the tear passing upwards obliquely, and leaving the
sphincter and recto-vaginal septum intact.

After the removal of the placenta and of the clots of blood from
the vagina, an interrupted suture was passed through the oblique
fissure, and the quill suture applied to that in the median line. The
thighs, as usual, were afterwards brought and kept together, and the
patient placed on her side. Every four hours, the urine was ordered
to be withdrawn, and a grain of opium given.

January 21st. Removed the deep sutures; union established ;
the parts looking well.

23rd. Doing very well.

26th. An enema was administered ; there was complete control
over the sphincter. She feels improving. The parts are well united.

She has since gone on very satisfactorily ; the perineum is com-
pletely restored.

It seems clear from the extent to which the perineum became
dilated, and the length of time it withstood the pressure of the head
forcibly propelled against it, that, had the head and shoulders not been
of so great dimensions, the perineum would have escaped even the
partial rupture it suffered. I should state that the head was 144 inches
in circumference, and the shoulders 173 inches.

Thus, although this particular case does not precisely prove the
proposition advanced, that ‘subsequent parturition is possible without
injury of the restored perineum,’ it proves that the sutured parts do
not form, as it has been said they must do, a hard, unyielding cicatrix ;
but that, on the contrary, they are sufficiently dilatable to afford the
best hopes of delivery without injury, under ordinarily favourable
circumstances ; as much so, I believe, as uninjured structures.

Under no pretence, surely, can the result of this case be quoted as
inimical to the attempt to restore a ruptured perineum in a female
likely again to bear children. This patient’s existence had been em-
bittered by the local injury for fifteen years ; and by the treatment
adopted she was entirely cured, and restored to the enjoyment. of life,

E 2

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56 LACERATION OR RUPTURE OF THE PERINEUM.

ordered a cough linctus, and an opium and belladonna embrocation
to the chest.

19th. Going on well. Edges of wound uniting, with very little
swelling. .

20th. Cough still troublesome. She is rather drowsy. Urine
withdrawn every six hours. Opium continued every four hours.

21st. Superficial sutures removed: deep ones beginning to ulcerate.
Black wash ordered to be applied over them.

22nd. The two posterior sutures removed: the parts found firmly
united. The ulcerated surfaces have a great tendency to bleed.

24th. A few hardened scybala passed from the bowel to-day with-
out pain or any injury.

25th. Remaining sutures removed. A few ulcerated sloughy spots
exist in the site of the deep sutures. There is no communication
between the rectum and vagina. Union firm. The ulcers to be
touched with nitrate of silver. To have an enema of warm water.

26th. The enema brought away some softened feces: other and
harder have been voided this morning. To-day, for the first time,
she passes water, resting on her hands and knees. Enema to be
repeated. A solution of nitrate of silver to be introduced into the
ulcerated holes.

Nothing further occurred sufficiently peculiar to warrant a con-
tinued daily report. The patient from this time progressed satisfac-
torily, and was discharged quite cured, having a good perineum, and
complete control over her bowels,

This case, like the last, had been previously operated on unsuc-
cessfully, and a severe fissure remained. I took the precaution to
make a very free incision on each side through the sphincter, involy-
ing the skin to the length of two inches. This allowed the adjoining
tissues to be freely drawn towards the united edges of the wound, and
thus prevented tension on the sutures.

I have lately (Nov. 1853) seen and examined the patient, and
found the perineum complete, and the anus perfect in its action,

Case. V.—Complete Rupture of Perinceum, of seven weeks’ stand-
ing ; Destruction of recto-vaginal septum: Operation ; Result.—Mrs.
W., xt. 39, admitted 23rd April, 1852, into Boynton ward, St. Mary’s
Hospital.

Seven weeks ago she was confined with her first child, (male.)
She had a difficult labour : instruments were employed, and complete
rupture of the perinzeum, extending through the sphincter ani and
recto-vaginal septum, ensued. From that period she has had no con-
trol over her evacuations.

On the 28th I performed the operation as usual; on account of
the great deficiency of sphincter muscle anteriorly, the first deep
suture was passed close to the rectum, so as to bring the pared edges
at that part closely together, the usual incision having been pre-
viously made.

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LACERATION OR RUPTURE OF THE PERINEUM. 57

The operation completed, she was placed in bed on a water cushion,
on her left side; two grains of opium given and some port wine. A
grain dose of opium to be repeated every three hours, and catheter
introduced.

29th. Considerable edema; much relieved by puncturing the sides
of the perineum.

30th. Gidema less; pulse quick; skin moist. Opium continued.
Chop and wine for dinner. ;

May 2nd. Going on well. Removed the external sutures, and
found that there was perfect union by the first intention.

4th. Removed the deep sutures. A small recto-vaginal opening
is discoverable ; apply strong acetum lyttee to its walls,

11th. The bowels were moved on the twelfth day, by the usual
means. The recto-vaginal opening not closing as quickly as could be
wished, I submitted the patient to the influence of chloroform, and
then, introducing a rectum speculum into the bowels, and a uterine
speculum within the vagina, I obtained a perfect view of the fistula,
and applied to it the actual cautery by means of a bent iron instru-
ment.

After two or three weeks from this date the opening completely
closed up ; the patient had a perfect and strong perineum, and entire
control over the bowel.

This case was one of much interest. The lesion involved not only
the sphincter, the anterior portion of which was lost, but also the
rectum; hence the difficulties of cure were greatly augmented.

Casz VI.—Complete Rupture of Perinewm ; Destruction of recto-
vaginal septum: Operation; Result—Harriet M., et. 46, admitted
into Boynton ward, Feb, 25th, 1853. The mother of four children,
of whom three are alive. ~

Her general health was good until the birth of her first child,
which was difficult, and effected by instruments, with the production
of lacerated perineum. Since that accident she has not been so well
in general condition ; has been unable to retain her motions : suffered
much from irritation of the parts, and other concomitant evils, but
not from bearing down nor prolapse. She has had no serious illness ;
there is no cough, and the thoracic signs are healthy. Hach succeed-
ing labour has aggravated the local mischief; and there is now, besides
ordinary complete perinzal rupture, a destruction of a portion of the
recto-vaginal septum. ;

March 9th. After some preliminary general treatment, I proceeded
to operate on this day in my usual manner. A protruding piece of
mucous membrane from the bowel had to be removed; great care was
taken to denude the recto-vaginal septum, and a very free incision
made through the posterior half of the sphincter ani, and to the ex-
tent of two inches through the superposed tissues. Lint saturated
with oil was inserted in the sphincter incisions; the patient placed in
bed on a Hooper's cushion, on her hips, with the knees drawn up.

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58 LACERATION OR RUPTURE OF THE PERINEUM.

The usual water-dressing was applied, and warmth to the feet. Port
wine, (2 oz.) to drink ; ice to suck; two grains of opium at once, and
one grain every four hours. 6 p.m.: Repeat wine; beef tea, Catheter
applied without disturbing patient ; circulation languid ; is rather
cold and feels low. 10 p.m. : Has been sick several times. Ordered mist.
potass. effervesc. with acid hydrocy. dil. (Ph.) mv, and a table-
spoonful of brandy every four hours. Catheter again used.

March 10th, 8 a.m. Sickness continues. Omit brandy and wine, and
give 1 grain of opium every six hours. 6 P.m.: Less thirst, no sickness.
Pulse 108. Complains of pain in the vagina, and of some in the
abdomen. 10 p.m.: Parts looking well ; cold-water dressing renewed,
and felt grateful. To take freely of barley-water. Urine drawn off
three times to-day.

11th. Has passed a better night. Pulse 108. Complains of pres-
sure on the bladder, and feels as if the bowels would act. Pieces of
lint removed from sphincter. Lotio nigra ordered to be applied.
10 p.m: Parts looking healthy.

12th. Has, on the whole, passed a comfortable night. The in-
cisions in sphincter looking unhealthy, the perineal wound healthy.
Ordered a mutton chop with the port wine. Continue pills every six
hours. At night the perineum looked rather red and swollen.

13th. Rest disturbed by a nervous feeling, which she attributed
to the pills; omit them till evening. 10 p.m.: Complains of the
nervousness, and of pains in her left hip. Pulse 108.

14th. Superficial sutures removed. Union appears generally firm.
No communication between the vagina and rectum.

15th. Has slept better. Deep sutures removed. Small sloughs
exist where the quills pressed. To-day she was allowed to pass
water as she rested on her hands and knees,

16th. The sloughs appear rather deep. The perineum has re-
ceded from the quills; there is considerable discharge; left margin
of the wound is more elevated than the right. Continue wine.

18th. Some of the adhesions have given way; the slough on the
left near the sphincter incision has come away, and reveals an
opening into the cavity beneath, She suffers from diarrhea. Ordered
one grain of opium every four hours.

19th. Diarrhcea subsided ; wound looking healthy.

April 5th. She states that she has now more control over the
bowel than when admitted. The anterior margin of the anus which
was deficient is well granulating forwards; the rectum is quite sepa-
rated from the vagina by complete adhesion.

9th. I denuded the prominences each side the gap, and brought
them together by two sutures of silver wire. The patient inhaled
chloroform during this process ; she was afterwards ordered four oz.
port wine, and a grain of opium every four hours.

May 3rd. Perineum is strong; two inches deep. She can now
control the bowels, even when suffering with diarrhea, and is

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LACERATION OR RUPTURE OF THE PERINEUM. 59

sensible of the passage of the stool through the rectum, which she
formerly was not; she has now no bearing down.

Case VII.—Complete Rupture of the Perinewm, eighteen months’
duration: Operation; Subsequent delivery; Result; Remarks.—Mrs.
C., xt. 26, the mother of two children. In her second labour, eighteen
months ago, the perineum was ruptured by the passage of the
shoulders. No instruments were used.

On examination, the entire perineum and the sphincter were
found lacerated, and the control over the bowel lost. She was again
three months pregnant. However, I determined to perform the
operation.

Nov. 12th, 1852. I removed the mucous membrane for only an
inch in length, instead of as usual an inch and a half on each side, so
as to leave as much opening to the vagina as possible, and then care-
fully dissected it off from the anterior half of the rectum, where the
sphincter was absent, and introduced my first deep suture close to
the rectum. Afterwards, the parts were brought into very nice appo-
sition by two other sutures, so as to leave no opening between the
vagina and the rectum, as ascertained by a careful digital examination.
The operation being completed in the usual way, two grains of
opium were immediately given, and one grain ordered every three
hours following. Water dressing was applied, the knees tied to-
gether, and a cushion placed beneath the patient.

The only peculiarity in this case was that I tied a small artery at
the edge of the rectum, cutting the ligature off close.

At 10 p.m. there had been some considerable hemorrhage, which
was then stopped, and the patient seemed comfortable.

13th. Since last night more bleeding has taken place, and the
vagina is filled with coagula. A strong solution of alum was there-
fore injected into the vagina, and a mixture ordered of infusion of
roses, dilute sulphuric acid, and tincture of henbane. At 9 in the
evening there had been no more bleeding. Pain occurred in

aroxysms, but was less severe.

14th. No recurrence of hemorrhage; pain less, but still much
uneasiness and throbbing in the vagina, To take the opium more
frequently.

15th. Has not slept well. No further bleeding.

16th. Has passed a good night, and is much better this morning.
In the evening I removed the superficial interrupted sutures. There
has been a considerable discharge of sero-purulent, offensive matter,
since which the pain in the vagina has ceased.

17th. Removed the posterior and middle sutures, and cut off half
the bougies.

18th. Removed the third and front suture, and the remainder of
the bougies. Examined per vaginam; found the union of the peri-'
neeum, and could discover no communication between the rectum and

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60 LACERATION OR RUPTURE OF THE PERINEUM.

vagina. Washed out the latter by an injection, and removed some
hardened coagula. The bladder is still irritable, and the urine de-
posits much thick, opaque matter, consisting of phosphates and lithates,
with no pus whatever.

19th. Ivritability of the bladder decreased. Perinzeum looking
well. Ordered a draught of nitric acid and tincture of bark twice a
day.

oth, Considerable irritation of the orifice of the urethra. The
patient ordered to void her urine resting on her hands and knees.

21st. The patient has not been able to pass her water as directed,
on account of the painful pressure of the pregnant uterus on the
bladder. The perineum looks quite sound. A digital examination
could discover no recto-vaginal opening. Omit the opium.

23rd. A dose of castor oil, and four injections of it, mixed with water,
produced a copious alvine evacuation without inconvenience, the
restored sphincter acting perfectly.

29th. Is now convalescent; can move about.

This patient was introduced to me by Mr. Knaggs, of Euston-
square, who, with Mr. Osmar King, Dr. Rogers, and others, was
present at the operation. The second named gentleman kindly sent
me (June Ist, 1853) a highly gratifying communication, to the effect
that Mrs. C. had been safely confined, and that no damage had
resulted to the restored perineum. I cannot do better than transcribe
his account of the event. He writes :—

“T was sent for on the evening of the 24th of May: the pains
were slow but at pretty regular intervals of twenty minutes ; the os
dilated to the size of half-a-crown, the membranes protruding ; pre-
sentation favourable. The vagina and os were excessively tender.
Fomentations were used from this time. The waters were kept
entire till they had well performed their duty; and the head was
protruded about an hour afterwards, safely, though a very large child.
There was a slight tear of a quarter of an inch laterally at the four-
chette, but the old cicatrix is uninjured. The bowels were relieved
on the third day, and there was and is perfect control of their func-
tions. Mr. Knaggs was present, and administered chloroform during
the pressure on the perineum and expulsion of the head. I
confess I felt a little nervous as to the result, especially having
been told by an eminent obstetrician, a short time previously, ‘go it
would,”

The lesion in this instance was of severe character, and yet, by the
plan pursued, it was cured in fourteen days, so as to enable the patient
to control the action of the bowels. Another point of interest was
the existence of pregnancy, and the absence of any uterine disturb-
ance from reflex action of the vaginal nerves implicated in the opera-
tion. The happy termination of labour also lends peculiar interest to
this case, which now consequently illustrates both my first and third
propositions.

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LACERATION OR RUPTURE OF THE PERINZUM. 61

_ Cass VIIT.—Complete Rupture of Perinceewm, of one year and
eight months standing ; Weak health: Operation ; Result.—Sarah 8.
zt. 22, admitted November 29th, 1852, into Boynton ward, St.
Mary’s Hospital.: is much marked by small-pox ; states she has never
been well since 14 years of age. Complains of pain in the stomach
and back, and other dyspeptic symptoms. The tongue is white ;
bowels regular ; catamenia absent since her confinement ; the cheeks
are flushed, appetite bad.

The perineum was ruptured one year and eight months ago, in
her first and only confinement, when instruments were used. The
laceration extends through the perineum into the rectum, merely a
band of mucous membrane separating the two canals : the structures
laterally are deficient. No operation has been attempted on account
of her weak health.

Having by medical treatment been considerably improved in
health, the operation to restore the perinzeeum was performed in the
usual way on the 22nd of December.

The after-treatment was according to the plan described, and the
satisfactory progress of the case offered no particulars worthy of a
daily record. On the tenth day, a careful examination per vaginam
and per rectum, proved union to be complete and firm ; and on the
following, the eleventh day, the bowels were allowed to empty them-
selves, assisted by repeated injections of warm water. This case
proved entirely successful.

Casz [X.—Complete Rupture of Perinewm, of fwe years dura-
tion: Operation ; Result.—Mrs. E., et. 39, came under my care in
January 13th, 1853, at the recommendation of Dr. Locock.

Five years ago she was delivered of her first child; instruments
were used, and laceration was the consequence. Since then she has
had no control over her bowels, and no hope of relief was held out to
her : she has had, however, two other children.

On examination I found the perineum and anterior portion of
the sphincter ani destroyed ; the uterus pressed on the rectum, and
ordinarily produced great difficulty to the passage of the freces through
the bowel, but when she took medicine she could not check the
alvine discharge when once it began. Her spirits are depressed. The
catamenia did not appear at the last regular period.

On the 24th I operated in the usual manner ; Dr. Locock, Messrs.
Coulson and Nunn being present. The patient was submitted to the
after-treatment advised, and everything went on well. On the 28th
I removed the superficial sutures, and two days afterwards the deep
ones. The edges of the fissure were firmly united.

February 2nd. Passed water, supported on her hands and knees.

4th and 5th. Bowels relieved by castor oil and injections.

10th and 12th. Able to control the evacuations and flatus. On
the latter day walked down stairs.

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62 LACERATION OR RUPTURE OF THE PERINEUM.

24th. Left town quite well, and wrote to tell me she had arrived
at Cheltenham without the slightest inconvenience.
I have lately seen this lady, and found her quite well locally and

generally.

Case X.—Complete Rupture of the Perineum ; Destruction of recto-
vaginal septum of siateen years’ standing : Operation; Death; Autopsy.
—C. B., et. 42, admitted February 12th, 1853, into Boynton ward,
St Mary’s Hospital. Has had four children. The accident happened
in her first confinement with a male child, having a large head; no
instrument was used. The laceration has been aggravated by the three
subsequent labours, which were, like the first, rendered more difficult
by the size of the heads of the children, who have in each instance
been male. The injury has now existed sixteen years. The rupture
extends through the perineum and sphincter ani, and much of the
recto-vaginal septum is lost. She cannot retain her motions ; there
is a constant dragging from the loins, and a bearing down, especially
upon exertion. The general health appears tolerably good. No
operation has hitherto been attempted. As an aperient I gave her,
pu. hydrarg. gr. iij.; fel bovin, gr. x., at bed-time.

On the 16th, I performed my operation in the usual manner, the
patient being under the influence of chloroform. The operation pre-
sented no special features to detail: immediately after it, I ordered
two grains of opium, and one grain to be continued afterwards every
four hours. In the evening she was rather restless.

17th. Did not sleep last night. Eyes staring ; expression wild;
catheter introduced every four or five hours. Water dressing to wound.

18th. Wound looking well.

19th. Catamenia appeared. Parts looking very healthy; healed
externally by the first intention. Complained in the evening of
chilliness, and was restless ; the face flushed, and pulse quick. Omit
the opium. Ordered, % spt. ammon. arom. 341i, mist. camph. 3 i.
liq. opii sedativ. ™ xx., to be taken at once.

20th. Still restless, with quick pulse. Says she has not any pain,
J Conf. opii gr. v. ter die.

21st. Still feverish, with agitated, unquiet manner. Has hardly
slept since the operation. Is thirsty ; tongue nearly clean. J Mist.
potass. effervesc. 3 j. ter die. In the evening still being without
sleep, and restless, a grain of acetate of morphia was given.

22nd. Slept well last night ; says she feels better. There is still,
however, a restless manner and expression. The superficial sutures
removed.

23rd. Passed a restless night. Had shivering this morning, and
is now flushed and perspiring. Pulse quick, weak. Manner agi-
tated. I% Spt. ether. sulph. co. M xv.; spt. ammon. arom. M xx,;
tr. hyoscyam. 3 ss. mist. camph. 3 j., statim. This draught was re-
peated at noon, and spt. camph. co. M xxx. ordered at bed-time. At

'

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LACERATION OR RUPTURE OF THE PRRINEUM. 63

12 p.m. was sleepless, restless, and anxious; without pain. To have
at once a grain of acetate of morphia.

24th. Slept but little last night. The wound this morning shows
a tendency to slough. She has no pain nor tenderness of abdomen.
Ordered brandy every four hours. Lotio nigra to the wound.
 Potass chlorat. 3 j.; tr. cinchone fy j.; dec. cinchon. f3j. ter die.

At four this afternoon had a distinct rigor, which lasted upwards
of half an hour, with blueness of face and cold extremities. Pulse
168, small, feeble. Repeat the ether draught, and take mixture every
three hours. The deep sutures removed.

In the course of the night she became very restless, and the coun-
‘tenance anxious ; face congested ; abdomen tender on firm pressure
being made, especially at the lower part ; breathing hurried ; expira-
tion attended by a loud creaking noise at the base of both lungs; the
heart’s action hurried, feeble. Brandy was given freely, but it did
not rally her, and she gradually sank, and died about six o’clock.

A post-mortem examination was made. The uterus was enlarged
and much inflamed, but contained no pus. The Fallopian tubes were
also highly vascular and inflamed, and contained pus, which oozed
from their extremities. A small quantity of pus appeared in the pelvic
cavity. The peritoneum and the intestines in the lower region of
the abdomen, were highly vascular. There was a slight serous effu-
sion in the pericardium ; a deposit of lymph, and congestion about
the base and posterior part of the left: lung. :

This case suggests the necessity of examining into the previous
history and condition of a patient, in determining on the advisability
or prospect of success of operation. This poor woman was particu-
larly leuco-phlegmatic, without tone or muscular vigour. Several
years ago she had a whitlow lanced, which would not heal until
after a sojourn at the sea-side for two months; and she at all times
exhibited a low vitality. Of these circumstances I was not informed
until after her decease.

I now come to cases in proof of my second proposition—viz.,
«That in the worst forms of Ruptured Perinzeum, the operation
should be resorted to immediately on the occurrence of the ac-
cident.” Two of the cases which illustrate this, fulfil the same
purpose for the third proposition—viz., “That subsequent par-
turition is possible without injury to the restored perineum.”
A proof of the last proposition is also furnished by cases I. and
VI.

Case XI.—Complete Rupture of Perineeum: Operation immediately
after the accident ; Result.—Mrs. G. I was sent for by the husband of
this lady, a medical man residing in St. John’s Wood. She was in

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64 LACERATION OR RUPTURE OF THE PERINEUM.

labour with her first child, and on my arrival I found the child just
born, the uterus refilled from internal hemorrhage, and the peri-
nzeum completely lacerated. The rent extended through the super-
ficial sphincter fibres, but left the rectum intact.

I immediately put in two deep sutures, fastening them with pieces
of bougie, and then a couple of small interrupted sutures to secure
perfect apposition of the surfaces. This done, I divided the sphincter
a quarter of an inch on each side from its insertion ; gave at once a
grain of opium, and ordered its repetition every six hours.

My friend told me that the labour for some hours progressed
slowly, the pains being cut short, but that eventually the labour ad-_
vanced rapidly, the head descended and was expelled during his tem-
porary absence, but the perineum did not then tear. On finding the
cord tightly twisted around the neck of the child, he relieved this,
and entrusted the nurse with the support of the perineum. However,
the shoulders were quickly and forcibly expelled, and in their passage
the laceration took place.

December 30th. Has passed a good night. There is no swelling
of the parts; pulse quiet. She has had some refreshing sleep. Ca--
theter used every six or seven hours. Ordered to take beef-tea and
milk.

31st. Very comfortable. The night has been good. There is
no pain ; no swelling about the wound. The vagina is injected with
tepid water three or four times a day, to ensure cleanliness, and to
prevent the irritation of the united surfaces by the lochia.

January Ist. Removed the quill sutures, and found strong adhe-
sion. On the following day, took out the interrupted sutures.

3rd. Going on well in every respect. The opium to be discon-
tinued. A dose of castor oil to be taken to-morrow morning, and to
be followed by an injection.

4th. The bowels have been well relieved without any injury
to the united parts. She now passes water, resting on her hands and
knees.

5th. Milk scanty ; in all other respects she is going on most
favourably, and is convalescent. She has perfect sphincter power,
and the perineum is strong and complete. :

The history of the labour in this case teaches a practical lesson.
The pains were ‘cut short, and apparently did no good: when this
happens we may be almost certain that it arises from the twisting of
the funis around the neck or body of the child, and that the uterus
will eventually suddenly expel both fcetus and placenta; and unless
the practitioner be or his guard, this is likely to be attended by peri-
eae laceration, and, it may be, by hemorrhage, and the death of the
child.

The successful treatment of this case shows that the lochia do not
so interfere as to prevent union of the surfaces when quill sutures are
used, and accurate apposition obtained by relaxing all tension by the

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LACERATION OR RUPTURE OF THE PERINEUM. 65

division of the sphincter. In this patient too, it should be noted that
the lochia were very abundant, by reason of the previous uterine
hemorrhage and the formation of coagula.

Case XII.—Complete Rupture of the Perinewm from abnormal
condition: Inumediate operation ; Subsequent delivery ; Result. Mrs. D.,
zt. 35, was delivered of her first child, after forty-eight hours’ con-
tinued labour, the perineum all the while having the character of
soaked pasteboard and being unyielding. No amount of grease and
fomentation availed anything; and, during the escape of the head,
the perineum gave way in its entire length, and with it also the super:
ficial fibres of the sphincter ani.

On the completion of delivery, I at once applied sutures, but did
not divide the sphincter. The perineal tissues united superficially,
but some of the untorn deep fibres of the sphincter kept up a constant
dragging, and a tendency to retraction of the united parts, the conse-
quence of which was a very prolonged cure, and it was not till after
two months that the perineum was firmly and entirely restored.

August 27th, 1852, I was summoned to this patient in labour at 2
A.M., and found the os uteri the size of a shilling, thin, but dilatable,
and the bag of waters protruding. The perineum was very thick
and unyielding. I determined to wait, and to make an examina-
tion but seldom.

At 3..m. the bag presented at the os externum, at a quarter past
the waters escaped, and the head of the child then descended on the
perineum. A crescent-like band was now felt stretched across the
vagina in the position of the constrictor vagine, very unyielding and
tense, like a catgut cord, resisting the advance of the head. It was
clear, therefore, that, unless great care was used, and the opposition
removed, the head would tear through the perineum between this
transverse band and the sphincter ani, especially as the pains now
came on forcibly. I therefore gave chloroform: this quickly relaxed
the band, more particularly the horns of the crescent; and then gra-
dually tearing through its extremities with my forefinger, the neces-
sary dilatation of the canal was obtained. Still keeping the patient
under the action of chloroform, I pressed with my left hand against
the head, so as to direct it downwards and forwards, whilst, by means
of the two forefingers of my right hand underneath, the head was
prevented from pushing against and stretching the transverse band.
The result of these proceedings was most satisfactory, for by half-past
four the head passed, and afterwards the shoulders and body without
the slightest laceration, though the child—a male—was above the
average size. : ; “5

This case affords a good illustration of the third proposition.

Case XIII.—Complete Rupture of the Perinewm : Immediate Ope-

ration ; Subsequent Delivery; Result. Mrs. V. xt. 29, came under my
F

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66 LACERATION OR RUPTURE OF THE PERINEUM.

care in her first confinement in October, 1851. She had been, previous
to my arrival, in strong labour for twenty-four hours; the pains of
late, however, not doing any good, and the head of the child resting
on the perineum, the practitioner in charge of the case had just
used the forceps, and rupture of the perineum had happened in its
entire length, and extended to the superficial fibres of the sphincter ani.

I at once proceeded with the operation to bring together the edges
of the fissure by the quill sutures; but having with me no bougies
for the purpose, I was compelled to employ instead, pieces of lint
tightly rolled up. I did not in this instance divide the sphincter,
which omission I afterwards regretted, as union was much slower than
it would have been if Ihad done so. However, the case did perfectly
well, and a sound perineum was restored.

On November 12th, 1852, I attended this ladyin her second confine-
ment. The labour was natural ; the bag of waters remained entire
until the complete expansion of the os uteri ; there was a copious
secretion to lubricate the parts, and the perineum yielding kindly,
the child was safely born without the least laceration.

This case, again, therefore, satisfactorily confirms the second
and third propositions. The two next, in illustration of the
second proposition, were operated on by my friend Mr. Obré, on
the plan I had laid down. The first, was a patient of Mr. C.
Stewart, who kindly furnished me with the following account:—

Case XTV.—Complete Rupture of Perinewm: Immediate Opera-
tion; Result ; Observations.—“ Mrs. M. J., et. 26, was taken in
labour with her first child, June 19th, 1852, at 1 am. The head
presented ; the os uteri high up at the promontory of the sacrum, was
dilated to the size of half-a-crown; the soft parts rather unyielding
and rigid; the pelvis of normal dimensions; the pains increasing in
frequency and vigour. The membranes presently burst; the head
became engaged in the brim of the pelvis, at the sacro-iliac joint.
From this period, although the pains seemed efficient, yet the head
progressed slowly ; consequently, about 6 p.m., I applied the forceps,
and turned the face into the cavity of the sacrum, when a violent
uterine contraction occurred, seconded by the efforts of the patient, so
suddenly as to force the child and forceps through the os externum,
with the result of rupturing the perineum into the rectum.

“The patient was directed to keep herself quiet; and at 9 p.m.,
Mr. Obré, myself, and a friend, proceeded to secure the ruptured peri-
num upon Mr. Brown’s plan, by the aid of chloroform.

As I had not previously seen the operation, and as Mr. Obré knew
it perfectly, I preferred his performing it, while I assisted. Three
deep double sutures were inserted, tied over a piece of elastic catheter
on each side, the superficial interrupted ones introduced, and the

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LACERATION OR RUPTURE OF THE PERINAZUM. 67

sphincter ani divided on either side. Cold-water dressings were ordered,
and a pill containing one grain of opium and two grains of extract of
henbane, three times a day. Diet to consist of milk, gruel, and
weak tea.

“June 20th. Doing well. At 6 A.M. introduced the catheter. At
1 p.m. she complained of soreness from the pressure of the sutures. She
has passed water once since I visited her in the morning, but, recol-
lecting my injunctions not to allow the urine to come in contact with
the united parts, she had avoided it by resting on her hands and knees ;
the nurse, too, carefully bathing the parts afterwards with cold water.
From this period I did not again pass the catheter. Same diet and

ills to be continued.

“21st. She has passed urine three times in the twenty-four -
hours, using the same precaution as yesterday. The parts look very
well. The pill to be taken twice a day.

“25th. Has continued to progress favourably. Ordered beef-tea
to be added to her diet. To continue pills.

“July Ist. The posterior of the three deep sutures broke in the
night, and has come away. The parts continue healthy and are evi-
dently healing.

“6th. The other sutures came away this morning. Union pro-
ceeding satisfactorily.

“Gave Ol. ricini, 3i, early this morning. This acted freely, and
without causing pain. (Thus constipation was maintained seventeen
days). Examined her with Mr. Obré, and found the wound perfectly
healed, with the exception of a very small opening anteriorly, just
admitting a probe into the vagina. To omit pills: to be allowed
meat daily.

“14th. The small sinus perfectly closed; the patient quite con-
valescent.

“This being the first case of ruptured perineum which had
occurred in my practice, and the first in which I had seen Mr.
Brown’s operation applied, I watched it with more than ordinary
interest, and was most agreeably surprised to find that it in nowise
interfered with my patient having, on the whole, a very good time.
Her milk came the third day, and although scanty in quantity while
she continued to take the opium, it increased immediately on its
omission, and especially on the improvement of her diet. The lochia
continued, as in ordinary cases; and from the first, she had neither
headache nor any symptom which could be deemed untoward. Her
infant thrived, and never required feeding; nor was there any occa-
sion to administer medicine.”

This must be admitted a very successful case. The treat-
ment in some minor particulars was varied from that ordinarily
pursued by me; the diet was more meagre than I allow; the

F2

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68 LACERATION OR RUPTURE OF THE PERINAUM.

sutures were let break and come away of themselves; and cathe-
terism was not persevered in as I advocate.

Cas—E XV.—Complete Rupture of Perinewm; Twins: Immediate
Operation ; Result.—This case of operation immediately on the occur-
rence of the lesion, happened in the experience of Mr. Lerew, but is
recorded by Mr. Obré, who operated.

“Mrs. B., et. 31, having been in labour with her first child for
fifty-three hours, Mr. Lerew considered it necessary, from the ex-
hausted state of the patient, and the fixed condition of the child’s head
for many hours at the brim of the pelvis, to deliver by means of the
forceps. The child was extracted with little difficulty, but on examina-
tion, a slight tear was observed in the perineum, and some embarrass-
ment was now felt, as another child was discovered in the uterus. On
the passage of this second child, every effort was used to guard the
perineum, but to no purpose; for as the head advanced, the rupture
slowly extended, and on the completion of delivery, the laceration had
reached and involved the sphincter ani, and the rectum to about
a quarter of an inch. The children were certainly the largest twins I
had ever seen.

“ An hour after the birth of the second child, I was requested to
ligature the parts, so as to restore them to their natural state. The
edges were quite smooth, almost as much so as if made with a knife.
TI passed three deep double sutures, making the entrance and exit of
the needles at least an inch and a half from the margins, and
traversing deeply, close to the mucous membrane. The first suture
was made at the fore part of the rupture: the third near to the
rectum ; and all the ligatures fastened on either side over a piece of
bougie. The edges of the integument were now also closed by inter-
rupted sutures.

“As only a very small portion of the sphincter muscle was rup-
tured, I did not think it prudent, as in Mr. Stewart’s case, to divide
the sphincter laterally.

“The case from this time was left under the care of Mr. Lerew,
with directions that water-dressing be applied; the catheter used three
times daily; light but nutritious diet allowed; and the action of the
bowels be restrained by the continued use of small doses of opium.

“On the fifth day, one of the deep sutures cut its way nearly out,
and was removed; the other two were withdrawn on the eighth day.

“The patient went on most favourably. On the fifteenth day
after the operation I visited her, and found, by examination with one
finger in the vagina and another in the rectum, that the parts were
healed. I then recommended the bowels to be moved by a dose of
castor oil, and an enema of warm water.

“T have had a subsequent opportunity of examining this patient,
and found the parts sound and well.”

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LACERATION OR RUPTURE OF THE PERINEUM. 69

The next cases belong to the third variety of lacerated peri-
num, and illustrate its treatment.

Case XVI.—Incomplete Rupture of Perincwm, of three years
standing, with Fissure of the Rectum: Operation; Result. T,,
zt. 37, admitted into Boynton ward, St. Mary’s Hospital, March
26th, 1852. At her first confinement, three years ago, the perineum
was ruptured by the sudden descent of the head, at the moment of its
extrusion, in the absence of medical assistance. The tear did not go
through the sphincter or recto-vaginal septum, and she therefore
did not suffer from incontinence of her motions, but very much from
procidentia uteri. The uterus not only partially projected from the
vagina, but also constantly pressed on the rectum, and produced
fissure of that bowel. These evils exerted an injurious effect on the
general health of the patient, causing nervous depression and dyspepsia,
besides the mere local inconvenience.

I first cured the fissure of the rectum, by dividing the sphincter
through the fissure itself. After the complete success of this step, I
applied the usual remedies for the restoration of the health, and also
for the procidentia uteri. With the latter I failed on account of the
deficient perineum, and accordingly determined to operate for its
restoration.

April 7th. On this day I sutured the ruptured parts in the ordi-
nary manner, and pursued the usual after-treatment.

Success crowned my efforts, and on the 24th of the month she was
discharged cured, having a sound perineum, and no procidentia uteri.
T have seen her frequently since, and ascertained the permanence of
the benefit derived.

This case presented two or three interesting and instructive
features. First, the production of fissure of the rectum by the
mechanical pressure of the uterus against it; second, the
dependence of the prolapse of the uterus on the absence of the
perineum,—the natural floor of the vagina, and support of the
pelvic viscera against their necessary tendency to descend, and
the cure of the displacement by renewal of the perinzeum:
a third, in the restoration of the bodily health by attention to
these mechanical causes of its decline.

Case XVII.— Incomplete Rupture of Perinwum, fwe months’
standing; Prolapsus Uteri: Operation; Result.—E. A., ext. 23,
admitted July 2nd, 1852, into Boynton ward, St. Mary’s Hospital.
She was confined with her first child nearly five months ago,
after a labour lasting three days. No instruments were used, but

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70 LACERATION OR RUPTURE OF THE PERINEUM.

the perineum was ruptured: the sphincter ani, however, escaped.
She complains of discomfort from the dragging of the uterus, which
prolapses to some extent; and from its pressure on the rectum, the
margins of the fissure are a good deal congested, and numerous
condylomata are scattered over them.

July 7th. The opposed surfaces of mucous membrane were dis-
sected off, and the edges brought together by quill sutures. The
sphincter was divided on both sides. Two grains of opium were at
once given, and one grain continued afterwards every three hours.
Pulse rather quick, soft ; skin cool. She was ordered a pint of beef-
tea, four ounces of port wiue, and a pint of porter.

9th. Pulse 126, soft; tongue with some patches of coating. Says
she has caught cold; complains of pain in the lower part of the
chest. The united surfaces look well. The urine drawn off regularly
every five or six hours.

12th. Has continued to do well. The sutures removed to-day.
Union is perfect, save in the centre, where is a small opening. This
to be touched with acetum lytte.

20th. Improving. The opening in perineum decreasing.

24th. The application of the acetum lytte continued. Ordered
a calomel and colocynth pill at night.

30th. Has progressed favourably to this date, and is now quite
well. The perineum perfect and firm. Discharged cured.

The operation in this instance was called for to remove the
prolapse of the uterus, and its ulterior injurious consequences.

Case XVIII.—Incomplete Rupture of Perinewm: Operation im-
mediately after the accident; Result—Mrs. W., et. 22, March,
1854. In labour with her first child, The head large; outlet
small ; perineum unyielding, and the expulsive pains strong. The
constrictor vagine suddenly gave way, and the perineum was torn as
far back as the sphincter ani, leaving that muscle intact. So soon as
the placenta had escaped, I applied one very deep interrupted suture,
and followed the usual after-treatment.

After three days I removed the ligature, and found the union of
the parts perfect. The subsequent progress of the case was very
successful, and presented no circumstances worth recording.

Other cases where the perinzum was ruptured will be found
among those detailed in the chapters on Vaginal Prolapse.

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CHAPTER II.

PROLAPSE OF THE VAGINA.

Tis condition presents itself under three forms, according
as it affects the anterior or posterior wall, or the entire circum-
ference of the canal. Hach form involves displacements of the
viscera connected with the vagina, and derives its importance
from them. The yielding of the anterior parietes of the vagina
drags down the bladder, and produces “ Prolapsus Vesicz,”’ or
“ Vaginal Cystocele;” the giving way of the posterior wall
induces “ Rectocele;”? whilst the descent of the entire circum-
ference presents a true prolapse of the vagina, and almost
necessarily involves more or less displacement of the connected
pelvic viscera. This last will need no consideration distinct
from that of Prolapse of the Uterus.

I. Prolapse of the Anterior Wall of the Vagina.—Prolapsus
Vesice, or Vaginal Cystocele.

Cystocele— This not uncommon accident usually results
from the stretching of the parts by repeated, or by difficult
labours, and progressively becomes worse when left to itself. It
may vary in degree from a slight bulging of the front wall of
the vagina to the production of a tumour filling or stretching
the canal, or even extending from it and hanging between the
thighs. A ruptured perineum, by removing the natural support
of the pelvic viscera, may predispose to this, and, indeed, to
either variety of prolapsed vagina. The relaxation of the vagina
in front immediately causes an alteration in the position of the

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72 PROLAPSE OF THE VAGINA.

bladder and of its meatus, so as to impede the evacuation of its
contents. This interference with the escape of urine again leads
to imperfect emptying of the bladder, and to excessive accumu-
lations, by the weight of which the vagina is stretched still
further, and thrust downwards and forwards. Instead of the
urethra rismg upwards behind the pubes, it becomes curved
backwards more and more, until eventually, in complete prolapse,
its course is actually downwards and backwards, and its orifice
external to the labia. See Prars ITI.

As might be presumed, the extruded bladder is liable to
injury, and may become the seat of ulceration or of other
morbid process.

Symptoms.—The patient complains of weight and bearing
down, and sensations of dragging in the lower part of the abdo-
men; uneasiness and pain in walking, and more or less dysuria,—
the bladder having, to a great degree, lost its power of contrac-
tion. Some patients are obliged to replace the bladder before
they can evacuate the urine. On examination, a soft, elastic,
fluctuating tumour is felt at the orifice of the vagina; it is of
a red or bluish-red colour, and can be greatly diminished
by catheterism: the finger can be passed into the vagina
below the tumour, and the os uteri can be felt behind, nearly
in its natural situation. The surface of the tumour, when
distended, is smooth, moist, and shining; but, when the
bladder is empty, it is thrown into transverse folds. There is
always very considerable mucous discharge, which is exceedingly
irritating to the labia and soft parts; and there is sometimes a
very distressing irritability of the bladder, and the urine, when
passed, is foetid, and contains much ropy mucus. This arises
from a small portion of the urme being always left in the
bladder, and the consequent decomposition of that secre-
tion.

Cystocele may be easily distinguished from prolapsus of the.

uterus; it is soft and yielding to the touch, and, on introducing
the catheter, the point will be felt through the walls of the
tumour, towards the anus; and, on passing the finger upwards,
the os uteri can be felt in its natural position. It can also be
distinguished easily from prolapsus of the posterior wall of the

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PROLAPSE OF THE VAGINA. 73

vagina or rectocele, or from inversion of the uterus—that con-
dition preventing the passing of the finger into the vagina
at all.

Treatment.—This will depend on the extent and duration of
the prolapsus. If it be of recent date, and occurring in young
females, the treatment should be frequent catheterism, recum-
bent posture, astringent injections within the vagina of alum,
oak-bark, infusion of galls, sulphate of iron, cold water, &c. An
additional means is to keep constantly in the bladder a bent
metallic catheter, with an elastic bag attached, and a sponge
tent within the vagina to uphold the bladder. The injurious
accumulation of urine is thereby prevented, and opportunity
afforded to the relaxed parts to recover themselves.

By this mode of treatment, I have seen much benefit result.
A lady, zt. 24, the mother of two children, who had cystocele of
some standing and severity—which, by the way, had been mis-
taken for uterine prolapse—was much improved by it.

If, however, the prolapsus be of long standing, and occur in
females beyond the period of child-bearing, the treatment should
be more severe and radical. Some recommend plugging the
vagina with pessaries, made especially for this condition. These,
however, frequently produce much writation, and hence the
greater need for a surgical procedure. It has been recommended
by some to remove a triangular slip of the mucous membrane,
the base being towards the orifice of the vagma, and to bring
the edges together by sutures, thus contracting the calibre of
the vagina. Others recommend the use of the actual cautery
so as to produce a slough, and subsequent cicatrization and
puckeriag. M. Jobert, of Paris, encloses within two curved trans-
verse lines an oval space, more or less considerable, on the pos-
terior surface of the vagina, by means of caustic, so as to form
an isolated spot, repeating the application of the caustic till the
mucous membrane is destroyed. He then pares the edges with
scissors or a bistoury,draws them together, and maintains them in
apposition by means of straight needles (the points of which are
removed) and a twisted suture. He operated thus on a patient
in July, 1838, and on two others, subsequently, with success.

These operations proceed on the principle of contracting the

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74 PROLAPSE OF THE VAGINA.

vagina, and of thereby mechanically preventing the protrusion of
the bladder. My principle of operating also is similar. Recog-
nising the prolapse of the bladder to be due to the relaxation of
the anterior wall of the vagina, my endeavour is to remove
this cause by a “ plastic” operation, which will be sufficiently
described in the history of the following case:—

Cask XIX.—M. T., aged 52, has had ten children. . She was
admitted into St. Mary’s Hospital, February 14th, 1853, suffering
from severe prolapsus of the vagina and bladder, which first began to
trouble her nine years ago, after her last labour. On the least
exertion of walking, or even standing, or coughing in the recumbent
position, the tumour came down and protruded through the external
orifice of the vagina, to the size of a large fist. On lifting up this
tumour, when so extruded, there were seen on the under and posterior
surface of the os uteri, which was dragged down by the vagina, two
or three ulcerated spots produced by friction against the posterior
wall of the vagina. The patient could, when reclining on her back,
replace the tumour. She had a cough from chronic bronchitis, which
she generally had in winter, complained of feeling weak, and her
appetite was capricious.

This patient being a servant in place, suffered greatly from her
condition, and was obliged always to wear a bandage or napkin to
prevent the extrusion of the tumour; and this very support, by the
friction and heat, rather increased than diminished the suffering. Her
spirits were depressed, and the poor woman became an object of great
pity and commiseration. Mr. Clarke, of Gerrard street, recommended
her to my care.

Operation.—The patient having been prepared, by emptying the
bowels, was on February 15th placed under the influence of chloro-
form, and then put in the position for lithotomy, each leg being held
by an assistant, a third assistant holding up the tumour with Jobert’s
bent speculum, and pressing it under the pubes in its natural position.
A piece of mucous membrane, about an inch and a quarter long and
three-quarters of an inch broad, was dissected off longitudinally, just
within the lips of the vagina. The upper edge of the denuded part
being on a level with the meatus urinarius, the edges were drawn
together by three interrupted sutures, this being repeated on the
other side of the vagina. The next stage of the operation consisted
in dissecting off the mucous membrane laterally and posteriorly in .
the shape of a horse-shoe, the upper edge of the shoe commencing half
an inch below the lateral points of denudation, taking care to remove
all the mucous membrane up to the edge of the vagina where the skin
joins it. See Plate IV. Two deep sutures of twine were then intro-
duced about an inch from the margin of the left side of the vagina,
and brought out at the inner edge of the denuded surface of the same

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PROLAPSE OF THE VAGINA. . 75

side, and again introduced at the inner edge of the pared surface of
the right side, and brought out an inch from its margin, thus bringing
the two vascular surfaces together, which were then kept so by means
of quills, as in the operation for ruptured perineum. The edges of the
new perineum were lastly united by interrupted sutures, and the
patient placed in bed on a water-cushion. See Prare V. Two grains
of opium were given directly, and one grain every six hours; simple
water-dressing applied to the parts; beef-tea and wine for diet. A
bent metallic catheter, to which was attached an elastic bag to catch
the urine, was introduced into the bladder : by this means the bladder
was constantly kept empty. This patient progressed satisfactorily
from day to day without a single bad symptom ; and, on the 22nd,

‘the deep sutures were removed, and the parts were found firmly
united. The lateral interrupted sutures were gradually removed, and
firm union found to have resulted.

February 26th. The deep union was perfectly sound, about three-
quarters of an inch thick, the lateral wounds well contracted ; the
tumour could not be brought down by coughing.

March 8th. The parts were all firmly healed; the patient was
much improved in health, with a very cheerful aspect of counte-
nance. She could walk about without inconvenience, and no amount
of exertion produced any prolapsus. She could empty her bladder
with comfort ; and all the leucorrheeal discharge, which was so dis-
tressing before the operation, had entirely subsided; the offensive
smell of the urine had also departed. On passing the finger into the
vagina, the os uteri could be easily felt in its normal position,
and the ulcerated spots which formerly existed on its surface were
healed. 5

On the 10th she was discharged cured, and resumed her duties as
domestic servant.

Remarks.—The object sought in this operation was the contraction
of the calibre of the vagina, which, as may be imagined, was exceed-
ingly enlarged and flabby. The first step of the operation was
directed to the contraction of the vagina laterally, so as to prevent
the tumour from falling down from above; the second step of the
operation was for the purpose of contracting the vagina posteriorly ;
and thus in the end, by contracting the orifice of the vagina at
least two-thirds, and by so adding to the extent of the perineum, that,
should the prolapsus not be restrained by the lateral contractions, it
could not extrude beyond the orifice of the vagina, but must neces-
sarily fall upon the new perineum. As was proved by the result, all
the objects sought had been fully attained; and it was scarcely
possible to imagine a more satisfactory result from any operative
procedure. The principle of this operation is equally applicable, as will
be hereafter shown, to the cure of prolapse both of the posterior wall
and of the entire circumference of the vagina; and also, with some
slight modifications, to the relief of prolapsus uteri.

After-Treatment. — This in most particulars resembles that pur-

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76 PROLAPSE OF THE VAGINA.

sued after the operation for ruptured perineum. Opium is given to
allay irritation and pain, and to prevent defecation ; the strength is
supported by nourishing diet and wine ; water-dressings are applied ;
and perfect repose is enjoined. The use of injections is, however,
contra-indicated ; for the sutured parts must not be interfered with
in any way. It is of the greatest importance to keep the bladder
emptied; and this point is best secured by retaining a catheter in the
bladder, with a bag to receive the urine as it escapes. After the
seventh or tenth day, according to the integrity of the union of the
parts, the patient may pass the urine resting on her hands and knees.

The time for the removal of the sutures must be regulated by the
circumstances of each case; but, in general, the deep ones may be
withdrawn from the third to the fifth day, the others a few days
afterwards.

Cast XX.—Mary Ann R., xt. 47, admitted into Boynton ward,
St. Mary’s Hospital, April 29th, 1853. Is a married woman; has
had nine children, and two miscarriages; her labours were protracted ;
her youngest child is now seven years of age. Her general health has
been bad. Twelve months since she had much bearing-down with
pain, and for the last month has experienced a much increased diffi-
culty in passing water. She noticed that the bearing-down was
accompanied by the appearance of a tumour, the size of a small apple,
which she took to be the womb. The urine has varied in quantity on
different days, and she experienced most pain when but little escaped.
Any exertion increased her sufferings, and even walking was painful.
The catamenia have been regular and abundant; the appetite is good ;
the bowels usually act properly ; the urine is of natural colour and
appearance.

On examination, a tumour, the size of an orange, was seen pro-
truding through the vulva, and occupying two thirds of the vaginal
canal, which was extremely relaxed.

May 4th. I performed the operation after the plan described; and
in the after-treatment gave her opium, nourishing diet, and after a
few days, port wine. On the 14th, her state demanding it, she had
a mixture of quinine and iron. All the sutures were removed by the
eighth day.

The case did well. On the 25th of June, on an examination of
the parts, no prolapse was seen; there was strong union of the sutured
parts, and the patient was able to get about with ease and comfort,
without any dragging or pain being felt, and had perfect and painless
action of the bladder.

Case XXI—M. A.M., eet. 45, admitted into Boynton ward, April
30th, 1853. Has had five children; her labours have been easy, but
as a servant has had much hard work. For above five years she has
suffered inconvenience from the bladder occasionally protruding into

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PROLAPSE OF THE VAGINA. 77

the vagina after exertion; for the last five or six months, however,
the displacement has been nearly constant, and a consequent cause of
much pain and distress, entirely disqualifying her from holding any
situation.

It is unnecessary to particularize symptoms, as they were of the
usual character. From her bodily sufferings, and her mental anxiety
at being precluded from gaining her livelihood, she was in a low and
nervous condition.

The state of the parts corresponded pretty nearly with that
described in Case XI 5

May 10th. I operated in my usual manner, and placed the patient
under the same after-treatment. She went on well. The deep sutures
were removed on the 14th of May: on the 25th she appeared quite
well, and was ordered to be discharged. The adhesions set up were
strong; there was no prolapse, no difficulty nor pain in making water,
and no bearing-down when walking.

I may state that this patient is at the present time perfectly. well,
and able to perform the arduous duties of a cook at the hospital.

Case XXII.—Mrs. W., xt. 33, of delicate and nervous constitu-
tion. Has been married five years. Her first child was born eighteen
months after marriage; for the first and last three months of preg-
nancy she suffered much from nausea and retching, and, during the
latter period, from bearing-down pains also, accompanied by difficulty
of micturition, and by the slight protrusion of a tumour into the
vagina. This tumour gradually increased in size, causing more pain,
and almost disabling her from walking, and at last even from standing.
After delivery she applied for relief, but was informed she had pro-
lapse of the womb, for which there was no remedy.

Thus four years were allowed to pass by without an attempt to
ameliorate her unfortunate condition, when, finding herself advanced
in the family way a second time, and suffering increased discomfort,
she applied at St. Mary’s Hospital. The management of her case
during delivery was assigned to J. M. Moullin, Esq., of Porchester-
terrace, the district surgeon-accoucheur of the hospital.

On the 3rd of August, she was taken in labour, and on examina-
tion, a large tumour, the size of a newly-born child’s head, was dis-
covered by Mr. Moullin, projecting from the vagina, and giving the
impression at first that the head had actually been expelled. This
tumour, however, proved to be the bladder, distended with urine, and
incapable of voluntary evacuation by reason of the child’s head press-
ing against it as it descended in the pelvis. The catheter was used ;
upwards of a pint of urine withdrawn; and then, the empty bladder
having been pushed back, the head speedily came forward, and the
birth was happily completed. Mr. Moullin observes that, if the case
had been mistaken, and relief not at once afforded, rupture of the
bladder must have been the inevitable consequence.

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sued after the operation for ruptured perineum. Opium is given to
allay irritation and pain, and to prevent defecation ; the strength is
supported by nourishing diet and wine ; water-dressings are applied ;
and perfect repose is enjoined. The use of injections is, however,
contra-indicated ; for the sutured parts must not be interfered with
in any way. It is of the greatest importance to keep the bladder
emptied; and this point is best secured by retaining a catheter in the
bladder, with a bag to receive the urine as it escapes. After the
seventh or tenth day, according to the integrity of the union of the
parts, the patient may pass the urine resting on her hands and knees.

The time for the removal of the sutures must be regulated by the
circumstances of each case; but, in general, the deep ones may be
withdrawn from the third to the fifth day, the others a few days
afterwards.

Cask XX.—Mary Ann R., et. 47, admitted into Boynton ward,
St. Mary’s Hospital, April 29th, 1853. Is a married woman; has
had nine children, and two miscarriages; her labours were protracted ;
her youngest child is now seven years of age. Her general health has
been bad. Twelve months since she had much bearing-down with
pain, and for the last month has experienced a much increased difii-
culty in passing water. She noticed that the bearing-down was
accompanied by the appearance of a tumour, the size of a small apple,
which she took to be the womb. The urine has varied in quantity on
different days, and she experienced most pain when but little escaped.
Any exertion increased her sufferings, and even walking was painful.
The catamenia have been regular and abundant; the appetite is good;
the bowels usually act properly ; the urine is of natural colour and
appearance.

On examination, a tumour, the size of an orange, was seen pro-
truding through the vulva, and occupying two thirds of the vaginal
canal, which was extremely relaxed.

May 4th. I performed the operation after the plan described; and
in the after-treatment gave her opium, nourishing diet, and after a
few days, port wine. On the 14th, her state demanding it, she had
a mixture of quinine and iron, All the sutures were removed by the
eighth day.

The case did well. On the 25th of June, on an examination of
the parts, no prolapse was seen; there was strong union of the sutured
parts, and the patient was able to get about with ease and comfort,
without any dragging or pain being felt, and had perfect and painless
action of the bladder.

Casz XXI.—M. A. M., wt. 45, admitted into Boynton ward, April
30th, 1853. Has had five children; her labours have been easy, but
as a servant has had much hard work. For above five years she has
suffered inconvenience from the bladder occasionally protruding into

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the vagina after exertion; for the last five or six months, however,
the displacement has been nearly constant, and a consequent cause of
much pain and distress, entirely disqualifying her from holding any
situation.

It is unnecessary to particularize symptoms, as they were of the
usual character. From her bodily sufferings, and her mental anxiety
at being precluded from gaining her livelihood, she was in a low and

~ nervous condition.

The state of the parts corresponded pretty nearly with that
described in Case XTX.

May 10th. I operated in my usual manner, and placed the patient
under the same after-treatment. She went on well. The deep sutures
were removed on the 14th of May: on the 25th she appeared quite
well, and was ordered to be discharged. The adhesions set up were
strong; there was no prolapse, no difficulty nor pain in making water,
and no bearing-down when walking.

I may state that this patient is at the present time perfectly. well,
and able to perform the arduous duties of a cook at the hospital.

Case XXIIL—NMrs. W., ext. 33, of delicate and nervous constitu-
tion. Has been married five years. Her first child was born eighteen
months after marriage; for the first and last three months of preg-
nancy she suffered much from nausea and retching, and, during the
latter period, from bearing-down pains also, accompanied by difficulty
of micturition, and by the slight protrusion of a tumour into the
vagina. This tumour gradually increased in size, causing more pain,
and almost disabling her from walking, and at last even from standing.
After delivery she applied for relief, but was informed she had pro-
lapse of the womb, for which there was no remedy.

Thus four years were allowed to pass by without an attempt to
ameliorate her unfortunate condition, when, finding herself advanced
in the family way a second time, and suffering increased discomfort,
she applied at St. Mary’s Hospital. The management of her case
during delivery was assigned to J. M. Moullin, Esq., of Porchester-
terrace, the district surgeon-accoucheur of the hospital.

On the 3rd of August, she was taken in labour, and on examina-
tion, a large tumour, the size of a newly-born child’s head, was dis-
covered by Mr. Moullin, projecting from the vagina, and giving the
impression at first that the head had actually been expelled. This
tumour, however, proved to be the bladder, distended with urine, and
incapable of voluntary evacuation by reason of the child’s head press-
ing against it as it descended in the pelvis. The catheter was used ;
upwards of a pint of urine withdrawn ; and then, the empty bladder
having been pushed back, the head speedily came forward, and the
birth was happily completed. Mr. Moullin observes that, if the case
had been mistaken, and relief not at once afforded, rupture of the
bladder must have been the inevitable consequence.

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The subsequent progress after delivery was favourable, and on her
becoming convalescent, she was anxious to have something done to
give her permanent relief from the miseries of the displacement she
had so long endured.

Sept. 6th. It having been decided on to operate, I proceeded in
my usual manner, the patient being under the influence of chloroform.

The case was complicated with a partial rupture of the perineum,
which had happened in her first labour, but it demanded no special
modification of the operation. The large dimensions of the cystocele
required an additional denudation of the mucous membrane of the
vagina of an inch square in extent, in the centre of the tumour; the
edges were in the last place brought together by two interrupted sutures.
A serous cyst, the size of a pigeon’s egg, in the left labium, was
a source of inconvenience in operating, but a still greater difficulty
was encountered from the tender state of the vaginal mucous mem-
brane, which tore with the slightest pressure, and precluded the possi-
bility of dissecting it off in a piece. It was therefore peeled off with
the forceps. One small artery had to be tied.

On the third day after the operation the catamenia appeared ; and
on the fourth, the quill sutures were removed, when the parts were
found perfectly united. On the ninth day, the remaining sutures were
withdrawn. The after-treatment was that commonly pursued by me.

Perfect success attended this operation, and the patient was
restored to a state of comfort she had not known for years.

The above history I have condensed from the account of the case
kindly furnished me by Mr. Moullin.

Case XXIII.—Cystocele, with Prolapse of the Uterus and Rectocele,
and partially ruptured Perinewm.—Mrs. L., et. 25, having returned
from Sierra Leone to England, on account of her health, was recom-
mended by Dr. Locock to see me with reference to the severe pelvic
injuries with which she was afflicted.

At her confinement with her first child, three months since, the
perineum was partially ruptured. Since then she has suffered much
from bearing-down of the womb and prolapse of the bladder and
recto-vaginal septum. She states that the urine was once retained
in the bladder for forty-eight hours, and she dates the aggravation of
her sufferings in that organ from that time. She has wasted consi-
derably, and become low, nervous, and sometimes hysterical. Has
had no connexion with her husband since parturition, and has not
nursed the child. She cannot sit up or walk without great local
distress. She had constant sickness on her voyage home, which
greatly increased her sufferings.

T ordered generous diet, and steel with belladonna in pills, with
her meals, I proposed to operate in a week.

February 14th, 1854. I operated in my usual manner. Two grains of
opium were given immediately, and one grain every four hours
afterwards.

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15th. Going on very comfortably. As in my last case, I directed
the urine to be withdrawn every four hours, instead of leaving the
catheter in the bladder as I had before done, for I found that its
continued presence caused irritation of the urethra ; and, by keeping
the bladder constantly empty and contracted, deprived it of its ordi-
nary power of retention after the recovery of the patient.

This patient was convalescent in a fortnight, and the local incon-
venience so much relieved as to enable her to be down stairs in the
drawing-room.

April. I have lately heard that this lady is quite cured of the
prolapse.

II. Prolapse of the Posterior Wall of the Vagina, or
Vaginal Rectocele.

This condition is generally gradual in its origin, and like
the preceding, tends, if left alone, to become worse, mechanical
causes seconding the operation of the primary one, viz., relaxa-
tion of the posterior wall of the vagina. The accident varies in
extent from a mere encroachment of the vaginal wall, to the ex-
pansion of it into a tumour projecting between the labia. Its
more aggravated stage involves other organs; the uterus is at
length dragged downwards and displaced.

Causes.—Rectocele may be produced by—

1. Habitual and prolonged constipation, The undue
stretching of the rectum by fcecal accumulation brings about a
relaxed and loose condition of its tissues; and the same cause
stretching the parietes of the vagina, produces a like looseness
of that canal.

2. Persistence in the use of strong purgatives in persons of
lax fibre.

8. An enlarged or a displaced uterus, so pressing on the
rectum as to impede the evacuation of its contents, and to cause
thereby an overloading and an over-extension of the muscular
fibres of the rectum, and the relaxation of the tissues of the
vagina, especially behind.

4. Rupture of the perineum, when this extends to, but does
not involve, the sphincter ani. The action of this cause may be
explained by supposing the detachment of the sphincter fibres

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from their connexion with the perineum, to produce their
relaxation, and thereby a deficiency of the natural support to
the recto-vaginal septum, especially during the evacuation of
the bowels. The perineum is the normal antagonist to the
diaphragm, counteracting its downward thrust of the intestines,
especially in the efforts at stool. Hence the permeum being
destroyed, the force of the diaphragm tends to displace the
intestines and pelvic viscera, and will be more particularly felt
on the anterior wall of the rectum.

Symptoms.—The general symptoms attendant on this affec-
tion resemble those of the preceding. The patient complains of
pain in the parts and in the back, with bearing-down and
dragging sensations from the loins, aggravated by walking and
exertion of any sort, and giving rise to various sympathetic
ailments. The special symptoms are tenesmus, the frequent
recurring desire to empty the bowels, generally fruitless and
attended with much pain, the evident increase of the vaginal
tumour, and more or less inconvenience or difficulty in emptying
the bladder.

Diagnosis —This tumour, so soon as perceived, is generally
mistaken by the patient for a descent of the womb, but a manual
examination will soon detect its real nature.

The patient being placed on her back, the finger is found to
pass into the vagina in front of the tumour, instead of behind it
as in cystocele, and reaches the os uteri higher up towards its
usual position, thus proving that it is not the uterus prolapsed.
Again, on introducing the finger within the rectum, it enters
into a cul-de-sac of its anterior wall, or in other words, into the
cavity of the apparent tumour in the recto-vaginal septum, and
may be felt through its walls from outside.

Treatment.—It is of great importance to cure this affection;
otherwise, by its continuance, it will drag down the uterus to rest
upon it, and thus aggravate the tumour, increase the miseries of
the patient, and, of course, render relief more difficult.

In the early stages of the displacement we may hope for
benefit from the recumbent posture, attention to the bowels to
prevent constipation, astringent injections, perineal bandages,
and such like expedients. If such fail, however, recourse to

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surgical measures should not be delayed. The operation I
recommend and practise resembles in principle that for cystocele,
and needs no distinct description. The narration of the follow-
ing cases will serve in illustration.

Case XXIV.— Vaginal Rectocele—Hannah H., et. 49; married.
Admitted May 6th, 1853, into Boynton ward, St. Mary’s Hospital.
Has had six children, the youngest now twelve years old. Menstru-
ation has continued regular. Dates her present illness from six years
ago ; has been under treatment for most of the time.

She complains of violent pain in the loins and side of the belly ;
pain when she passes water and when she has a motion ; the latter
can only be procured by aperients, and its passage is attended with
much difficulty. The straining causes the appearance of a “lump” in
the vagina, which she took to be the uterus or a tumour from it. The
endeavour to walk causes the tumour to prolapse from the vagina, and
hence she is obliged almost always to keep in the recumbent posture.
She has suffered from considerable leucorrhea, and from heat and sore-
nessa bout the vagina. Intercourse with her husband is impeded by the
tumour. The urine is thick and ropy.

On examination, the tumour was found to be a prolapse of the
posterior wall of the vagina. The finger was introduced into the
rectum passing forwards into the tumour, as it projects from the vulva.
The perineum had been torn in some previous labour, and was shorter
than natural by imperfect reparation. The leucorrheal discharge was
found to come from the upper part of the vagina and os uteri, the
surfaces of which were abraded by friction, the uterus having been
displaced obliquely forwards, so that its mouth pressed against the
posterior wall of the vagina.

IT considered the case favourable for operation ; and, accordingly, on
the 7th of May, having previously cleansed the rectum by an enema,
I proceeded to operate (anesthesia being produced by chloroform) on
the same general plan as in cystocele, omitting, as unnecessary in this
prolapse, the anterior denudation and sutures. This will be at once
understood by referring to Phare IV. The paring off mucous
membrane, and the insertion of the interrupted sutures (at c) are the
parts of the operation for cystocele omitted in that for rectocele ; since
the object is only to contract the posterior wall of the vagina.

The patient after the operation was placed as usual in bed ona
water-cushion beneath the pelvis, and a grain of opium ordered every
six hours.

On the 13th the pulse was quick and feeble ; there had been some
slight sickness, and excitement of manner, with free perspiration.
Opium omitted, and a draught with five grains of the citrate of
iron and quinine ordered three times a day. In the afternoon there
was a forcing of the rectum, when an opium suppository was used.

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14th. Feels better generally, but the tissues between the two
quills look red and inflamed. This afternoon the quill sutures were
removed, as rigors had occurred, with some bleeding ; this last was
arrested with ice. The wound indicating a tendency to slough, a lotion
of liquor sode chlorinate was ordered. At 7 P.m., rigors still troubled
her; the pulse was 120; tongue moist; skin perspiring ; tenderness
over lower part of abdomen, and a forcing of the bowels. To have
an enema containing an ounce of castor oil, at once; and to take a
saline draught, and a powder of hydr. é. creté and pulv. ipecac. co.,
every four hours.

15th. The shivering and pain have ceased. The left side of the
wound looks puffy.

16th. Is better. Pulse 100; countenance more cheerful; appear-
ance of wound healthier.

After this date the case proceeded satisfactorily ; firm adhesions
were set up, and the prolapse was cured. On the 12th of April she
was discharged. Ihave since seen her, and find that she remains
quite well.

Cas—E XXV.—Vaginal Rectocele—Ruptured Perinceum.— Maria
L., admitted into Boynton ward, January 6th, 1854, et. 32; married.
Has two children; the younger three years, the elder four years
old. Was forty-eight hours in labour with her first child, and
for eight, in extreme agony; the presentation, however, was natural,
and, as she states, the pains good and the child small. Two days -
afterwards the perinseum was found to have been lacerated ; no instru-
ments had been used. The power to control the dejections was not
lost, and these never escaped except through the natural outlet. She
suffered from almost constant tenesmus and leucorrhea, and her
health failed. The catamenia continued regular. When standing or
walking, a tumour protruded from the vagina, which she imagined to
be the womb; and she felt a fulness with bearing down and dragging
pains.

On examination, the perineum was found lacerated as far as the
sphincter, which had escaped. A rounded, reddish tumour extruded
between the labia, occupying about two-thirds of the orifice, and
proved to be a prolapse of the posterior vaginal wall, or a rectocele.

January 19th. Is not well. Complains of cough, and has forcing
pains in the rectum. Ordered for cough, vin. ipecac. m xv. ;
tr. camph co. m xx.; syr. scille, f4j.; aq. £3]. : ter die.

10th. To be operated on to-morrow. Ext. fell. bovis, gr. x.: h.s.
An injection in the morning.

11th. Was operated on in the usual way. Opium as usual.

12th. Has had a bad night. The cough is troublesome; she is
feverish and complains of great pain. Tongue clean ; pulse 90. To
have mel boracis, 4j., pro re nata.

13th. Is rather low this morning. Has been in much pain; the
cough very bad, and there is considerable fever, with a furred tongue.

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PROLAPSE OF THE VAGINA. 83

The sutured parts were very cedematous last night, when they were
punctured with a lancet; to-day they are much less so. To take spt.
etheris nitrici, f48s; potasse nitrat. gr. viij.; pulv. tragac. comp. gr.
xV.; syr. papav. f4ss; aque, 3j: 4tis horis. This evening the sputa
were streaked with blood, and vin. antim. potass. tart. m xij., was
added to the mixture.

14th. Feels better. Tongue not so furred, and skin less hot.
urine clearer ; pulse 96. The quill sutures were to-day removed;
some suppuration existed. At night the cough was again worse, with
increased dyspnea and fever. The vin. antim. potass. tart. was in-
creased to 1 Xxjj.

16th. Past night has been better; expectoration and breathing
easier. The catamenia have come on. The perineum appears united.
Mixture to be taken every five hours.

20th. The chest symptoms are alleviated. The superficial sutures
were this day removed; the healing is complete.

24th. Cough much better. Complains of frequent desire to pass
urine, which scalds her: it is acid, clear, and with very slight sedi-
ment; bowels regular. To take lig. potasse, m xx.: tr. hyoscyami,
m xx.; dec. lini. £3].: ter die.

29th. Has a good deal of bearing-down pain, and the urine still
scalds; in other respects she is better. The vaginal rectocele is
removed, and the perineum perfect.

Casz XXVI.—Vaginal Rectocele, Prolapse of the Uterus, and
Ruptured Perineum.—Mrs. F., xt. 24, was married when only fifteen,
in India, and had the first child before she was sixteen years old. In
the course of delivery the perineum was much torn, and ever after-
wards standing was attended with pain. Fourteen months after the
birth of a second child, the womb came down and protruded exter-
nally. It was replaced, and she was kept in the recumbent posture
for some time. In the course of the following year (1846), she mis-
carried at the eighth month, and was afterwards absent from her
husband until the beginning of 1847. In October of that year, she
was confined with another child, and a fourth was born in 1849.
Moreover she had a miscarriage in 1850, at the seventh month (the
child dying in a few hours), and again in June, 1851, at the sixth
month,

She states that during each pregnancy something constantly pro-
truded from the vagina, (except when in the recumbent posture,) the
length of a finger, having a smooth surface, and feeling like a bladder.

The existence of this tumour, and the state of the perineum and
uterus, caused her so much trouble, annoyance, and pain, that she
made the journey to England for further advice. For the last three
or four years she had been almost constantly confined to the recum-
bent posture. By the kindness of Dr. Locock she was referred to me.

On examination, I found incomplete rupture of the perineum ;
prolapse of the vagina posteriorly, or rectocele; displacement of the

G2

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84 PROLAPSE OF THE VAGINA.

uterus, so that the os was directed against the rectum, and the fundus
tilted forward ; moreover, unless supported by a pad and bandage,
the vagina in its entire circumference prolapsed.

Notwithstanding this complication of complaints, I came to the
conclusion, that by restoring the perineum, and by contracting the
dilated, relaxed vagina, the condition of the patient might be most
materially relieved, if not entirely rectified.

Having subjected my patient to the common preliminary treat-
ment for two days, I proceeded on the 19th of January, 1854, to
operate, taking advantage, as usual, of the anesthetic virtues of chloro-
form. The operation, as shown in Prats IV., but with the omission
of the anterior denudations,* consisted in dissecting off the mucous
membrane from the sides and posterior wall of the vagina, in the
shape of a horse-shoe, and fully one inch wide over the rectum, but
not above half an inch at the lateral parts of the dissection. Rather
more integument at the junction of the skin and mucous membrane
was removed than usual, on account of the greatly relaxed state of
the perineum. For the latter reason also, I did not consider division
of the sphincter ani requisite. The parts were brought together by
two quill sutures of well-waxed twine, and superficially, by four inter-
rupted sutures. The inclination to bleeding from the vagina was
controlled by the insertion of a small piece of ice. The patient was
placed on her side, the urine drawn off every three hours, and a grain
of opium given every four hours.

Jan. 20th. There has been great irritability of the stomach, with
repeated vomiting, and consequent prostration. A mustard poultice
was placed on the stomach; an opium (er. iij.) suppository introduced,
and a teaspoonful of brandy and cold beef-tea ordered every hour.
There was no tension of the parts operated on.

23rd. The suppository repeated every night; good nourishing diet
prescribed; deep sutures removed; the parts looking well, and union
by the first intention set up.

25th. Removed interrupted sutures. Union complete. The patient
takes plenty of nourishment; is allowed wine and bitter ale.

29th. The bowels relieved for the first time. She has gained in
flesh and strength considerably.

30th. The integrity of the parts quite restored; the ruptured
perineum united ; the rectocele cured, and also the prolapsus uteri;
and the patient can stand and walk with ease and comfort. One of
my perinzal bandages to be worn for some months to sustain the
newly-formed tissue.

Remarks.—This case illustrates the bad effects likely to ensue
from neglecting to restore the perineum, even when the rupture is
but partial, The displacements of the uterus and vagina may be
here attributed to it.

* The paring of the anterior surfaces is only needed when, as in cys-
tocele, it is wanted to contract the front wall of the vagina.

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CHAPTER III.

PROLAPSE OF THE UTERUS.

Or this affection there are three varieties, which, according
to the description of my respected teacher, Dr. Blundell, are
respectively called, Procidentia, Prolapsus, and Relaxation of
the Womb. Several examples of these varieties of prolapse are
recorded in the chapter on Ruptured Perineum, with which
lesion they were associated, and of which they were doubtless in
a great measure the consequences.

I. Procidentia Uteri is said to exist when there is complete
prolapse, with protrusion of the uterus beyond the vagina. It is
consequently the severest form of prolapsed. uterus.

Causes—The immediate causes of this disease are:—

. Relaxation of the Ligaments of the Uterus.
. Relaxation of the Vagina.

. Laceration of the Perinzeum.

. Polypus Uteri; and

. Congestion of the Uterus.

This displacement consequently appears in subsidence of the
uterus from deficient support, either from above or below. Such
a want may arise from various causes originating in the general
health of a patient, in local affections of the uterus,.and in
mechanical injuries.

One most common cause is the too early adoption, or too
long continuance of the erect posture after delivery or mis-
carriage, before the uterus and its connexions have recovered
themselves in position, size, and tone; i. e., speaking generally,
before the end of the third or fourth week. Again, a violent
cough at, and after labour, tends to thrust down the uterus by

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86 PROLAPSE OF THE UTERUS.

the strong action of the diaphragm in the act of coughing, when
too the vagina has not recovered itself and can render littie
support.

Single women, however, are not exempt from this accident,
and in them mostly, from the nature of the causes, cure is more
difficult to effect.

Symptoms.—One of the first symptoms of procidentia uteri
is pain in the back, succeeded by some in the groins and labia,
in which also there is a feeling of fulness. The pain in the
back soon assumes a dragging character; there is a sensation
.of bearing-down or of weight, “as if” (as patients will describe
it) “everything were dropping through.” Together with these
symptoms there are, an increased mucous discharge from the
vagina, often a frequent desire to micturate, and sometimes a
degree of strangury, irregularity of the bowels, and interference
with the process of defecation, sympathetic disorder of the
stomach, loss of, or capricious appetite, dyspepsia, distension of
the abdomen, &c.

With the pain and other local evils, and with the general
bodily disorder, it is not to be wondered at that the spirits
flag, that every occupation becomes tiresome, and life oftentimes
a burthen.

Diagnosis.—With a little care, the os uteri may, by manual
examination, be detected, and by observing its position and
relations, our diagnosis may be readily made from polypus uteri,
and from either variety of vaginal prolapse.

Treatment.—For a long period, in the progress of most cases,
the uterus returns of itself or otherwise is easily replaced, on
the patient assuming the recumbent posture. Hence, in the
early stage, this posture, with the hips considerably elevated, must
be insisted on, and continued for a long time; attention being at
the same time given to maintaining perfect quiet. The food
should be unstimulating, and opium administered by the mouth to
prevent the action of the bowels, and so to keep the parts quiet;
injections, however, being occasionally used. So soon as all
inflammatory symptoms have subsided, cold, astrmgent and
stimulating injections may be employed; the cold douche over
the abdomen is especiallybeneficial. At the same time the system

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PROLAPSE OF THE UTERUS. 87

generally requires to be braced by tonics, change of air, and
good or generous diet. Let the introduction of pessaries be
avoided. I will here state my objections—and they apply to
each variety of prolapse, whether of vagina or uterus—to
pessaries of all forms, as mechanical supporters. As a general
rule they are bad; they are prone to produce irritation and exco-
riation, and with these leucorrheea; they are incompatible with
perfect cleanliness; and they stretch and tend to keep up the relax-
ation of the canal. To afford local support I find nothing so useful
as the form of perinzal bandage which I devised and described
some years back, and have constantly used. (See woodcut.)

 

Fig. 3. Fig. 4.

   

 

 

 

 

Should these measures auxiliary to the efforts of nature in
recovering the normal tonicity and status of the parts be
unsuccessful, or should the diseased condition have been pre-
viously neglected until no longer amenable to medical treat-
ment, then we may seek a cure by surgical means. The
measure I propose resembles in principle the one I have
adopted in prolapse of the anterior and posterior walls—viz., in
mechanically curing the displacement by contracting the relaxed,
loose mucous canal. With this object I suggest the removal of
a portion of mucous membrane anteriorly, posteriorly, and
laterally, and the introduction of sutures after the same plan as
in the other operations. A similar course of proceeding appears

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called for in those very rare instances of prolapse of the entire
vaginal canal without procidentia uteri. Such a condition is
spoken of as a distinct one by Dr. Churchill, who quotes a case
recorded by Noel, where the prolapse reached the knees. But
a relaxation of the vaginal walls seems almost necessarily to
entail a more or less complete subsidence of the uterus, when,
according to the accepted nomenclature, we should rather refer to
the condition as one of prolapsed uterus than of prolapsed vagina.
However this may be, the general treatment would be the same.

II. Prolapsus Uteri—Resembles procidentia in all points but
in the extent of displacement, which does not proceed beyond the
canal of the vagina. It is of more common occurrence than
procidentia. The symptoms attending the two conditions are
alike, except that in procidentia they may present greater
severity. Moreover, the causes and general treatment are
similar, and need here no detail. It seems almost unnecessary
to add that, as in the last accident, I object to pessaries. Unless
the perinzeum be much dilated, and have lost its usual tonicity,
I should confine myself to the use of the perineal bandage to
support it, and to obviate the pressure of the uterus upon it; but
if much dilated, then I should attempt to restore its natural
supporting power by contracting it and the dilated vagina, by
removing a piece from the centre of the perinzeum, dissecting
back the mucous membrane over the recto-vaginal septum, and
bringing the edges together by sutures.

III. Relaxation of the Uterus—This is the least degree of
displacement of the viscus. It implies merely a subsidence of
the womb from debility of its structures—its attachments or, so-
called, ligaments, and of the vagina. It is very open to general
medical treatment, associated with attention to the recumbent
posture, avoidance of fatigue, straining, &c., and proper hygienic
conditions.

In this slight form surgical measures are not called for.

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CHAPTER IV.

VESICO-VAGINAL FISTULA

Has been especially considered one of the opprobria of surgery,
and, with few exceptions, attempts at cure have failed. By the
term “ vesico-vaginal fistula” is understood an unnatural com-
munication between the bladder and the vagina, allowing all or
a part of the urme to escape through it, imstead of solely
through the urethra. This opening is different from that pro-
duced by a rupture of the bladder ; as in the latter the structures
are simply torn asunder, whereas in the former, the mucous
membrane of the vagina and the coats of the bladder are
destroyed by a slough.

Causes.—1. The wall of the vagina may be wounded during
criminal attempts to procure abortion.

2. Retention of a pessary within the vagina, inducing in-
flammation and subsequent ulceration.

3. The long impaction of the head of the child in the pelvis
during labour, by pressure inducing inflammation ending in
ulceration and perforation.

4. Careless or improper use of instruments in attempting to
deliver, especially if the bladder be not empty.

5. Corroding cancer of the uterus or vagina may perforate
the bladder.

6. Stone in the bladder at the time of delivery is sometimes
a cause, from the bladder being pressed between the head of
the child and the stone within.

The situation of the opening is of considerable importance
with reference to treatment; it may be either in or about

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90 VESICO-VAGINAL FISTULA.

the neck or body of the bladder itself. The fistula is some-
times circular, at others longitudinal, running from within an
inch of the meatus urinarius up to the os uteri, which is itself
occasionally fissured; sometimes it is transverse, stretching
across the whole breadth of the vagina.

Symptoms.—The involuntary escape of the urine will be the
prominent and leading evidence of the nature of the accident,
rendering the condition of the patient painfully distressing.
In the words of Dr. Fleetwood Churchill, “the escape of urime
is attended with so marked and irrepressible an odour, that the
patient is placed ‘hors de société’ Obliged to confine herself
to her own room, she finds herself an object of disgust to her
attendants and even to her dearest friends. She lives the life
of a recluse without the comforts of it, or even the consolation
of its being voluntary. It is scarcely possible to conceive an
object more loudly calling for our pity, and strenuous exertions
to mitigate, if not remove, the evils of her melancholy con-
dition.” The escape of the urine also produces excoriation of
the vagina and external parts.

Wherever this sad condition is suspected, a most careful
examination should be made by passing a catheter or probe
into the bladder, and introducing the forefinger of the other
hand into the vagina, when, if there be an opening, the finger
will come in contact with the catheter or probe at some point
or other. The best position for examination is, for the patient
to rest on her hands and knees; then the vagina being held
open by retractors, the surgeon can see as well as feel the size
of the fistulous opening. An examination is especially neces-
sary, as partial paralysis of the bladder may induce incontinence
of urine. The examination is easily made when the vagina
itself is not cicatrized. The use of Fergusson’s speculum, by
dilating the vagina, renders it possible to detect the fistulous
opening when the plan just proposed fails to do so: indeed, I
always use the speculum so as to satisfy myself of the exact
nature, size, and position of the opening.

The results of treatment in producing a cure will depend
upon the situation and duration of the lesion, and also upon the
cause of the accident. If it has been produced by a sharp

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cutting instrument, the early application of sutures will occa-
sionally prove successful; and, in other cases, if sutures be
applied as soon as possible after the discovery of the opening,
that is, before the edges have become thickened and turned
inwards towards the bladder, then a favourable result may be
anticipated.

The probability of the cure also depends upon the situation.
When the fissure is far back, and there is considerable loss of
substance, success seldom attends the efforts used; but when
it is near the neck, there is a better hope of success.

I shall now allude briefly to the different modes of operation
that have been tried.

Dessault’s method consisted in plugging the vagina and main-
taining a catheter constantly in the urethra, so as to divert the
discharge from its unnatural channel and allow this to close up.

Chopart, Peu, 8. Cooper, and Blundell, relate cases of cure
by this means. It is, however, in some cases impracticable,
owing to the irritability of the bladder, to continue the catheter
in the urethra.

Cauterization— Various modes of cauterizing have been
recommended: the nitrate of silver, the nitrate of mercury and
the actual cautery, and galvanism (as recommended by Mr. Mar-
shall, University College Hospital) have all been tried, but with
very partial success. A few successful cases are, however,
recorded by Dupuytren, Delpech, Dr. M‘Dowell, Dr. Kennedy,
Mr. Liston, Dr. Colles, Dr. Ferrall, &. In using any form of
caustic, the patient should be placed on her hands and knees,
and a speculum introduced, through which the caustic should
be passed, and then lightly applied to the edges of the wound.
A piece of dry lint should be immediately afterwards introduced
to plug the vagina, the patient placed in bed, and a long
metallic or gum catheter introduced, having attached to it an
india-rubber bag to receive the urine. Solid opium given im-
mediately, and continued from time to time so as to prevent
pain and produce constipation, is a point in my estimation of
the greatest importance; for I am convinced any action of the
bowels by which the pelvic viscera are disturbed, tends seriously
to prevent contraction and union.

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92 VESICO-VAGINAL FISTULA.

Other Methods of Treatment.—Dr. Blundell relates a case
where the fistula at the neck of the bladder was cured by
laying it open into the urethra, and then healing up the wound,
just in the usual way of treating a rectal fistula. Mr. Porter,
of the Meath Hospital, performed a similar operation which
turned out well. Velpeau suggested, and Jobert put in practice
a rhino-plastic operation similar in principle to that followed in
restoring the nose: of four cases so treated, two were cured,
one failed, and one died.

Suture—This method has long been put in practice; the
merit of its introduction is due to Roonhuysen. It has been
used with success by Dieffenbach, Blandin, Chanam, Jobert
(to whose recently published interesting work I shall presently
allude more fully), Malagodi, of Bologna, the late Mr. Earle,
Mr. Hobart, of Cork (who states he has had at least ten suc-
cessful cases), by Mr. Hayward, of Boston, United States,* and
also by my friend Mr. Spencer Wells, who has had some
successful cases.

M. Jobert (de Lamballe) gives a very elaborate account of his
modes of operating. In some cases he thoroughly pares the edges
and surrounding surface of the fistula, and then paring the side
of the uterus, he brings the denuded surface of the bladder on to
the denuded surface of the uterus, and keeps them in apposition
by the interrupted suture. In other cases he dissects back the
whole of the anterior lip of the uterus and unites the posterior
lip with the denuded opening in the bladder : and he relates cases
cured by this means where the menstrual discharge subsequently
camc through the urethra. In some cases he fastens the
edges of the opening almost round the neck of the uterus.
He lays great stress upon free incisions with a view to remove
all tension, and also insists upon constant catheterism after the
operation. He relates six cases, out of which he cured three,
and greatly alleviated and very nearly cured two others; the
remaining one died.+

* See published case in the American Journal of Medical Sciences,
Aug. 1839.

+ See Jobert’s “Traité des Fistules Vesico-Uterines, Vesico-Utero-
Vaginales, Entero-Vaginales, et Recto-Vaginales.” 1852.

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VESICO-VAGINAL FISTULA. 93

The above-named surgeons employed the common interrupted
sutures, but the quill suture, or rather pieces of bougie used in
place of quill, is far preferable; but still better is the method
recommended by Dr. Marion Sims, of Boston, United States,
which is described in Ranking’s “ Half-yearly Abstract of the~
Medical Sciences,” (vol. xv., pt. 1, page 232,) as follows :—
“The suture used by Dr. Sims he calls the ‘clamp’ suture.
It is composed of annealed silver wire the size of horse-
hair and fastened to crossbars like the quilled suture. These
crossbars are also silver, or lead highly polished. Properly
applied, Dr. Sims states that this suture never ulcerates out,
having always to be removed. It may be allowed to remain as
long as ten days after scarifying the edge of the fistula. This
suture is introduced as follows—the number depending upon the
dimensions of the fistula :—

“A long spear-pointed suture needle, armed with a silk
thread, is introduced half an inch anterior to the scarified edge
(in the centre of the fistula first), pushed deeply into the
vaginal septum without transfixing it, brought out just before
the mucous lining of the bladder, entered into a corresponding
spot on the other side of the fissure, and made to emerge into
the vagina half an inch above. A loop of this ligature is then
secured by the help of a tenaculum and the needle is with-
drawn, to be used as before for as many sutures as are
required.

“The sutures having been passed and drawn out so that both
ends of each thread hang out of the vulva, each is made to act
as the guide for the metal suture now to be substituted. This
is done as follows:—Take a piece of the hair-wire above
mentioned, twelve or eighteen inches long, secured by a band to
the silk, which then pull till the wire occupies its place. This
is repeated for each. The next step is to fix the sutures by
means of the clamps. :

“ The following diagram will assist the reader in understanding
this manceuvre, as well as the previous steps of the operation.

“Tn this figure the wires are represented as passed ; the ends
aaaand 64d hanging out of the vulva. The ends a are
fixed to the crossbar c by being passed through holes and

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94 VESICO-VAGINAL FISTULA.

clamped by split shot. This done, the ends 6 are drawn down
till the bar is pulled close to the needleholes at d, after

Fic. 5.

 

which it remains to attach a crossbar to the lower ends of the
ligature and push it up to the lower perforations at e. To do
this and fix it there it is only necessary to attach split shot
upon each ligature and close them by means of appropriate
Fic. 6. forceps or pincers. The edges
of the fistula are now brought
together and retamed in situ
by a clamp on either aspect.
It only remains to cut off the
wires an eighth of an inch
below the shot, and twist the
end so as not to injure the mucous membrane. The condition
of the parts is represented im fig. 6.”
This plan has been successfully followed by my friend Dr.
Druitt ;* and I have myself used it with varied success, as will
be presently seen in the cases recorded. On the whole, I am

 

* See “The Surgeon’s Vade Mecum,” 1854, page 572.

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VESICO-VAGINAL FISTULA. 95

convinced that itis the best form of suture that we yet have.
Before entering further on the treatment of this affection, I
cannot avoid remarking that, as far as my experience goes, the
prevention of this lesion is very much under the control of the
accoucheur; and I cannot but consider that, with ordinary care, by
keeping the bladder empty, and still more, by never allowing the
head to remain long in its passage through the os externum,
this serious injury would not so often occur. I am aware that in
thus advocating the early delivery of the head, I am opposed to
many of the most eminent obstetric writers. Still, when I
reflect on the very many cases which have come under my notice,
and find that in almost every case this accident has occurred
after protracted delivery, I am strengthened in my own opinion.
The history of some of the cases which I shall briefly record
will adduce the strongest evidence of the truth of this opinion.

Position for Operating.—The patient should be placed either
in the position for Lithotomy, on her back, or, still better, in
the prone position as recommended by Dr. Marion Sims, as
follows: —‘ The knees must be separated some six or eight inches,
the thighs at about right angles with the table, and the clothing
all thoroughly loosened, so that there shall be no compression
of the abdominal parietes. An assistant on each side lays a
hand in the fold between the glutei muscles and the thigh, the
ends of the fingers extending quite to the labia majora; then by
simultaneously pulling the nates upwards and outwards, the
os externum opens, the pelvic and abdominal viscera all gravitate
towards the epigastric region, and stretch this canal out to its
utmost limits, affording an easy view of the os tince, fistula, &c.
To facilitate the exhibition of the parts, the assistant on the
right side of the patient introduces into the vagina the lever
speculum, and then by lifting the perineum, stretching the
sphincter, and raising up the recto-vaginal septum, it is as easy
to view the whole vaginal canal as it is to examine the fauces by
turning a mouth widely open up to a strong light.”

Another very good plan for placing the patient has been
recommended by Dr. Hayward, of Philadelphia,* as follows :

* See “ Ranking’s Abstract,” vol. xiv., pt. 2, p. 194.

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96 VESICO-VAGINAL FISTULA.

“The patient being previously etherized, the bladder is brought
down by introducing a large-sized bougie (one made of whalebone
highly polished is to be preferred) into the urethra, to the very
fundus of the bladder, and carrying the other end up to the
pubis. In this way the fistula is readily brought in sight.
Its edges can be pared with the scissors or a knife; though
usually both these instruments are required; and this part of
the operation is much facilitated by holding the edges by means
of a double hook. It is not difficult to dissect up the outer
covering from the mucous coat of the bladder, to the distance of
two or three lines. The needles are then to be passed through
the outer covering only, and as many stitches must be intro-
duced as may be found necessary to bring the edges of the
fistula in close contact.”

The edges are to be pared by making an incision about three
lines on each side of the fistulous opening, through the mucous
membrane of the vagina (by means of a sharp-pointed knife with a
long handle, as described in fig. 7), and then carefully dissecting off
the mucous membrane ; a pair of long forceps made on purpose
(see fig. 8) bemg used to seize it. This done, a needle armed with
silver or platinum wire, if that substance be used, is passed three
or four lines from the edge of the incised surface, and made to
penetrate the vaginal mucous membrane, and some of the fibres
of the muscular coat of the bladder, but not through its mucous
coat ; to ascertain this, itis better to introduce the little finger of
the disengaged hand through the urethra into the bladder. The
needle should next be carried through the opposite side of the
fistulous opening, and brought out at the same distance from
the edge of the denuded surface as it was first inserted. Two,
three, or more sutures, according to the size of the opening,
should be introduced in a similar way. Various forms of
needles have been suggested for this operation. I myself use
those (shown in the following figures), made at my sugges-
tion by Mr. Blaise, of the firm of Savigny & Co.* One was

* I may here say that I have been indebted to this firm for making,
by my direction, all the instruments I have used in my various opera-
tions described in this work.

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VESICO-VAGINAL PISTULA. 97

suggested to me by Dr. Wilkes, of Philadelphia (as seen in
fig. 9), which represents the needle A, which has an eye at ,

Fie. 7. Fie. 8.

 

and another at c. The ligature is passed through the eye B,
the needle screwed to the stem p is then passed until the
ligature appears through the wound; the hook = is then passed
through the eye c, and held in the left hand; the stem p is
then unscrewed with the right hand and withdrawn ; afterwards
the needle is carefully withdrawn by the purchase of the
hook g.

A second, which is an improvement of Jobert’s porte-aiguille,
was invented by my friend Mr. Moullin, and is shown in fig. 10,
A is a needle-clasp, which opens by a spring, and is inclosed in

H

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98 VESICO-VAGINAL FISTULA.

a sliding tube B, which being pushed forward, closes the clasp
tightly together. The plates c are furrowed with rough grooves

Fig. 9. Fic. 10.

 

so as to seize and fix the needle firmly at any angle. p isa
needle so clasped. After it has been inserted in its proper place,
the clasp is withdrawn, and re-fixed near the point of the needle,

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VESICO-VAGINAL FISTULA. 99

which is thus drawn through the wound and detached from the
ligature.

A third instrument, (fig. 11,) made at my suggestion, by Mr.
Blaise, is so contrived that by turning a screw at the handle
A, the needle B may be bent to any angle with the stem,
and the ligature being passed through an eye near the point of

Fic. 11. Fic. 12.

 

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100 VESICO-VAGINAL FISTULA.

the needle, is seized by a pair of forceps, and the needle is with-
drawn in a retrograde direction.

A fourth form of needle, invented by my friend Dr. Druitt,
(fig. 12,) has a fixed curve at an acute angle, the point devi-
ating obliquely from the staff. Those delineated in the figure
are intended for the right and left hands.

Besides these, I am accustomed to use other needles, bent at
various curves and angles, and in some cases, it is necessary to
use a straight one.

So soon as the sutures are made fast, free incisions should
be made through the vaginal mucous membrane, and through
some of the muscular fibres of the bladder, distant about four to
six lines on each side of the closed wound, so as to relieve any
traction upon the apposed surfaces. The principle of this ex-
pedient is precisely similar to that recommended in my opera-
tion for ruptured perineum, as also in that for cleft palate, as
recommended by Fergusson, and is one of the greatest practical _
importance. This is fully dwelt on by Jobert.

After-treatment.—The patient should be placed on a water-
cushion on her side, the hips being elevated and the knees flexed
upon the abdomen. A catheter should be introduced, bent in
a serpentine direction, so that the end within the bladder is
turned up behind the arch of the pubes, on which it rests. To
the other extremity should be attached an elastic bag, capable
of holding from four to six ounces. Two grains of solid opium
should be given immediately, and one grain every four or six
hours for the first twenty-four hours, and afterwards once in
twelve hours until the sutures are removed. This will prevent
pain and also keep the bowels quiet. A bland and generous
diet should be allowed, and wine is often required from the very
commencement. The vagina should be syringed once a day
with cold water so as to insure cleanliness.

I shall now relate some cases to illustrate the difficulties of
any operative proceeding in these troublesome lesions, and

make such practical remarks on each case as may appear most
useful.

Caste XXVII. Vesico-Vaginal Fistula of one year’s standing : Sia
Operations ; Result; Remarks.—Fliza Z., set. 32, married, aspect

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VESICO-VAGINAL FISTULA. 101

healthy, dark red hair, dark irides,—was admitted into Boynton
ward, St. Mary’s Hospital, under my care. June 18th, 1852.

She reported that she was confined July 4th, 1851. The labour
continued two days and a half and instruments were used. After the
labour, she was unable to retain her urine, and she has continued in
the same condition ever since. Bowels costive, not acting without
medicine since her confinement; were not so before. She is otherwise
quite healthy: her child was destroyed during the labour.

The condition of the parts before the operation was as follows :—
On introducing the finger into the vagina, at about two inches from the
meatus urinarius, it passed into the fistulous opening, which was
equal in breadth to two fingers. The os uteri could not be felt with-
out passing the finger to. the left side high up in the vagina, where
a small opening barely admitting the tip of the index finger, led to a
cul-de-sac of the vagina, in which was the os uteri. It was found that
the fistulous opening extended completely to the os uteri. She said
that the urine did not flow away to any amount while she was lying
down, but chiefly while in the erect posture.

The bowels having been opened, the operation was performed on
July 17th. The patient being placed on her abdomen, and the
entrance to the vagina being separated as widely as possible, the edges
of the fistulous opening were pared, and four sutures introduced from
below upwards, and held in situ by bougies, so as to bring the edges
exactly in apposition ; the lower edge of the cul-de-sac enclosing the
os uteri was pared, and great care was taken not to close up the
orifice leading to the os uteri. The patient was kept under chlo-
roform for one hour and a quarter, the time occupied by the opera-
tion. When consciousness returned, two grains of opium were given,
and the bent catheter, with a bag attached, introduced.

18th. She slept pretty well the night after the operation, skin at
present warm, pulse 144, tongue coated at the back, with some red
papille at the apex; bowels not acted, and no urine passed per
vaginam: it flows through catheter into the India-rubber bag ; she
complains of some uneasiness in hypogastrium, but there is no ten-
derness ; thirst; no appetite. :

19th. Bowels not acted, tongue more moist and clean ; complains of
flushes of heat and shiverings succeeding each other. The urine
seems to pass only through the urethra.

21st. Bowels not acted ; to be opened by enema. Tongue cleaner ;
otherwise the same. St

22nd. A good deal of blood flowed away with the urine into the
receptacle last night ; suffered much pain in the night ; is easier now ;
less hypogastric uneasiness ; tongue coated at back, less so, and rather
moist at front; bowels not open to-day, only slightly acted upon by
enema. The blood seems to have flowed from the uterus, probably in
anticipation of the monthly period; the ligatures have given way,
and the fistulous opening is just as 1b was before the operation.

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102 VESICO-VAGINAL FISTULA.

25th. Tongue rather coated with papille; bowels open; slept well.

29th. On examination yesterday, it was found that another opera-
tion could be hardly performed with any prospect of success at
present ; she is therefore discharged.

Dec. 11th. She was re-admitted, and on the 14th the septum between
the vagina and the cul-de-sac containing the os uteri was divided, so
as to lay the two into one, and also enlarge the cavity of the vagina,
The perineum was also cut through as far as the commencement of
the sphincter ani, and the wound dressed with oiled lint. This was
found to afford a much greater space for manipulations during the
operation of paring the edge of the opening and bringing them
together, which was done on Dec. 30th in the manner described
at page 93, figures 5, 6. <A flexible metallic catheter was then
passed through the urethra into the bladder and retained, and the
patient placed on her left side. She was under chloroform one hour.

Jan. 16th, 1853. Clamps removed, and the wound found to be
healed, with the exception of a small orifice close to the cervix uteri,
which admits the extremity of a female catheter.

Feb. 15th. The edges of the remaining opening were pared and
brought together as before with clamps, the os uteri being directed
into the bladder; she was under chloroform upwards of an hour,

16th. No urine has escaped through the wound; feels comfortable.

18th. Doing well.

19th. Complains much of the catheter giving her pain. Catheter
removed; the urine to be drawn off every two or three hours, or
oftener, if needful. No urine has escaped by the wound since the
operation.

22nd. Some urine has escaped through the wound into the vagina
—clamps removed; they had become somewhat twisted. A small
opening close to the os uteri still remains.

23rd. Urine escapes in considerable quantity through the opening.

24th. Less urine escapes; she passes a considerable quantity per
urethram.

March 8th. Retains much of the urine when in bed, and when
sitting, but when walking, suffers from it dribbling away. The
opening is smaller than it was; actual cautery applied.

10th. No urine has come away through the opening for two nights,
and very little when she walks about.

19th. Urine still coming away; the actual ‘cautery was again
applied completely into the very small fistulous opening, and lint
soaked in oil applied to the vagina, and some dry lint over that, so as
to plug up the vagina.

April 5th. Fistulous opening very small; cautery applied again.

9th. Actual cautery applied; opening still small.

14th. Actual cautery applied thoroughly.

15th. No escape of urine since.

25th. Urine passes both ways; feels very easy.

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29th. Bowels open; sleeps well; no pain on passing urine.

May 3rd. No urine passed per vaginam since the 28th.

7th. Examination made very carefully ; small quantity of urine
escaped from wound. Discharged.

Re-admitted Oct. 31st, 1853.

A week after admission had nitrate of mercury applied to a vascular
excrescence, which was growing in the old line of union in the vagina.

Nov. 19th. To-day the same was applied to the fistulous orifice.
The growth had disappeared, leaving some slight vascularity.

Dec. 6th. The nitrate of mercury was again applied, and afterwards
-a solution of bicarbonate of potass.

10th. Same application.

13th. Parts painful; lint applied. She is not materially relieved.
Discharged.

She was again operated on, Feb. 22, 1854, in private apartments.

The patient being placed on her abdomen and the vagina being
well opened by retractors, there was found at the uterine extremity
of the vagina, a large cul-de-sac with a very small entrance from the
vagina, in which was the os uteri, which had fallen within the bladder
and which could be felt within that organ by introducing the finger into
the urethra. This cul-de-sac was freely laid open and the os uteri seized
and dragged up by two pairs of vulsellum forceps one on either side,
the right side of the os uteri was then well vivified as was the bladder
round the opening: the bladder was then stitched to the side of the
uterus by means of sutures of platinum wire and moveable needle,
and retained in apposition by clamps and shot: free lateral incisions
were made to let go the bladder and to guard against all tension on
the sutures—sickness occurred directly after the operation, but not
afterwards. Ice given, and an hour anda half after the operation
two grains of opium were given.

6.45 p.m. Water drawn off and tube (with bag attached) intro-
duced.

23rd and 24th. Going on well.

26th. Doing well; sanious purulent discharge; no escape of
urine.

27th. Still doing well; healthy discharge of pus; no escape of
urine. :

28th. An injection was given, and a great accumulation of frces _
came away.

March Ist. Examination ; parts looking-well, clamps well together,
no escape of urine. The clamps being removed, it was found that
union had taken place between about three-fourths of the surfaces
apposed to each other. Some urine escaped through the remaining
portion when she stood up.

20th. The remaining portion of the fistula was denuded, as also the
side of the cervix uteri, and they were stitched together by inter-
rupted sutures of twine. She did well, with no escape of urine, up to

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the 27th, when the sutures were removed; still no escape, and no
opening could be found by probe or by examination with finger.

30th. Examined carefully, when one small opening was discovered
barely admitting the probe, and then only from the vagina.

April 4th. On again carefully examining, another opening was
found of the same size as the former, lower down, both of them being
overlapped by the os uteri, part of which was within the bladder and
part in the vagina. Both these small openings were denuded and
again brought together by three interrupted sutures.

6th. The catamenia, a week before the proper time, passed chiefly
through the urethra.

8th. The sutures came away, and again it was found that one of
the openings was not quite closed. Discharged for the present.

Practical Remarks—As might be expected, this patient is not
inclined at present to undergo any further treatment, as no urine
escapes except in the act of walking.* I still feel sanguine that this
opening will be closed on a future occasion when her strength and
courage return. This case is extremely interesting, as showing the
great difficulties which are met with in the treatment of these trouble-
some lesions: and although it cannot be said that the patient is
cured, still she is so much relieved as to be well repaid for all she has
undergone.

Case XX VITI.— Vesico- Vaginal Fistula, of three years’ standing, the
effect of the Pressure of a Stone in the bladder during Labour; Operation;
Cure; Remarks.—Hannah B., et. 48, mother of ten children, admitted
into Boynton ward, St. Mary’s Hospital, under my care, March 24, 1853.
She states that she was injured three years ago during a tedious labour.
The waters broke on a Thursday morning, and she was not delivered
till Saturday morning ; the child was born suddenly, no medical
attendant being present at the time. The funis broke and the placenta
remained, and had to be removed by the introduction of the hand of
a medical attendant. There was a great quantity of feces accumu-
lated in the rectum, and great pain in passing the motions after
taking castor oi]. She got out of bed on the ninth day and tried to
pass her water, but could not ; something seemed to fall down and
prevent her ; no water passed for two or three days, then “a, little
piece fell down about the size of a finger nail, and water has escaped
ever since.”

In July, 1852, she had another child, natural delivery ; cannot re-
collect how long she was in labour; frequent constipation subsequently.

March 24th. Examination. There was a small fistulous opening
near the os uteri; a large calculus could be felt within the bladder,

* Since writing the preceding remarks, I find that the patient can
now retain half a pint, even whilst walking. (April 28th.)

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VESICO-VAGINAL FISTULA. 105

which on being grasped by a pair of forceps through the urethra,
began to peel, and by repeated applications of the forceps, assisted
by the scoop, the whole was removed : the stone was two inches long,
an inch and a half broad, and three inches and a half in circumference,
weight two ounces and a half. The patient was under the influence
of chloroform during the operation. There was a very slight lacera-
_ tion of the anterior part of the urethra, which was otherwise unin-
jured, so dilatable was it found to be. The bladder was injected four or
five times with cold water, and no bleeding followed. She was much
depressed by the chloroform, with feeble pulse and somewhat laboured
respiration; had distinct arcus senilis. Ordered 15 minims of liquor
opi sedativus, 15 minims of compound spirit of sulphuric ether,
and an ounce of camphor mixture immediately ; and this was ordered
to be repeated after six hours.

8. 30, p.m. Doing well; circulation recovered; countenance good ;
no sickness. To take two drachms of liquor ammonie acetatis,
fifteen minims of spirit of nitric ether, fifteen minims of tincture of
henbane, ten grains of compound tragacanth powder, and an ounce of
camphor mixture, every four hours.

25th. Passed a good night; has had no pain in the bladder, no
hemorrhage ; all the urine escapes through the fistulous opening; takes
beef-tea and barley-water.

April 5th. The fistulous opening is a mere point and very high up,
small particles of calculi still passed through. Actual cautery with
small point thoroughly passed into the orifice. A catheter, with bag
attached, introduced and retained to prevent the urine escaping at all
through the fistula.

9th. An incision was made half an inch from the fistulous opening
on all sides, by which the mucous membrane was divided, so as to take off
all tension from the opening, after which the actual cautery was applied.

16th. The opening is quite closed, and the incisions through the
mucous membrane healing up by granulation ; no water escapes but
by natural passage.

19th. No urine escapesthrough the vagina: on examination with the
speculum, there is a granulating surface about the size of a shilling in
the situation of the opening; os uteri irregular and abraded; urine
clearer.

28th. On careful examination, no fistulous opening could be found,
and there was no evidence of any urine escaping from the vagina.

30th. Discharged cured.

Practical Remarks —This case is interesting, as showing the mis-
chief sometimes done during labour by the presence of a stone in the
bladder ; a circumstance not mentioned, to my knowledge, by any
author. It also shows the importance of liberating the fistulous open-
ing from any dragging of the surrounding parts, by incising the mem-
brane before applying the cautery.

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CasE XXIX.—Vesico-Vaginal Fistula of seven months standing ;
Two operations; Cure of the Fistula; Subsequent Death from Effusion
into the Pericardium and Left Plewra.—Mrzs. T., eet. 25, consulted me
March 18th, 1853. She gave the following history of herself:—

On August Ist, 1852, she was delivered of her fifth child ; her
labour was very tedious: the legs, body, and arms were born at half-
past ten a.m., but the head was not born till half-past seven p.m. On
the ninth day she was taken with violent pain; leeches were applied
and a warm bath afterwards, on coming out of which, she found she
could not hold her water, and had not been able to do so since, except
when sitting or lying down, and then not for more than two hours.

Examination. On placing her on her hands and-knees and passing
the finger into the vagina, I found an opening into the bladder about
an inch and a quarter from the orifice of the urethra; this opening
readily admitted the finger ; on examination by speculum, I saw the
mucous membrane of the bladder protruding through the opening, and
a considerable quantity of phosphatic secretion oozing through. On
passing the speculum further up, I brought the os uteri into view, and
found it fissured from two considerable lacerations, and the whole os
in a state of ulceration. I applied caustic to it..

20th. Examined again carefully, and applied caustic to the os and
cervix uteri, and introduced a bent catheter, with India-rubber bag
attached, to catch the urine.

25th. Catamenia appeared after two months’ cessation.

On April 4th, 2 p.m, present, Messrs. Wilkin, Borham, World,
Trotter, and my son, I proceeded to operate as follows :—I pared
the edges of the fistula and applied three silver wires and clamps. I
found, on passing my finger into the urethra and examining the open-
ing from within, that there were two points admitting the end of the
probe not in apposition between the sutures, so that, in fact, I had not
enough sutures. I therefore introduced two more under the clamps,
and tied them over ; this appeared to secure them perfectly. There
was a good deal of hemorrhage. She had ice before the operation,
and afterwards she was ordered to take one grain of opium every two
hours, and the catheter to be passed every two hours by the nurse.

9 p.m. Considerable hemorrhage ; applied ice within the vagina and
iced lint within the vulva.

5th. 9 a.m. No fresh hemorrhage; urine fall of dark blood; has
had some refreshing sleep.

9 pM. Syringed out the bladder and vagina with ice-water, and left
a bent catheter, with bag attached, in the urethra.

6th. 9 am. Has not had a very good night. Some considerable
quantity of clots from the bladder. Pulse quiet and soft; allowed her
to sit up on the bed-pan, and pass the water herself. A large quan-
tity of clots came away; and from this time she was easier. I ordered

a mixture of infusion of roses, dilute sulphuric acid, and tincture of
henbane.

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10 p.m. Has had a very comfortable‘day, on the whole; no more
hemorrhage. Beef-tea and barley-water.

7th. 9 a.m. Passed a good night.

2pm. Passed some large clots from the uterus, which produced
fainting and prostration.

10 p.m. Very comfortable.

8th. 9 a.m. Very good night. No bleeding.

10th. An injection of warm water and salt brought away a good
deal of scybalous matter ; ordered some acid and bark mixture, and
an opium pill at bed-time.

llth. Has passed a good night, and is very comfortable.

12th. Examined and found the upper stitches had all given way,
and that there was a large quantity of phosphates coming away like
mortar.

She gradually recovered her strength, and could hold the urine for
three or four hours, except when walking. She returned into the
country in May to recruit, and on January 31st, 1854, came up to
town again, her health being very much improved.

She was placed under the influence of chloroform, Feb. 6, and I pro-
ceeded to dissect away the meatus urinarius from the symphysis pubis,
and from its attachments laterally, so as to let it go quite back and not
to offer any traction on the rent of the bladder. There was a great deal
of hemorrhage, principally venous. The hemorrhage being so great, I
did not, as I intended, proceed to dissect away the bladder from its
attachment to the uterus, and from its attachments laterally, so as to
let it be quite free and void from all traction before proceeding to
the treatment of the fistula) The hemorrhage was stopped by ice,
and the little that took place afterwards was immediately stopped by
fresh ice. The consequence of the operation was, that the urethra con-
tracted well backward, towards the fistula, insomuch that the patient
could control her urine until she asked for the bed-pan.

Feb. 12th. The catamenia appeared. She can hold her water even
when she sneezes. I now determined to attempt the complete closure
of the fistula, and on the 20th I proceeded with the following
operation.

The patient being placed on her abdomen and the pelvis raised, the
anterior lip of the os uteri was dissected from the bladder ; indeed, it
was divided into two portions horizontally, and then the incision was
carried round to the right side of the vagina, so as to detach the
bladder completely from behind up to the pubis; the same was done
on the other side; then a needle, armed with a double suture of twine,
was passed through the upper part of the opening, (which was the
size of a half-crown,) and then the edges were pared with the knife/aud
scissors, and finally united by six sutures, fastened to'two pieces of
bougie. The operation took two hours and a quarter, during which
time the patient was kept under chloroform. Not much blood was
lost, considering the depth of the incisions which were made through

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108 VESICO-VAGINAL FISTULA.

the plexus of veins on each side of the urethra and bladder. Wine
and ice were administered as soon as she recovered from the chloroform,
aud hot bottles applied to her feet; one grain of opium an hour
afterwards, and’ a hent metallic catheter introduced, with a bag
attached.

21st. Almost incessant sickness.

22nd. Very sick all night, sleeping an hour or two at a time;
ordered some Bass’s bottled ale, which stopped the sickness ; had some
fresh mutton chop minced up; ordered to continue the opium every
six hours.

23rd. Much better, and no sickness.

24th. Discharge from the vagina very offensive; syringed it out
with chloride of lime water; the bent catheter was completely filled
with phosphatic secretion. It was cleaned out with acid, and re-
introduced. No escape of urine from vagina.

25th. Injection of chloride of lime used,—discharge of healthy pus,
no escape of urine per vaginam.

26th. Careful examination. Consultation as to whether the sutures
should be removed or not; there was no sloughing from pressure,—
healthy discharge and no escape of urine,—parts looking well, and it
was determined not to remove the sutures.

27th. Doing well; no escape of urine.

28th. A little shivering in the morning, headache, and sickness; a
great deal of bile vomited. An injection ordered; great accumula-
tion of feces came away,—no escape of urine.

March Ist. The sutures have nearly all ulcerated away; removed
the rest. The union appears to be perfect.

6th. Is able to retain her water for three or four hours, and she
then passes it entirely through the urethra.

At half-past eleven, I was called to her suddenly, and found she had
had a severe rigor. On examining the left side of the chest and
heart, there was evidence of considerable effusion in the pericardium
and pleura. I sent for Mr. Moullin, who stayed with her some hours.
Day by day she gradually sank, became delirious, and died on March
13th. Her brother, a surgeon, was present for some days before
she died. Post-mortem examination not allowed.

Thus ended one of the most interesting, and apparently one of the
most successful cases on record.

CaszE XXX.—Vesico-Vaginal Fistula with Ruptured Perinewm.—
Mrs. M., et. 29, married, admitted into Boynton ward, St. Mary’s
Hospital, September 20th, 1853.

A thin, healthy looking woman, has been married about two years;
suffered much for the first seven months of her pregnancy, but ex-
perienced no inconvenience the last three. She says she was confined

one month later than she ought to have been, making ten months that
she was with child. Was taken in labour August 26th; the pains

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VESICO-VAGINAL FISTULA. 109

continued with great violence until the 28th, when she was delivered
of a large female child, which her medical attendant had previously
told her was dead, and which he said, on its birth, had been dead at
least a fortnight. On her complaining of great pain, the nurse told
her she was “ripped.” About a week afterwards, she found she had
no control over the sphincters, which want of power continued till
about a fortnight since, when she began to evacuate as usual, except-
ing that when she was in bed the water passed in small quantities
without her knowledge. She has suffered from and been cured of a
swelled leg, which she attributed to the cramp during labour. Or-
dered two drachms of liquor ammoniz acetatis, fifteen minims of tinc-
ture of henbane, and an ounce of camphor mixture three times a day.
Six drachms of liquor plumbi diacetatis, and six ounces of water, for
a lotion.

22nd. Zine ointment to be applied to the lacerated surfaces.

27th. Ordered an ounce of decoction of bark, a drachm of tincture of
bark, and a drachm of sesquicarbonate of ammonia, three times a day.

29th. Examination. Fistula in bladder about two inches from the
urethra, sufficiently large to admit a finger. Perinzeum completely
ruptured even through the anterior fibres of the sphincter.

November 2nd. Operation under chloroform. Incisions were made
round the edges of the fistula and the actual cautery applied. The
vagina was plugged with lint.

19th, Fistula much smaller, healthy granulations; doing well.

26th. Doing well ; parts touched with acetum cantharidis.

29th. The same application was applied.

December 6th. Fistula much smaller, granulations healthy. Acetum
cantharidis applied. One grain of opium immediately, and to be re-
peated every three hours, if necessary.

13th. Acetum cantharidis applied.

21st. Operated on again to-day ; an incision was made on either
side of the orifice, and also one in front and behind, in order to take
away the tension; then the edges being pared, sutures of silver wire,
with shots attached at the ends, were applied from side to side, and
from above to below, so as to pass each other at right angles. This
being done, a catheter was introduced into the bladder, and it was
ascertained that the orifice was quite closed. A piece of lint was
then applied. One grain of opium every six hours.

22nd. Seems very poorly ; very hot and feverish ; has been sick
and is still nauseated. No urine has escaped ; simple diet and beef-
tea; half a grain of opium every three hours.

23rd. Still very feverish ; not so sick ; feels thirsty ; three ounces
of wine ; effervescing mixture occasionally. :

24th. Better this morning, not so feverish ; was in some pain last
night, and felt something give way, which eased her. Repeat the pill
every night. Some urine has escaped. On examination, it was found
that the antero-posterior suture had given way, the other re-
maining firm.

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110 VESICO-VAGINAL FISTULA.

25th. Has been in great pain all night ; thinks it is from the lint
applied yesterday with collodion. Lint removed.

26th. Very much better to-day ; pain nearly all gone. Removed
the wire and shot ; no union.

Jan. 3rd. Applied actual cautery, and plugged the opening with a
little piece of lint introduced on the point of a probe.

9th. Since the opening has been plugged, it seems to have got a
little larger.

12th. Less urine escapes ; lint placed against the opening.

14th. Four pieces of twine tied together were passed through the
urethra into the bladder, and out of the opening by an eyed probe, a
piece of lint was then attached to the twine to plug the opening, and
the two extremities of the twine were then tied together at the
surface of the vagina.

18th. States that no water has escaped since the application of
the plug.

21st. Doing well ; water does not escape, one of the four pieces of
twine removed.

25th. Last night urine began to escape a good deal.

29th. Urine still escapes, scalds her a good deal; twine all re-
moved ; lint applied.

Feb. 1st. Operated again in the same manner as before, only not
paring the edges, it being found that they were quite raw, and
divested of mucous membrane. On passing the finger through the
meatus into the bladder, a small opening was discovered, and in
addition to the two wire sutures used on a former occasion, a third
wire was introduced at an acute angle with the other two. After
the operation, a grain of opium was given every four hours.

2nd. A little feverish, not much pain. Had a good night.

3rd. Much better ; no urine has escaped ; has some scalding.

7th. Complains of much pain, which prevents her sleeping ; water
better than it has been, passed with little scalding.

9th. Better ; had a good night, but still complains of slight pain.

11th. Does not complain of so much pain in passing her water.

14th. Great want of appetite, and does not sleep so well.

15th. Operated upon as before ; one grain of opium every four hours.

16th. Less feverish than after the other operations.

17th. No escape of urine; wound looks healthy.

19th. Large escape of urine during the night.

27th. Now no escape, but still keeps the catheter in.

28th. Urine escapes ; actual cautery applied.

29th. Slight escape of urine. :

30th. The escape is nearly the same as before the last operation.

April 14th. The opening has become gradually smaller since the
last report, and she is now able to pass her urine by the urethra
every three or four hours, and suffers only from occasional dribbling
‘from the fistula ; and, from the condition of the parts, I see my way
clearly to a perfect cure.

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The preceding cases will illustrate the various points of dif-
ficulty which are met with in the treatment of this distressing
lesion; and although they do not exhibit a great amount of
success, they may fairly be looked upon as valuable illustrations
of our present knowledge and practice; and I still look forward
to a greater amount of success, by steady observation and per-
severing efforts, which the late improvements in surgical
science certainly justify; especially as the difficulties are
rather mechanical than pathological. It cannot be concealed,
however, that it requires no ordinary amount of perseverance
and determination, to bear up under the vexatious disappoint-
ments which are constantly occurring in the hands of the most
painstaking operators.

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CHAPTER V.
RECTO-VAGINAL FISTULA.

By this term is understood an opening between the rectum
and vagina, through which either the feeces or flatus may
pass from the bowel into the vagina. Although this condition
is not of so distressing a nature as the foregoing, still it is one
which is extremely annoying to the patient, and moreover, often
produces so much irritation to the vagina as to induce inflam-
mation and excoriation of that organ. Of course the amount
of inconvenience will depend upon the size of the opening.

Causes.—It may be produced (1), by recto-vaginal abscess;
(2), by stricture of the rectum; (8), by laceration during deli-
very; (4), by sloughing after long impaction of the head; (5),
by the use of instruments in delivery; or (6), by corroding
cancer, either of the rectum or of the vagina. ~

Treatment.—This will depend upon the nature of the cause.

1. If it arise from recto-vaginal abscess, it will very often
yield to the application of caustics; or it may be cured by lay-
ing open the rectum from the fistula to the anus, as in the
operation for fistula in ano, and by subsequent dressings, so as
to insure healing by granulation.

2. If it be produced by stricture of the rectum and consequent
ulceration of the recto-vaginal septum, division of the stricture
simply will frequently be sufficient for the healing of the aper-
ture: if it fails, caustics, or even laying open the bowel, as just
described, may be requisite.

3. If it arise from laceration during delivery, whether by the
use of instruments or by the force of the labour pains, lacerating
the rectum without lacerating the perineum, then, putting the

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RECTO-VAGINAL FISTULA. 113

patient immediately in a quiescent state with the knees flexed,
confining the bowels by opium, and applying a well-adapted
perineal bandage, will generally suffice for the healing of the
laceration.

4. Ifit arise from sloughing after long impaction of the head,
then, as soon as all sloughing has disappeared, the treatment
may become more complicated; and it may be necessary to pare
the edges and to bring them together by suture. Any of
the forms of suture recommended for vesico-vaginal fistula
may be used for this. If the opening be not larger than the
head of a probe, the actual cautery may be sufficient to effect
contraction and closure, and this I have found successful even
when the opening is larger. It will often be found more
advisable to apply the cautery per vaginam than per rectum.
Another mode which I have found successful is to pass three or
four threads of twine through the opening, bringing one end out
of the rectwm, the other out of the vagina, and daily moving the
threads for several days, so as to produce a healthy granulating
surface, which heals on their removal.

Lastly; in cases where the fistula is produced by corroding
cancer of the rectum or vagina, nothing remains to be done by
operative treatment, and our only resource is allaying the irri-
tation by opium, and cleansing the parts by the frequent injec-
tion of warm water. -

After-treatment.—This consists in great attention to cleanli-
ness, but more especially in constipation of the bowels by the
frequent administration of opium. It is also necessary to con-
fine the patient to one position on her side, and to keep her on
generous and dry diet. It will be observed that the success
of the operation for this lesion is much greater than for vesico-
vaginal fistula, on account of the great facilities offered by the
use of opium in keeping the parts perfectly quiet after the ope-
ration..

I will now relate a few cases in illustration of the foregoing
points.

Case XX XI.—Recto-Vaginal Fistula from Abscess in the Rectum, of

several years’ standing : Operation ; Cure—I was requested by Dr.
Locock, in the month of February, 1853, to visit a single lady, set. 52,

I

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114 RECTO-VAGINAL FISTULA.

who had been suffering for four or five years from vaginitis, inflamma-
tion of the labia, &c., and had for sometime past observed an occa-
sional discharge of fecal matter from the vagina. The most diligent
examination had, however, failed to discover any recto-vaginal opening,
although several eminent practitioners had examined her. As she had
had a deep perineal abscess, and also an abscess in the rectum some
years before, it was the opinion of Dr. Locock that there must exist
some undiscovered communication between the two passages ; and in
this opinion I fully concurred. I examined the rectum carefully
with the rectum speculum, but found nothing. J then examined the
vagina most carefully with the uterine speculum, and after some
difficulty discovered a small sore about two inches up the passage, in
its posterior wall; this was evidently the seat of the opening, but
the mucous membrane of the rectum seemed to close it or to fall
over it as a valve, so that the finger introduced into the rectum
could not be brought in contact with the end of the probe when
pressed against the fistulous opening in the vagina, although it could
be felt in the rectum by gently moving it.

Operation.—Feb. 16th. The patient being placed under chloroform,
I first applied the actual cautery to the fistula per vaginam, and then
divided the sphincter ani on both sides. Cold water dressing was
applied, and forty drops of laudanum administered.

Feb. 17th. Severe sickness from the chloroform, which was relieved
by twenty drops of chloroform given on sugar. Bowels relieved
with pain.

18th, 19th, 20th. Much the same.

23rd. An external pile, which created considerable inconvenience,
was excised. ,

25th. Bowels acted without pain ; no fecal matter or flatus ha
escaped through the opening since the operation. é

From this time the patient suffered no inconvenience from the
fistula.

Cas—E XXXII.—Small Recto-Vaginal Opening : Operation ; Cure—
Mrs. W., xt. 34, mother of one child, consulted me, Nov. 30, 1853, and
stated that since her confinement she had passed flatus per vaginam.
On examination, I found, about one inch within the rectum, a small
fistulous opening through the septum, through which I could just
pass the head of a probe. I then attached a piece of twine to the eye
of the probe, and drew it through the opening. I twisted round this
a piece of lint, which I drew into the fistulous opening, and then tied
the two ends of the twine together over the perineum. This
produced, in twenty-four hours, inflammation, and subsequently the
secretion of healthy pus, and in a week after the removal of the lint,
the fistula was found closed. This patient has continued well to the
present time, having been, in the interim, delivered of a second child.

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RECTO-VAGINAL FISTULA. 115

Cass XXXIII.—Large Recto-Vaginal Fistula: Operation ; Cure.—
Mrs. D.,aged 47, consulted me in the latter end of the year 1852, having
been confined with her last child seventeen years ago, since which she
had suffered from the passage of feeces per vaginam as well as per rectum.
On examination, I found, about an inch from the anus, an opening
sufficiently large to admit the point of the little finger. This was
caused by the injudicious application of instruments for the purpose
of effecting delivery. The case was treated by the free and repeated
application of the actual cautery both per vaginam and per rectum,
which closed the opening in the course of a few weeks. My
original intention in this case was first to reduce the size of the
opening by the cautery, and afterwards to operate by paring the edges,

- but to my gratification, the cautery proved entirely successful.

12

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CHAPTER VI.

LACERATED VAGINA.

Tuis lesion may arise either from forcible expulsive efforts
during labour, or from the application of instruments; and the
consequences are often of so serious a nature as to demand the
careful attention of the surgeon. Because, if the laceration is
considerable, or especially if there are-two or more lacerations
of the vagina at the same time, with or without partial rupture
of the perinzeum, the great degree of contraction produced by
the cicatrization of the lacerated surfaces when left to them-
selves, sometimes results in such an amount of occlusion of the
vagina as to prevent sexual intercourse. Hence it is of im-
portance that immediately after the accident the wound should
be plugged with lint smeared with ointment or oil, so as to
prevent the puckering which might otherwise result. If this
treatment is neglected in the first instance, and severe contrac-
tions by cicatrization ensue, then they should be freely divided.
and dressed as just described. But my chief object im com-
menting upon this unfortunate accident is to insist on the im-
portance of careful examination and proper treatment imme-
diately after its occurrence. I shall illustrate the treatment by
relating one case only out of many that have come under my
notice.

Case XXXIV.—Lacerated Vagina, with Contractions producing
Incontinence of Urine: Operation ; Cure.—Mary M., xt. 27, married,
admitted into Boynton ward, St. Mary’s Hospital, Dec. 23rd, 1853.
Mother of one child ; states that she was confined about nine weeks
ago, having been in labour from a Thursday evening to the following
Sunday morning. Her medical attendant told her that the head, which
was very large, was in the world two hours before the body. The

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LACERATED VAGINA. 117

child was born dead; no instruments were used. After she was
confined, her feces and urine came away involuntarily, and seemed
all to come through the vagina. About a month after this she
got much better, and the urine and feces came through their proper
channels, which they do at the present time, and she has perfect con-
trol over them when lying down, but not when standing up ; in this
position the urine escapes involuntarily. Her bowels will not act
without medicine. Has always enjoyed good health. On examina-
tion, the perinzeum, which had been ruptured, was found to be tightly
cicatrized ; the vagina also was puckered, and on one side a cul-de-sac,
the size of a finger, was formed; this dragged on the bladder, and thus,
when she stood up, the sphincter of that organ could not contract so
as to control the urine.

Operation—I divided the anterior margin of the cicatrized
perineum, and also the bands in the vagina, and applied lint soaked
in oil, to keep the parts separate. She was placed on a water-cushion,
and a catheter was introduced within the bladder with a bag
attached. ;

Jan. 3rd. Parts looking healthy, and granulations coming up well.

9th. Feels very well in herself; bowels not open ; Ol. Ricini, 3ss.
statim.

14th. Where the incisions were made, the parts are filling up well.
A band can be felt on the left side running across; this was now
divided.

16th. Catamenia appeared.

20th. Doing well ; feels better.

24th. Parts seem to be quite healed.

27th, States that now when she stands up she has perfect control
over her urine. Feels quite well. Parts quite healed. Discharged
cured,

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CHAPTER VII.
POLYPUS OF THE UTERUS.

Tuer pathology of uterine polypi has been described so fre-
quently and satisfactorily in various works on surgery and
midwifery, that I shall content myself with a very brief resumé
of the principal facts, my chief object being to indicate the
surgical treatment of these common morbid growths; especially
the ordinary pedunculated fibrous tumours—to which the term
polypi is chiefly applicable, and which are most amenable to
operative measures.

Polypi are of various forms, according as they may arise from
the fundus or cervix. They are, however, more generally
found either spherical or pear-shaped. They vary much in size,
being found little larger than a pea in some cases, and even
then frequently productive of serious consequences, while in
other cases they grow to an enormous size. One was excised
in the Meath Hospital some years ago, which was more than
fourteen inches in length, and four or five in its extreme
diameter.* Many similar examples are mentioned by authors.+

Polypi differ in colour. This depends partly upon the degree of
vascularity of their surface, and partly upon their exposure to air ;
some being quite white, others reddish, or dark brown. Occa-
sionally the substance of a polypus is traversed by a few small
vessels.

Polypi are attached, some to the fundus, others to the walls ;
some to the inner surface of the cervix, and others to the lips
of the os uteri. Dr. Gooch, in his work on diseases of women
(p. 251) dwells very graphically on the importance of distin-

* Churchill on Diseases of Women, page 201.

+ Siebold saw one of the size of a child’s head. Frauenzimmer-
krankheiten, vol. i. p. 687.

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POLYPUS OF THE UTERUS. 119

guishing from what part they arise, as the mode of operation
for their removal, and the difficulties to be encountered, will
depend upon this circumstance. Sometimes, in the early stage
of their growth, it is difficult if not impossible to detect the
point of attachment, as the finger cannot be introduced into
the cavity of the uterus. It is only by repeated examinations, and
by observing that the neck can be no longer distinguished, that we
can finally determine the nature and origin of the tumour ; and
cases have been observed, in which the polypus in its passage
outwards has become so firmly adherent to the cervix and os,
that it appears to form one body with them. A case of this
kind will be hereafter related. Polypi which grow from the
lip of the os do not necessarily hang from a stalk-like pedicle,
but sometimes appear as part and parcel of the lip itself; and
it is necessary in operations in these cases to remove a portion
of the lip. Dr. Denman says, that occasionally we find more
roots than one.* Sometimes a polypus will protrude through
the os uteri and afterwards recede; and this may be many
‘times repeated.

The structure of the majority of polypi may be referred to
one of three species :—1. The glandular. 2. The cellular. 3. The
fibrous.

The glandular polypus consists in enlargement of the glan-
dule Nabothi. Dr. Lee says, “One of these two bodies is
sometimes converted into a cyst as large as a walnut or
even a hen’s egg, and hangs by a slender peduncle from the
cervix or lip of the os uteri. It is smooth and vascular, and
contains in some instances a curdly matter, or yellow-coloured
viscid fluid. The tumour produces great irritation, and gives
rise to copious sanguineous and mucous discharges from the
vagina.” >

The cellular polypus is the least frequent of either kind: }
it is soft and lobulated, or divided into bundles of fibres: in
colour it is of a violet or yellowish hue, and indeed very much

* Denman’s Midwifery, p. 50. :

+ Dr. Lee’s paper in the ‘Medico-Chirurgical Transactions,’ (vol. xix.
pp. 127-8.) ;

+ See Clarke on Diseases of Females, (vol. i. p. 244.)

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120 POLYPUS OF THE UTERUS.

resembles the nasal polypus. It has a very slight connexion
with the uterus, and is easily detached with a pair of forceps.
“The fibrous polypus resembles in structure those fibrous
tumours which project from the walls of the uterus; and is the
most common kind of polypus. It has, reflected over its sur-
face, the mucous membrane of the uterine cavity, with its vessels.
These growths vary in density, some being found hollow,
according to Boivin and Dugés; some containing grumous
blood or gelatinous matter and hair. An interesting case of
this kind is related by Mr. Langstaff, in the 17th volume of the
Medico-Chirurgical Transactions (p. 63). The tumour is always
covered by a continuation of the liming membrane of the uterus.*
This pathological fact has been perfectly well established by the
researches of Lee, and it explains the fact stated by Dr.
Charles Johnson, that, contrary to the received opinions,
polypi are not always insensible. These growths are very
scantily supplied with blood-vessels. There are, however,
several cases mentioned, where a small artery and vein have
been detected. I have not myself been able to discover any
vessels in the polypi which I have removed. It is difficult to
explain the cause of the alarming floodings which attend the
progress of these growths. For the reasons just stated, we
cannot attribute the hemorrhage to the vessels of the tumour
itself; and different authors entertain different views as to the
source from which it flows. I would briefly refer the reader to
the works of Gooch, Hamilton, and Oldham, for their opinions
_on this subject. I am myself inclined to think it depends
much upon reflex nervous influence from the tumour acting on
the general surface of the uterus, and causing the flux. There is
one fact worthy of note, as proving the slight degree of vascularity
of these growths,—namely, that they never assume a malignant
character,

Symptoms.—The symptoms which attend this disease are,
first, a mucous discharge, mixed at different times with blood,
by which the constitution becomes extremely debilitated.
Sometimes large coagula of blood will come away without any

* See Denman (p. 50.), who dwells fully on this subject.

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POLYPUS OF THE UTERUS. 121

mucous discharge: in other instances, the blood poured out
lodges in the vagina and becomes putrid, when there is a
very offensive discharge, often exciting suspicion of the ex-
istence of cancer. There is always a sense of pressure or
bearing down, more or less, according to the size and weight

—~~—~~.af_ the polypus. If the tumour be large, so as to fill the
cavity of the pelvis, it may interfere with the functions of
the rectum and the bladder; and it very frequently happens
that strangury occurs, owing to the sympathy between the
uterus and the bladder, and owing to this also there are frequent
nausea and vomiting.

Diagnosis—When these symptoms are present, it is of the
utmost importance that a careful examination be made, both
by the finger and by the speculum. If by neither of these
modes of examination can a polypus be detected, it may yet
exist in its early stage within the cavity of the uterus; and
therefore it is only by repeated examinations that any satisfac-
tory diagnosis can be made. Sometimes by insinuating the
finger within the cervix the tumour may be felt, and the finger
or the uterine sound can be passed round it, when we may
conclude that the polypus grows from the interior of the uterus,
as this cannot be accomplished when it grows from the cervix.
Professor Simpson recommends dilating the os uteri by means
of sponge tents, until the finger can be readily passed up into
the cavity of the uterus. These should, however, be used with
great care. Dr. Montgomery has published a valuable paper on
this subject, to which I beg to refer the reader.*

Polypus may be distinguished from pregnancy (with which it
has been known to be confounded) by the entire absence of
the audible, and by the less marked and non-progressive sym-
pathetic signs; by the slower course of the disease ; and by the
frequent attacks of hemorrhage.

From vaginal hernia it may thus be distinguished: “ These
protrusions of intestines into the vagina,” says Dr. Davis, “are
for the most part exceedingly easily distinguished from polypi of
that passage, by their elastic and otherwise characteristic feel,

* Dublin Journal of Medicine, August, 1846.

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122 POLYPUS OF THE UTERUS.

by their perfect sensibility to the touch, and by their being
covered by a production of the mucous membrane of the vagina
itself.”*

From vaginal cystocele (or protrusion of part of the bladder
into the vagina) polypus may be thus distinguished :—In the
former condition, the tumour is covered by the mucous mem-
brane of the vagina, and if a catheter be introduced into the
bladder, the end of it may be felt in the tumour. The tumour
may also be pressed up above the arch of the pubes; which
cannot be done in polypus.

From scirrhus uteri, by the absence of the severe pain which
precedes ulceration in this disease ; and although hemorrhages
occur in both, in cancer it is after ulceration has commenced,
whereas in polypus no ulceration can be detected. If the
polypus is within reach, of course the diagnosis is very easy.

From cauliflower excrescence, by its greater smoothness and
density, and by its not bleeding when touched.

From prolapsus uteri, by the absence of the os uteri in the
projecting part, and the normal length of the vagina, which is
shortened or obliterated in prolapsus. The sensibility of the
uterus and the insensibility of the polypus will also distmguish
the one from the other.

From inversio uteri, by its gradual advance, not occurring
suddenly after labour, or with symptoms of collapse ; and by the
vagina admitting the finger, whereas in inversio uteri there is
no vaginal canal to be found.

Prognosis.—The prognosis must always be unfavourable so
long as the polypus remains within, or attached to the uterus,
on account of the severe hemorrhages to which the patient is
exposed. If the polypus be not removed, it may then prove fatal
by exhaustion, or may produce prolapsus or inversio uteri; it
may prevent conception, or give rise to abortion; or, if the patient
should go her full term of pregnancy, it may offer a serious
obstacle to delivery, or may tend to promote after-flooding
by preventing contraction of the uterus. On the other
hand, the patient may be assured that, nothing unfavourable

* «Obstetric Medicine,’ vol. ii. page 622.

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POLYPUS OF THE UTERUS. 123

occurring in connexion with the operation, she may anticipate a
perfect restoration to health after the removal of the polypus.
But it should be clearly understood that the success of the
operation will much depend upon its early performance, before
the health is materially impaired.

Treatment.—The first thing to be done when we suspect
there is polypus, is to ascertain by careful examination whether
it is within reach or not. There are some cases in which the
polypus is still within the uterus, and cannot be felt. In such
cases various means have been recommended to excite the
uterus to expel it, such as the ergot of rye. Boivin and
Dugés have recommended the free application of belladonna.
Dupuytren advised that the cervix should be incised. Another
plan, which my colleague Dr. Tyler Smith has found successful
in a case in St. Mary’s Hospital, is the repeated application of
galvanism to the os and cervix uteri.

If the polypus is within reach, our first duty is to attempt
its removal, as that alone will check the hemorrhage and save
the patient. There are various modes recommended for this
purpose:—1. Twisting off the polypus. 2. The application of
ligature, and allowing the polypus to slough off. 3. Excision.
4, The actual cautery.

1. Torsion—This has been practised by several surgeons,
but especially recommended by Mr. Toogood, late surgeon to
the Bridgewater Infirmary. The mode of operating is simple
enough. The polypus is to be seized by the finger and thumb,
or a pair of forceps, and gently twisted till the stalk breaks.
The only after-treatment required is frequent syrmging with
tepid water to keep the parts clean. This mode is only prac-
ticable in those cases where the pedicle is very slender.

2. Ligature-—This is the method generally recommended and
most frequently practised. Various instruments, more or less com-
plicated in their construction, have been proposed for this purpose
by Gooch, Burns, Blundell, Desault, and others: for the descrip-
tion of which I refer the reader to any of the standard works on
midwifery. Various kinds of ligature, silk, silver wire, silk
covered with wire, whipcord, common twine, &c., have been re-
ce mmended. The common practice has been to tie the pedicle of

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124 POLYPUS OF THE UTERUS.

the polypus tightly, day by day increasing the tightness, and
thus to strangulate the tumour, until it perishes and becomes
separated. It is evident that this plan must fail where the
neck of the polypus is so thick that the pressure of a single
ligature is not sufficient to strangulate the tumour. In this
case a needle with a double ligature is passed through the neck
of the tumour and tied on both sides. Dr. Robert Lee tells me
that he usually removes the ligature after a few days, without
waiting for the entire separation of the polypus, with a view of
relieving the patient of a source of irritation.

3. Excision—Many eminent practitioners, impressed with
the inconveniences and dangers of the ligature, have substituted
for it excision by the scissors or bistoury. Amongst them we
find Osiander, Siebold, Mayer, Dupuytren, Brodie, Arnott,
Locock, &. Dupuytren states, that he has removed by exci-
sion 200 polypi in the course of his practice, and that hemor-
rhage occurred in two cases only. Dr. Fleetwood Churchill
has recommended that a polypus should be excised after a liga-
ture has been tightly applied twenty-four hours.

4. The actual cautery—This has been recommended by
Siebold, who states that he has employed it with success. An
ingenious mode of applying the actual cautery to detach a
polypus has been suggested, consisting in surrounding the neck
by the two wires of a galvanic battery, which, on the setting up
of the voltaic current, become red hot, and so cut through, and
at the same time sear the bleeding surfaces.

In preference to any of these, I venture to propose enothe plan,
namely, the application of a ligature or ligatures (according to
the size of the pedicle), and instead of allowing the polypus to
slough off in the ordinary way, or to remain twenty-four hours,
as Dr. Churchill recommends, to excise that portion of the
polypus external to the ligature immediately after its applica-
tion. My reasons for preferrmg this method to the simple
ligature are, that I have seen the most serious consequences
ensue from allowing a putrid polypus to remain within the
vagina. Not only does it emit a most offensive smell, detri-
mental to the health and comfort of the patient, but it also
produces excoriation and irritation of the vagina and labia. But

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POLYPUS OF THE UTERUS. 125

further, a still more serious result is the absorption of some of
the secretion from the putrid mass, which poisons the system,
and produces sometimes uterine phlebitis, sometimes boils
in different parts of the body, and sometimes abscesses in
one or more organs, whilst the patient is frequently many
months recovering from the effects of this poison. I find that
my colleague, Dr. Tyler Smith, has also frequently observed the
occurrence of boils and abscesses after this operation. Cases of
uterine phlebitis succeeding the operation are recorded by Mr.
Babington, late surgeon of St. George’s Hospital, and also by
M. Blandin. Dupuytren also relates that he met with eight or
ten fatal cases which presented all the symptoms arising from
the absorption of pus into the system.

I need not say that the plan above proposed is only appli-
cable to those cases where the ordinary ligature would be applied.
by others, and is not at all intended to supersede the plan
of excision where it can be safely adopted. My friend Dr.
Locock almost invariably prefers excision even in cases which
would be thought by others unfit for that mode of treatment;
and I have heard him state that he has never seen any ill results.

The following are the details of my mode of procedure.

The patient is placed in the position for lithotomy, under the
influence of chloroform, the vagina gently opened by re-
tractors, when the polypus is seized by a pair of vulsellum
forceps with long handles, and if the pedicle be small, a ligature
is passed round it by the fingers; if large, a long needle (repre-
sented in figures 1 & 2), carrying a double ligature, is passed
through the centre of the pedicle and tied on both sides. The
polypus is then removed either by a pair of curved scissors or a
blunt-pointed bistoury. A piece of lint soaked in a strong
solution of alum is then applied to the cut surface, so as to
prevent any chance of even slight hemorrhage. If hemor-
rhage should occur, even after this application, the actual
cautery should be applied through a speculum.

Each of the following cases presents features of interest which
are worthy of record.

Case XXXV.—Polypus: Removal; Cure.—k. P., et. 29, unmarried,
consulted me, December 2nd, 1852, She is of pale complexion and

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126 POLYPUS OF THE UTERUS.

anemic in appearance, and has not menstruated for three months. She
complains of headache at the vertex, and depression of spirits. On
examination per vaginam, I found a small polypus growing from the
superior lip of the os uteri, and extending up the cervix, making the
os very patulous. I applied leeches to the os uteri every three or
four days, and gave blue pill and ammoniated tincture of iron. After
ten days the catamenia returned, and though rather scanty, they con-
tinued for some days.

On the 27th, the patient being placed under the influence of chlo-
roform, and in the lithotomy position, I seized the os with a pair of
vulsellum forceps, and the vagina being held open with retractors, I
brought the polypus into view, and carefully dissected it away from
the os and cervix uteri. It was irregular in shape, and about the size
of a two-shilling piece. Lint soaked in a strong solution of alum was
applied to the os, and the patient placed in bed. One grain of opium
to be taken every four hours.

28th. No bleeding, little pain in the abdomen; the urine is drawn
off by catheter. This case progressed favourably without any unto-
ward symptom, and now, after the lapse of some considerable time,
no recurrence of the polypus, nor indeed of any inconvenience about
the uterus, has troubled the patient. This was a case where the base
of the polypus was so broad, and the polypus itself so short, that it
could not very easily be tied, although it might have been excised ;
still many surgeons would have thought the base too broad to recom-
mend excision.

Cast XXXVI.—Polypus, from the fundus uteri, adherent to os and
cervix : Removal ; Subsequent death from disease in the chest.—K. 8.,
et. 45, married, and has five children. She enjoyed good health
until two years ago, when she was admitted into the Middlesex
Hospital for some affection of the uterus. Fourteen months ago
she applied at St. Mary’s for retention of urine, which she had
frequently suffered from, and became an out-patient under my
care. She had also chronic bronchitis, which added very much to her
distress. On proceeding to make a vaginal examination to ascertain
if there were any uterine cause for the suppression, I found an en-
larged uterus with the os and cervix very patulous, through which
the finger could be easily passed, and then discovered a polypus occu-
pying the whole cavity of the uterus, which appeared to be of the size
of a small apple. It was, moreover, evident that the pressure of the
enlarged uterus on the bladder had produced the suppression of urine.
This poor woman had suffered from repeated attacks of hemorrhage,
and her general health was much impaired. After a few months,
the polypus gradually protruded out of the uterus, tightly encircled
by the os and cervix, giving great pain and suffering to the patient.
Finally, a portion of the polypus, about an inch and a half in length,
wasseen projecting from the vulva, of a yellowish colour, surrounded by
a margin of fleshy substance, which on careful examination was found

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to be the os uteri extremely dilated, and inseparably adherent around
the polypus; and when the patient was placed on her back for exami-
nation, it presented exactly the appearance of a distended glans penis
projecting from the vagina, and completely filling up the orifice of
that cavity. It could, however, be pushed back out of sight, but did
not remain so. She was now admitted into Boynton ward, December
12th, 1852, the chest was examined, and no disease found except
chronic bronchitis.

December 29th. She was placed under chloroform, in the lithotomy
position; the end of the polypus was seized by a pair of vulsellum
forceps, being held by an assistant. I proceeded first to make a cir-
cular incision around the tumour at the point of juncture with the
os uteri, dividing some of its fibres; then carefully dissected back the
os and cervix, separating their very firm adhesions to the tumour,
which extended upwards two inches. I then found the bands of ad-
hesion became fewer, and easily broken down by the finger. The
polypus could now be distinctly felt growing from the fundus of the
uterus. Having forcibly pulled out about three inches of the polypus,
I passed a needle with a double ligature through its body as high up
as possible, and tied a ligature on either side, so as completely to
strangle it. J then cut off with a scalpel the portion anterior to the
ligature. The operation occupied rather more than an hour. The
patient was then removed to bed, had a rigor immediately afterwards,
and vomited freely. Some brandy and water was given her, which
having subdued the sickness, one grain of opium was taken, and
ordered to be repeated every four hours. In the course of the even-
ing she complained of slight shooting pains about the abdomen, with
pain on pressure over the lower part. Her tongue being dry, she
was allowed to suck ice freely. An injection of alum and water was
ordered to be thrown up the vagina night and morning. A draught
composed of one drachm of Hoffman’s anodyne, half a drachm of the
liquor opii sedativus, and camphor mixture, was given her at bed-time.

30th. Slept well during the night; complains of pain on pressing
the abdomen; very troublesome cough; tongue dry, with some little
sickness; pulse 130. That portion of the polypus below the ligature
appeared to be sloughing. Diet, milk and arrow-root. Towards the
afternoon the pain in the abdomen became more severe, and twelve
leeches were ordered, and a linseed-meal poultice to be kept on con-
stantly after their removal. ;

10, p.m. Pain less; she is able to straighten her legs with comfort.

31st. Slept well; pain very much less; pulse 100.

6.30, p.m. Bowels have been twice relieved; no pain in the abdo-
men; states that she feels very comfortable.

Jan. Ist, 1853. The discharge from the vagina is fetid. Ordered
a lotion with chloride of soda. Bowels much relaxed; has been very
sick; is depressed; extremities cold. Ordered an ounce of port wine
every four hours, and two pints of strong beef-tea during the

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128 POLYPUS OF THE UTERUS.

day. Half a drachm of the compound creta powder with opium
ordered.

2nd. The bowels were quiet some hours after the powder, but are
again very much relaxed this morning. Powder to be repeated.

3rd. Bowels quiet ; complains much of thirst. Vaginal discharge
free, and less offensive.

4th. Less thirst ; bowels open once; slept well; cough much better.

5th. Has slept well; bowels once relieved; the polypus is nearly
separated. .

11, pm. All the polypus has sloughed away. She is very low;
pulse 132. Ordered a sedative draught, and to have some brandy
and arrow-root from time to time.

6th. Much better; enjoys her food; bowels regular.

7th. Bowels very much relaxed during the night. An opiate
enema ordered.

8th. Pulse 116; mouth and throat very sore. Ordered the bi-
borate of soda lotion.

10th. Did not sleep well; cough very troublesome; mouth still very
sore; very slight discharge per vaginam. Ordered compound tincture
of bark and dilute sulphuric acid, in addition to the four ounces of
port wine which she has taken daily.

12th. Mouth aphthous; complexion of a dark sallow colour; feeble
quick pulse. From this time she gradually got worse, and died on
the 3rd of February, five weeks after the operation.

Post Mortem.— Uterus well contracted, containing no remains of the
polypus; no evidence of any disease of the pelvic viscera, but on
examining the chest, both lungs were found studded with small
tubercles in a state of suppuration, although no evidence of this con-
dition was discovered before the operation. The lining membrane
of the larynx, trachea, and bronchial tubes was found in a state of
chronic inflammation, and the aphthous condition of the mouth
extended through the cesophagus to the stomach.

Remarks.—This case I have related as being one of unusual interest
from the various complications in connexion with it. The constitu-
tion of this patient was so shattered by her long suffering antecedent:
to the operation, that it is evident her death was not attributable to
the latter, whilst the complete removal of the polypus, and the absence
of disease in the pelvic viscera, clearly show the success of, and the
justification for, the operative procedure.

Case XXXVII.—Polypus: Operation; Cure—Mary P., et. 44,
married, by occupation a laundress, was admitted, Sept. 2nd, 1853,
into Boynton ward, St. Mary’s Hospital.

She is a healthy woman, was married at seventeen, has had three
children, and always enjoyed good health till two years since, when
the catamenia stopped suddenly, which gave no inconvenience except.
occasionally, when she had headache. Three weeks afterwards the

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catamenia returned violently, and continued for ten days; after which,
she was unwell regularly every fifteen days, and continued so for a
twelvemonth, since which time the hemorrhagic discharge has never
ceased for more than a day. The discharge consists of large clots of
blood and a transparent fluid. On the 26th ult., she was obliged to go
to bed and send for her medical attendant, who said it was a tumour,
and advised her to go to the hospital.

Sept. 3rd. On examination, there was found a polypus of the uterus,
On the 7th, the patient being placed under the influence of chloroform,
I brought the polypus well down with a pair of vulsellum forceps,
transfixed it with a needle with double sutures, and tied the tumour
in two portions, its circumference being from three to four inches.

9th. A mixture with sulphuric acid, tincture of henbane, and
decoction of bark was given.

10th. To have a dose of castor oil at hed-time.

In the evening of the 11th, she had a violent attack of peritonitis ;
five grains of Dover’s powder were given, and twelve leeches and a
linseed poultice applied to the abdomen,

12th. Repeated the Dover's powder, leeches, and poultice.

13th. She is much better; ligatures have come away, pulse 80,
bowels opened, tongue not very clean; a mixture of sulphuric acid,
syrup of white poppies, and tincture of orange peel, was given three
times a day.

11 p.m. She has been very unwell from diarrhcea and cold, but is
now doing well.

14th. Pain in right groin extending down the leg, cedema in foot,
tongue foul, bowels open, pulse 108; fomentation of poppy heads to
be applied to the leg, and ordered to take a mixture of sulphuric
zether, opium, and camphor mixture.

From this time she gradually improved in health, and on Dee. 3rd
was discharged cured.

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CHAPTER VIII.
STONE IN THE FEMALE BLADDER.

Urinary Catcuni are probably formed as frequently in the
female bladder as in the male; but the shortness of the female
urethra and its remarkable degree of dilatability, so frequently
provide means for a ready and spontaneous escape of the stone
before it arrives at any great size, that the surgeon is less
frequently consulted by women suffering from stone than by
men.

Diagnosis——The symptoms of calculus in the female are
somewhat analogous to those in the other sex, but differ in
this——that they are particularly liable to prove fallacious.
Nothing is more common than for hysterical girls to complain
of pain at the neck of the bladder, and at the extremity of the
meatus, frequent calls to micturate, and a sudden arrest of the
flow of urine before the bladder has been emptied. But upon
examination by a sound or catheter, no stone can be detected.
It is also by no means uncommon to find the female bladder
occupied by a solid substance, very different in form and struc-
ture from ordinary calculi. Many cases are on record in which
the female bladder has become the receptacle of extraordinary
nuclei. <A case is related in the Medico-Chirurgical Transac-
tions (vol. i. p. 128), by Mr. Thomas, in which an ear-pick
was extracted from the bladder of a young female.

Dr. Toogood, late of Bridgewater, in his lately published and
most interesting volume, “ Reminiscences of a Medical Life,”
(page 155,) relates two cases, in which the surgeon accidentally
allowed a catheter to slip into the female bladder. In one case
it was in the bladder fifteen days, and produced but slight irri-

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STONE IN THE FEMALE BLADDER. 131

tation. It was removed by dilating the urethra by a sponge
tent, and then introducing the finger, directing the catheter
into the long axis of the bladder, and then seizing it with
a pair of forceps, as recommended by Sir Astley Cooper. In
the other case, it was in the bladder seventeen days, and
removed in the same manner.

In January, 1853, a young girl was admitted into St.
George’s Hospital under Mr. Hawkins,* who had suffered from
symptoms of stone in the bladder for four years, in consequence
of having passed a hair-pin through the meatus into the bladder.
Attempts had been made repeatedly to extract it, but without
success. On her admission the urine was found to be offensive,
and it contained a large quantity of ropy mucus, but no blood.
It came away involuntarily at first, but not afterwards, though
the patient was obliged to pass it very frequently. When the
sound was introduced, a foreign body, not easily moveable, was
felt in the bladder. It was extracted with extreme difficulty by
first incising and then dilating the urethra and introducing the
forceps. The hair-pin was broken on extraction, and was sur-
rounded by an incrustation of triple phosphate, with phosphate
_ of lime. The urine was alkaline. After the operation, she
could not retain her urine more than three hours at a time,
except at night. In this case, as in many cases of calculus in
the female, there was, before the extraction, rather an impedi-
ment to the retention of urine than a difficulty in passing it.

Among the symptoms of stone in the female may be noted
that the meatus is always dilated, there is always pain after
passing the urine, generally pain in sexual intercourse, and the
urine often deposits a mucous, and sometimes a sandy, sediment.
Frequently there is vaginal cystocele in the first instance,
followed by prolapsus uteri. Although the urgency of these
symptoms varies a good deal in different cases, there is often
much suffering produced. Sir Astley Cooper says:—“ I think
the symptoms of stone in the female are more urgent than
those in the male. It is horrible to witness the sufferings
which a woman experiences in consequence of this disease. She

* “Lancet,” May 28th, 1853.
K2

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132 STONE IN THE FEMALE BLADDER.

has a dreadful pain at the extremity of the meatus urinarius,
and in addition to this, there is a forcing down of the lower
parts of the pelvis, as if they were about to protrude; a frequent
disposition to make water, and all the pains suffered during
delivery. There is generally a prolapsus uteri, and a discharge
of bloody urine. In addition to these symptoms, there is
almost constantly an incontinence of urine, a great urgency to
discharge it, and an incapacity to retain it.”*

These symptoms, or some of them, may arise from scirrhus,
or from chronic inflammation of the mucous membrane of the
bladder, polypous tumours within the bladder, or excrescences
in the meatus. The detection of the stone by the sound is the
only satisfactory evidence of its existence.

Treatment.—Although stone in the female does not always
produce much distress, and may even escape spontaneously, yet,
when discovered, it ought not to be allowed to remain, as it
may grow to a size indefinitely large; and, if the patient should
become pregnant, it may prove a source of great difficulty and
danger during parturition: it may even produce vesico-vaginal
fistula.

There are three ways of removing calculi from the female
bladder,—incision, dilatation of the meatus, and lithotrity, with
or without dilatation. :

1. Incision —Lithotomy in females is much more easy of
execution, and less dangerous to life, than the same operation in
the male subject. It may be done in various ways, but until
recently the plan was to divide the urethra and neck of the
bladder, and introduce a pair of forceps. The objection to this
operation is, that incontinence of urime is apt permanently to
follow the operation. The late Mr. Hey, of Leeds, cut two
female patients for the stone, both of whom were afterwards
unable to retain their urme. A modern method is to incise
the anterior margin of the meatus, and then gradually dilate
the remaining portion of the urethra until the finger can be
passed into the bladder. But even this plan is often followed
by a greater or less degree of incontinence of urine. And to

* Cooper's “ Lectures on Surgery.”

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STONE IN THE FEMALE BLADDER. 1383

this point I shall have soon to call the reader’s particular
attention.

2. Dilatation of the Urethra.—The female urethra is well
known to be capable of dilatation to a great extent, but few
practitioners are aware either of the extent to which it may be
dilated, or of the conditions on which that dilatation can be
effected without laceration or subsequent incontinence of urine,
or any other injury. In regard to the dilatability of this
canal, there is ample evidence that it will admit a calculus to
pass through it of almost any size which these concretions are
likely to attain. Numerous examples are adduced by surgical
writers in which calculi of immense size have been spon-
taneously voided through the meatus urinarius, either suddenly
and without pain, or after more or less time and suffering.
Heister mentions several well-authenticated instances of this
kind. Middleton has also related a case where a stone weigh-
ing four ounces was expelled in a fit of coughing, after lodging
in the passage a week. Collett speaks of another instance,
where a stone about as large as a goose’s egg, after lying
in the meatus urimarius seven or eight days, and causing a
retention of urine, was voided in a paroxysm of paim.* Dr.
Molineux relates a case (‘“ Philosophical Transactions’) in which
a woman voided a stone of which the long circumference was
between seven and eight inches, the shortest circumference (in
the thickest part) five inches and three quarters. I have my-
self extracted a stone through the dilated meatus three inches
and a half in circumference; and in the case already quoted, in
which Mr. Thomas extracted an ear-pick from the bladder, he
says, “The left forefinger was most easily introduced, and
I believe, had the case required it, both thumb and finger
would have passed into the bladder without the smallest
difficulty.” It is clear, therefore, that there is no absolute or
mechanical necessity for incising the canal in order to allow
ordinary calculi to pass. Still, objections have been brought
against the practice of dilatation:—1. That it frequently takes
a long time and gives great pain to dilate it effectually.

* See Cooper’s “Surgical Dictionary,” (Art. Lithotomy.)

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134: STONE IN THE FEMALE BLADDER.

2. That laceration is lable to occur. 3. That incontinence
of urine has sometimes followed.

As I am anxious to demonstrate the practical importance of
availing ourselves of the dilatability of the female urethra in the
extraction of calculi from the bladder, I shall now consider
these objections seriatim. 1. The tediousness of the operation
and the pain it produces, are objections the whole force of
which has been dissipated by the introduction of anzesthetics
into operative surgery; and in this case chloroform has a double
claim upon our notice. It not only prevents all pain, but it
prevents all tediousness likewise. So long as the patient is
conscious, the process of dilatation is rendered difficult and
tedious by the contraction of the sphincter fibres of the meatus;
but under chloroform these fibres are relaxed, and the dilatation
can be accomplished easily and quickly. 2. The second objec-
tion is disposed of in the same way. Laceration can only occur
in the walls of this loosely arranged structure, in consequence
of the rigidity of the muscular fibre: relax this rigidity by
chloroform, and the danger of laceration no longer exists. 3.
Incontinence of urine does not occur after dilatation under
chloroform. And I think this may be thus explamed. When
the dilatation has been a tedious and painful process, it has at
length been accomplished (physiologically) by exhaustmg the
irritability of the fibres, and thus rendering them powerless for
the time; or (mechanically) their structure may have given way
under tension; or both these circumstances may have occurred;
and in either of these occurrences, subsequent imperfect contrac-
tion, and consequent incontinence, are perfectly explicable.
Whereas under chloroform there is no wasting or bearing down
of the local nervous irritability, nor, as the rigidity of the canal
is destroyed, is there any danger of laceration; there is, therefore,
no probable cause for incontinence, as a subsequent evil. I
state these things advisedly, and after considerable experience,
having had frequent occasion to dilate the female urethra, not
only in cases of stone in the bladder, but in operating for
vesico-vaginal fistula. ‘

I ought, however, to add, that Mr. Fergusson, Mr. Coulson,
and other modern surgeons, advise, when the stone is large, that

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STONE IN THE FEMALE BLADDER. 135

the anterior portion of the meatus should be divided, and the
remaining portion dilated. In this way Mr. Fergusson has
extracted a stone three inches in circumference. Mr. Coulson,
however, in his admirable and practical work on Lithotomy
and Lithotrity (p. 261), rather recommends lithotrity when the
stone is very large.

Lithotomy in the female, as it was formerly performed, is an
operation which should be utterly discarded from practice. Sir
Astley Cooper says:—“ The extraction by dilatation is greatly to
be preferred, not only because there is much less danger in it,
but because it does not leave behind it the melancholy conse-
quences of lithotomy in the female. I mean the loss of the
retention of urine. A woman who undergoes the operation for
stone, generally loses, for ever after, the power of retaining her
urine. Her condition, therefore, is most deplorable. The con-
stant discharge of urine, and the constant excoriation of the
parts render her offensive to all around her; her health is
broken, and she is completely cut off from all society.”* Dr.
Blundell, my highly respected preceptor at Guy’s Hospital, and,
before him, Dr. Haighton, strongly recommended the removal
of calculi from the female bladder by dilatation of the urethra.
Nothing more need be added to justify me in urging my brethren
in all cases to avoid incision of the meatus. Dilatation under
chloroform is both safe and easy, and will generally allow the
stone to be removed entire; or if it be very large, it may easily
be broken down by lithotrity.

Case.—At page 104 of this work will be found a case in
which I extracted a stone from the female bladder by dilating
the urethra under chloroform. The case is interesting in many
points. The calculus had been the cause of a difficult labour
three years before, and, by its pressure, a vesico-vaginal fistula
had been produced. Although the stone was three inches and
a half in circumference, it was extracted without much difficulty,
and with a very slight laceration of the anterior portion of the
urethra, which healed, and the patient recovered, without any
difficulty in retaining the urine, which indeed had for three
years been discharged through the vagina.

* “Cooper's Lectures,” p. 368. Renshaw, 1839.

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CHAPTER IX.

VASCULAR TUMOUR IN THE MEATUS URINARIUS.

Few diseases of trifling magnitude occasion more distress
than a vascular excrescence, varying in size from a large pin’s
head to that of a horse-bean, which is sometimes found growing
from the female urethra. The exquisite sensibility shows it to
be as well supplied with nerves as with bloodvessels. The tumour
sometimes arises from the projection which generally exists
around the orifice of the meatus, but it frequently grows from
the internal surface. The tenderness of the parts is so great as
not to allow of sexual intercourse, and it may thus become a
cause of sterility. There is sometimes a mucous discharge;
and Mr. Coulson observed, in a paper recently read before the
Medical Society of London, that inflammation may extend from
the meatus to the bladder occasioning cystorrhcea.

The disease is common to the single and married woman.
Sir C. M. Clark and Dr. Blundell describe it as confined
to females under the middle age, and generally to young
women. But I have myself seen it in a woman of sixty; and
Morgagni, who was the first to describe the disease, says,
“ Examining the body of an old woman, about the year 1751, I
met with a small triangular excrescence within the external
orifice of the urethra, but it was not prominent.”

Diagnosis —An exquisite degree of sensibility of the part
being the leading symptom of the disease, the patient complains
of excessive pain in micturition, in coitu, and, indeed, from any
the slightest pressure on the part. It may reasonably be
suspected that such a tumour exists, when the ‘acuteness of
sensation is confined to the meatus, and does not extend to the
vagina or the vulva. Still, as the symptoms much resemble

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VASCULAR TUMOUR 1N THE MEATUS URINARIUS. 137

~ those of circumscribed inflammation of the vulva, it is evident

that correct information can only be obtained by careful exami-
nation. Upon separating the labia and nymphe, the nature of
the complaint will generally become obvious. A small tumour,
of a florid scarlet colour, resembling arterial blood, is observed
on or just within the orifice of the meatus. It easily bleeds on
rough handling. It is exquisitely tender, and its surface is
somewhat granulated. It appears to grow, by a loose attach-
ment, from the surface of the urethra. Upon turning it a

‘little on one side, its insertion, sometimes into the tubercle above

the meatus, sometimes into the lip of the meatus, can generally
be observed. Occasionally there are more than one of these
excrescences, and they extend along the urethra towards the
bladder. They sometimes produce great constitutional disturb-
ance dyspepsia, and nervousness.

Treatment.—Ligatures are useless, as they cannot be made to
include the whole of the diseased mass, nor can they be made to
tie it with any degree of force without exciting inflammation, as,
in order to a cure, some portion of the mucous membrane should
be included. Yet this has been recommended on high authority.
Excision alone is speedily followed by a renewed growth, unless
it be followed by caustic applications. A better practice is to
excise the tumour with a pair of scissors, or a small well-pointed
knife, taking care that not only the excrescence itself is removed,
but also that small portion of mucous membrane from which it
grows, taking it up carefully with a fine pair of forceps, fig. 8. To
the wound thus made, nitric acid should be applied on a piece
of stick pointed like a pencil, the parts around being filled with
lint previously soaked in a strong solution of nitrate of potash.
Or, nitrate of mercury may be applied in the room of nitric
acid, and a piece of lint dipped in cold water applied over the
part immediately afterwards. In this way I have cured many
cases, and recently a case in which a plurality of excrescences
required three or four excisions of small portions of the mucous
membrane at different times. This is better far than excising the
whole at orice.

My friend, Mr. Brigham, of Lymm, informs me that
during the twenty years he held the appointment of surgeon

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138 VASCULAR TUMOUR IN THE MEATUS URINARIUS.

to the Lock Hospital at Manchester, he had frequent oppor-
tunities of seeing these peculiar tumours, and he found, after
trying many modes of treatment, that the most certain and
quickest plan was the application of the actual cautery, just
touching the extremity of the body; and that it seldom required
more than one application. I have never tried this method,
but most certainly shall do so on the very next occasion, because
I rely implicitly on the statement of my friend, knowing how
earnest he is even now, in his retirement from practice, in the
pursuit of truth and in the investigation of progressive surgery,
having often seen him and my esteemed and talented friend
Mr. Jordan, of Manchester, in London, watching at the different
hospitals various new operative proceedings.

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CHAPTER X.

IMPERFORATE HYMEN.

In its natural state, the virgin hymen closes the vagina im-
perfectly, generally occupying the inferior portion of the ostium
vaginee in the form of a semi-lunar membrane, leaving an aper-
ture in the upper portion from the size of a quill to that of
a thimble, for the transmission of the menstrual fluid. But it
occasionally happens that the membrane is congenitally entire
or imperforate. This may not be discovered until puberty,
when the female will suffer severely every month by the
accumulation of the menstrual secretion within the vagina, pro-
ducing ultimately a pelvic tumour and a bulging out of the
membrane which closes the vagina, causing severe pain and
other serious symptoms. In this case, the uterus as well as the
vagina, and even the Fallopian tubes, become distended with the
menstrual fluid, which increasing in quantity at every menstrual
period, presents at length an urgent necessity for an operation.
The method of relieving this condition has been to divide the
hymen by a crucial incision, and the fluid having been discharged,
generally nearly black in colour, and of the consistence of treacle,
the uterus is well syringed out with warm water, and a bandage
applied around the abdomen.

This appears very simple and easy. Yet many young women
have lost their lives by this operation from consequent perito-
nitis; and the subject is one which is worthy of careful
investigation.

The fatality of this operation has been ascribed by Dr.
Blundell to the epidemic influence of puerperal fever, then
raging in the neighbourhood. His opinion is worthy of great
respect: I therefore quote his words. He says, “It seems that

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140 IMPERFORATE HYMEN.

where puerperal fever is epidemic, women in whom the hymen
has been divided in this manner, are liable to inflammation of
the peritoneum afterwards, in the same way as they are lable
to similar inflammation after they have been recently delivered.
Cases of this kind, two in number, if my memory serve, have
been mentioned by Denman; and a few years ago, at the
London Hospital, a case occurred, for a reference to which I
was indebted to Mr. Mitchell, of Kennington. In this case, the
accumulation of the catamenia amounted to two gallons or more.
The obstruction was divided; inflammation of the peritoneum
ensued, but the patient was saved by rigorous antiphlogistic
remedies. As this is the case, if I had a patient under my
care, I should dissuade her from submitting to the operation
till the epidemic disposition to puerperal fever had subsided;
even though she waited for three or four years; for, without
pretending to assert that abdominal inflammation from this
cause is equally dangerous with the genuine fever of puerperal
women, I think it not impossible that it might cost her her life.
Why the discharge of the accumulated catamenia should, like
parturition, give rise to peritonitis, I do not pretend to explain ;
but the fact is curious. Is there any analogy between the lochia
and the catamenia ; and is this the cause of these similar effects?
Perhaps some great pathological truth lies concealed here.’”’*

Without for one moment questioning the propriety of defer-
ring this, or any other operation upon the pelvic or abdominal
organs, whenever and wherever puerperal fever is epidemic, I
have a strong impression that fatal peritonitis has succeeded this
operation when there was no such influence to account for it.
At all events, many such cases are recorded without any re-
ference being made to the existence of an epidemic puerperal
fever.

Treatment.—When the surgeon is consulted in the case of a
young female before the age of puberty, on account of an occlu-
sion of the vagina, it will generally be found that the united
parts may be separated by the thumb of each hand being
applied, and some little force bemg used, the child being placed

* Blundell’s “ Midwifery,” p. 689.

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IMPERFORATE HYMEN. 141

‘in the lithotomy position. Cutting is rarely required in children.
A piece of oiled lint should be introduced to prevent reunion of
the separated parts, after they have been thus torn asunder. If
the obstruction is of a longer standing, and the tissues are
thickened and indurated, then the question to be considered is,
how is it to be divided? Every author who has written on the
subject recommends a crucial or stellate incision. This leaves
the divided portions of the hymen to retract and remain on each
side of the vaginal orifice; and when the operation is performed
in the earlier stage, before puberty, or a few years afterwards,
these relics of the thickened hymen may create no irritation of
consequence; not so, however, when the patient has passed her
25th or 80th year; the divided portions do not then shrivel or
pucker up, so as to create no inconvenience. On the contrary,
vaginitis is very apt to be set up by the friction of these
surfaces upon each other, produced by every movement of the
body. It is easy to understand how inflammation thus set up
in the mucous membrane of the vagina may extend into the
uterus, Fallopian tubes, and ultimately to the peritoneum. I
would therefore throw out the question, whether the frequent
occurrence of peritonitis after this operation, simple as it
appears to be, may not thus be explained.

Being strongly convinced that these two methods of dividing
the hymen, namely, by the crucial and stellate incision, attended
as they are by so many inconveniences, and, as I believe,
dangers, are not so eligible as a more perfect surgical pro-
cedure, by which the whole of the abnormal structure is at
once removed, I recommend that the hymen be removed
entire by a circular incision at the point of its Junction with the
labia.

The following cases will more clearly illustrate the views
I wish to enunciate.

Case XXXVIII.—Imperforate Hymen in an unmarried lady:
Painful Menstruation; Operation ; Cure—Miss B., xt. 29, consulted
me January 3rd, 1853, suffering from painful menstruation since
puberty, and at every epoch so severely, that her health was seriously
impaired. She had, in fact, become a confirmed invalid: She stated
that the pain was accompanied with a sense of bursting, as if some-

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142 IMPERFORATE HYMEN.

thing must give way “at the mouth of the bladder.” Considering it
necessary that a vaginal examination should be made, I introduced
my finger between the labia, and immediately fourtd a firm resisting
band which prevented its further progress. I then proceeded to make
a visual examination, when I found a perfect closure of the vaginal
orifice, but an enlarged meatus urinarius, She stated, upon further
questioning her, that the menstrual discharge came from the mouth of
the urethra ; and on passing a probe into the lower part of the meatus,
I found that it slipped into a tortuous canal below the meatus (the
size of the probe) running up into the vagina. It was from this canal,
evidently, that the menstrual fluid escaped. It was now clear that
the hymen was congenitally imperforate, thick, and organized. I
recommended that it should be removed, and promised her relief on
future occasions of menstruation. Accordingly, having prepared her for
a few days previously for the operation, I placed her in the position
for lithotomy, under the influence of chloroform, and then proceeded
to dissect out the hymen by a semicircular incision on each side, so as
completely and cleanly to remove the whole structure. No hemor-
rhage of any consequence took place. The parts were dressed with
lint soaked in oil, which dressing was repeated from day to day, and
in one fortnight all the parts were quite healed, and on the following
period she suffered no pain or inconvenience, and has continued well
at every subsequent catamenial period.

Case XXXIX.—Imperforate Hymen in a married lady, obstruct -
ing connubial intercourse: Operation; Cure.—Mrs. G., aged 35,
married eighteen months, was requested to see me by Dr. Locock,
February, 1854, who had ascertained from the patient that she had
been married some eighteen months, but that her husband could have
no proper connexion with her; that it was not his fault; that she has
been in good health; menstruation has been regular, although it com-
menced late in life. On examination, he found the vagina a cul-de-sac
not more than a short inch, the urethra very capacious, and the
patient described the menstrual discharge as coming through that
orifice. The uterus could be distinctly felt per rectum, and appeared
to be quite normal. Dr. Locock advised her to return to town again
when the catamenia were flowing, in order to ascertain whether the
discharge actually issued from the urethral orifice, and then to stop in
town for the purpose of having some operation performed.

On the 28th of February I had an opportunity of examining the
patient, and after a very careful investigation, I discovered, about a
third of an inch behind the meatus, a small projecting piece of mucous
membrane like a cowpox pustule on the third day, and from this I
saw some leucorrhceal discharge ooze out. Still I could not pass the
smallest probe through this little projection. I then carefully intro-
duced the little finger of my left hand into the bladder, and clearly
ascertained that there was no communication with the uterus 3 which

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IMPERFORATE HYMEN. 143

organ I could plainly feel through the coats of the bladder, as also by
passing another finger up the rectum. I examined again and again,
and could find nothing but a thick fibroid hymen completely obstruct-
ing the vaginal orifice, extremely unyielding. At last, seeing some
more leucorrheeal discharge ooze out, and hearing from the patient
that she occasionally had a considerable quantity of that secretion, I
again tried, and ultimately succeeded in insinuating a very small
probe through a valvular opening into the vagina, when the instru-
ment readily passed two inches upwards. I therefore advised her to
stay in town till her husband’s arrival, and proposed, subject to the
approval of Dr. Locock, that she should undergo the operation of
removal of the hymen. She remained accordingly.

Operation.—March 4th, 1854, the patient was placed in the litho-
tomy position, and chloroform having been administered by Mr.
Moullin, with the assistance of Dr. Locock and Mr. Nunn, I carefully
dissected away the entire structure, and removed it in one piece. It
was nearly a quarter of an inch thick in some places, and was found
lined within and without by a mucous membrane, with a strong fibroid
tissue intervening. A spacious and healthy vagina was then dis-
covered, and a normal os uteri could be felt by the finger. A small
speculum was easily introduced, and immediately on its removal
the vagina was plugged with lint soaked in oil. The patient was
placed in bed, and opiates were given. No hemorrhage of any con-
sequence ensued. The urine was drawn off by catheter every four
hours, and perfect quiet was enjoined. On the 6th day the bowels
were opened by enema. The patient recovered without any un-
favourable symptoms, and on the 18th returned home, having pre-
viously menstruated normally.

This mode of operating has been objected to on the ground that
constriction of the vagina will occur in consequence of the circular
incision being immediately around the constrictor vagine. This objec-
tion would hold good if no attention were paid to the after dressing ;
but if the plan be steadily followed which I have recommended,
namely, plugging the orifice daily, after the first seventy-two hours,
with lint soaked in oil, it will be impossible that any constriction can
take place. In these two cases, as in several others which have come
under my notice, certainly no constriction has followed the operation.

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CHAPTER XI
ENCYSTED TUMOUR OF THE LABIA.

TuEsE tumours are met with of various sizes, but are gene-
rally circumscribed. Some authors assert that they are always
semi-transparent; but this I believe to be a mistake, as I have
not found them invariably so. If they are superficial, then they
are semi-transparent, but not when they are deep-seated, being
covered on the outside by skin with more or less of cellular
tissue beneath.

Symptoms.—These are few in number, and, in the smaller
and superficial kinds, slightly marked; but when the tumours
attain a great size, or are attended by inflammatory action, then
of course the symptoms are more prominent. The patient may
complain of a certain degree of uneasiness and weight, aggra-
vated by locomotion, by defecation, micturition, or, if in the
married state, by sexual congress. Some authors assert that
the skin covering these tumours is rarely changed in colour,
but my experience does not warrant my acceding to this
opinion, as I have found the skin sometimes of a bluish, at
others of a reddish-brown colour. When opened, they are
found to contain fluids of different character in different cases,
sometimes of a glairy nature, sometimes of a dark appearance,
at other times of a puriform character.

Sometimes the contents are more or less solid.

These tumours may be caused by a fall or a blow on the soft
parts, a long time antecedent to the formation of the cyst.

Diagnosis.—The slow growth of the tumour, and in most cases
the absence of pain, will distinguish this disease from simple
phlegmon of the labia; and its encysted character from warty
tumours.

Treatment.—There are several modes of treatment recom-
mended.

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ENCYSTED TUMOUR OF THE LABIA. 145

1. Simple incision, and evacuation of the contents. 2. Inser-
tion of a seton through the tumour, so as to produce suppura-
tion. 8. Dissecting out the tumour, care being taken that the
entire cyst be removed. 4. Injections of iodine. 5. The actual
cautery.

1. The first of these methods—namely, simple incision—may
be practised with occasional success where the tumour is very
superficial and semi-transparent.

2. The plan of treatment by seton I have never tried, nor do
I think it one to be recommended.

3. The third kind of treatment—namely, dissecting out the
entire cyst—is the mode which I greatly prefer, care being
taken with the after dressing to ensure a healthy granulating
surface at every spot. This may be accomplished either by
dressings of dry lint, or by a cerate made of turpentine oil and
resin cerate, equal parts; or by touching the surfaces with nitrate
of silver.

4, The next best plan is injecting iodine, but as I have
always found the third plan successful, I have never had recourse
to injection.

5. The late Mr. Liston practised the actual cautery, but I
cannot understand upon what grounds such a desperate remedy
could be had recourse to, except the well known fact that these
tumours frequently recur after the ordinary modes of operation.

T shall only relate one case, in which the third kind of treat-
ment succeeded.

Case XL.—Encysted Tumour of the Labia in an unmarried
lady: Operation ; Cure—M. H., ext. 26, consulted me, complaining
of great pain in the lower part of her back, pain down the inner part
of the thigh, and pain in the left labium, extending back to the
rectum : she stated that nine or ten weeks ago she suffered from acute
pain at that spot; that ever since that period she has had considerable
uneasiness there, and that now she feels a swelling. Upon examina-
tion, I found an encysted tumour of the left labium, between the
vagina and the tuberosity of the ischium, running up towards its
ramus, about the size of a small pullet’s egg. Feb. 28th. I ordered a
dose of castor oil at bedtime, and on March Ist, proceeded to operate.
The patient being placed under the influence of chloroform, and put
in the position for lithotomy, and all hair being shaved off the labium,
an assistant passed his finger into the vagina, and pressing the tumour

L

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146 ENCYSTED TUMOUR OF THE LABIA.

forwards, an incision of an inch and a half was carefully made through
the skin and sub-cellular tissue, down to the cyst, which presented a
blueish aspect. Having dissected away, as much as possible, the
surrounding tissues, which were closely adherent, I punctured the
cyst for the purpose of saving the fluid, and then seizing it with a
pair of vulsellum forceps, I dissected it out, dividing two or three
arteries, which bled freely at first, but were stopped by pressure,
plugged the space, which was about an inch and a half deep, with lint
soaked in oil, and applied two interrupted sutures to the upper part
of the wound, leaving the rest open. Ordered her to take opium, cold
water dressing to be applied constantly, and that she should suck ice
freely.

She was very sick for the first twenty-four hours, but this evidently
arose from the chloroform. On the third day I applied the black
wash to the wound, varying the dressing by sometimes applying dry
lint, and at others touching the granulating surfaces with caustic, and
then applying dry lint; after six weeks of uninterrupted attention,
the parts healed well and sound, and she left town for the country to
recruit her strength.

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CHAPTER XII.

DISEASES OF THE RECTUM RESULTING FROM
CERTAIN CONDITIONS OF THE UTERUS:

Tue substance of this chapter is a transcript of the paper
which I had the honour of reading before the Medical Society
of London in February last. .

It is a fact, generally admitted, that diseases of the rectum
are more common in women than in men. Of this a partial
explanation may be found in the more sedentary habits of the
former, but, in my opinion, it should much more frequently
be referred to a uterine origin. The sundry altered conditions
to which the uterus is subject—such as enlargement, displace-
ment, deranged circulation—act mechanically and otherwise
upon the rectum, and produce in it various lesions.

These, so to speak, secondary disorders of uterine origin, seem
to me not to have been sufficiently recognised and insisted on ;
and hence, I believe, has resulted the too frequent failures in
the treatment of diseases of the rectum in females, which
most practitioners have to lament. The influence of the
enlarged uterus in pregnancy in developing disorders of the
rectum, has, indeed, attracted general attention; but that of
other enlargements and of displacements has never, so far as I
am aware, been put prominently forward. Yet if the uterine
origin of the disease be not suspected, we may treat a woman
affected secondarily with constipation, piles, intestinal irritation
of a dysenteric character, or other allied disorders, by measures
directed to the Lowel as the primary seat of the disease, and yet
the patient shall derive no benefit from any of them; for the
uterme and intestinal affections are related to each other as

L2

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148 DISEASES OF THE RECTUM RESULTING FROM

cause and effect; and it can be only on a recognition of this rela-
tion that we can apply remedies with any certainty, or look with
any confidence for a favourable issue. ;

Displacement forwards or backwards, and enlargement of
the uterus, from whatever cause,—whether pregnancy, hyper-
trophy, inflammatory engorgement, distension by fluid or by
hydatids, polypi, or scirrhus, or any other disease—alike tend
to injuriously affect the rectum.

As displacement may occur without enlargement of the uterus,
it may operate singly in inducing rectal disease; but more often
the two conditions concur, and it is then chiefly that the mischief
is so considerable. The evils, too, will be greater when, with
retroversion, engorgement of the body of the uterus, and with
anteversion, that of its neck, go together. On the other hand,
enlargement, without deviation of the womb forwards or back-
wards, may, and oftener does, act singly in provoking disease of
the rectum, than either of these displacements does without it.

The conditions of the uterus under consideration act on the
rectum injuriously in two ways: first, by mechanical pressure;
and, second, by inducing vascular disturbance like that present
in themselves. An enlarged uterus drags on its lateral liga-
ments, elongates them, subsides lower down in the pelvis, and
so comes to press on the lower bowel, to interfere with its
muscular action and the circulation through its bloodvessels, and
to irritate its mucous lining. At the same time any hypercemic
state of the uterine vessels causes an increased fulness of the
hemorrhoidal, and a determination of blood to them. Thus, by
reflecting on the anatomy of the parts, it will easily be under-
stood why and how diseases of the rectum, such as hemorrhoids,
prolapsus, fissure, stricture, fistula, as well as disordered func-
tions of the bowel, as constipation, dysenteric irritation, &c., do
sometimes result directly, either from the mechanical pressure of
an enlarged uterus, or simply from the derangement of the
hemorrhoidal circulation, resulting from uterine disease.

By retroflexion and retroversion, the fundus uteri is thrown
backwards against the rectum, and will consequently exercise an
amount of compression on that viscus, according to its degree, to
the bulk of the uterus and the capacity of the pelvis. Retro-

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Plate VI.

 

Normal condition of the Pelvic Viscera
a Synrphysis Pubis The Bladder c¢ Uterus d Rectum e Vagma.

“CC &L CE Fort bth Ford & West Imp

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Plate VII.

 

Showing Partial Retroversion of Uterus pressing upon upper part of Rectum
CC 4: CH Bard lah Ford & West Imp

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Plate VIL |
if
|
|
|
}
\

|

Showmg the result of a more complete Retroversion |

{

CC.aet CH.Ford lub Fad & “ese inp |
4

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CERTAIN CONDITIONS OF THE UTERUS. 149

version is occasionally so complete that the fundus uteri depresses
the posterior peritoneal cul-de-sac, and even descends below the
level of the cervix. Now, as deviation of the uterus posteriorly
is no unfrequent consequence of distended bladder—a common
occurrence in females—owing to their natural reserve, and the
restraint imposed by our social habits, and as its ulterior effects
on the rectum must be expected, we so arrive at one reason for
the greater prevalence of diseases of the rectum among them.

In anteversion and anteflexion, the fundus falls forwards
against the bladder, and thus the cervix uteri will impinge
against the rectum more or less, according to the extent of the
deviation, the size of the womb, especially of its neck, the
capacity of the pelvis, and the degree of fulness of the bladder,
which in these displacements has its outlet more or less
obstructed.

A reference to Piares VI. VII. VIII. will best explain the
mechanical interference exerted by these several mal-positions of
the uterus, and likewise the normal relations of the pelvic
viscera. It is obvious, that in the treatment of the various
affections so arising, unless the attention of the practitioner is
directed to their uterine origin, no permanent. benefit can
possibly result. Therefore, when any of these affections occur
in females, it is necessary to inquire into the condition of the
uterus, which will often at once explain the cayse and. indicate
the treatment. I now propose to demonstrate these views by
cases.

Hemorrhoids —The hemorrhoidal vems suffer more from
pressure than the arteries, because the coats of a vein are thin
and capable of great distension, and not resilient, whereas the
artery is smaller, firm, elastic, and very resilient, and the vis a
tergo being greater, the circulation of the blood is less liable to
interruption. Therefore, as might be expected, its mischief is
greater in the veins than in the arteries. Hence we find that
the blood stagnates, and occasionally coagulates in the veins, and
forms a semisolid tumour, whilst the cellular tissue around
becomes thickened, and the mucous membrane covering them
xcessively veascular and sensitive. I allude here entirely to
internal hemorrhoids of a varicose nature.

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150 DISEASES OF THE RECTUM RESULTING FROM

Cast XLI.—L. C., aged 31, unmarried; had suffered for several
years from three or four large piles, which, she stated, protruded
in the act of walking, and also created great uneasiness in the sitting

‘posture. Every three or four weeks, she lost a considerable quantity
of blood from them. Her bowels were seldom opened more than once
in three or four days, and then only from taking some aperient.
After each defecation, she had always increased inconvenience and
pain. She suffered much from indigestion, headaches, and general lassi-
tude. I first inquired as to the menstrual function, and found that,
although she was generally regular every four weeks, the quantity was
very small, and the discharge seldom continued more than one day,
and that, at this time, she generally lost a considerable quantity of
blood from the hemorrhoids. On making a digital examination per
vaginam, I found the uterus enlarged and painful to touch, and lower
in the vagina than normal. I directed that three leeches should be
applied to the os uteri, and that the bleeding should be encouraged by
a hip-bath immediately on their removal; that the bowels should be
freely opened by a saline aperient; and that this treatment should be
pursued once a week. She was further directed to take twice a-day
the sixteenth part of a grain of the bichloride of mercury, and her diet
was ordered to be simple, nutritious, and unstimulating. The result
of these measures was, that at the next menstrual epoch there was
a more copious uterine discharge, and an absence of bleeding from the
hemorrhoidal vessels. The same treatment was continued for another
month, and resulted in an improvement in menstruation, both in
quantity, and in the duration of its flow; the uterus had much
decreased, being nearly of its normal size, and not painful to touch. I
now considered it advisable to remove the hemorrhoids, which I did
by passing a ligature of twine around the base of each. I then placed
the patient in bed, giving her a grain of opium every four or six
hours, for the purpose not only of affording relief from pain, but also
of constipating the bowels till the ligatures should come away, which
they did in five or six days. The case progressed satisfactorily, and
the patient returned to the country perfectly recovered.

This case presents some striking practical facts, which will serve to
illustrate my preliminary remarks.

1. The bleeding from the hemorrhoids at the menstrual epoch. It
is a fact that hemorrhoids are always more troublesome at the time
of menstruation, because more blood is circulating through the blood-
vessels of the rectum as well as of the uterus; and, if there be any
obstruction in the uterine vessels to prevent the menstrual flux, then
the hemorrhoids often bleed freely.

2. The enlarged and inflamed uterus, with the absence of the men-
strual flux.

3. The great relief afforded by the antiphlogistic treatment.

4. In ligaturing the hemorrhoids I prefer twine. Its advantages
over silk are very marked :—first, in procuring a quicker separation of

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CERTAIN CONDITIONS OF THE UTERUS. 151

the tumour; and, secondly, in causing less pain to the patient. It
will also be observed, that I preferred the ligature to the scissors in
the removal of these tumours, acting upon the golden rule laid down
by my old and esteemed friend, Mr. Copeland, in all operations upon
the rectum, “to cut skin, and tie mucous membrane.” I am also in-
debted to the same gentleman for the practical hint to prefer the use
of the vegetable product—twine, to that of the animal product—silk.

I think it is not too much to assert, that had I at first devoted my
attention to the hemorrhoids in this case, I should not have succeeded
in restoring my patient to the condition of health.

Case XLII.—Prolapsus Anii—H. A., et. 28, unmarried, upper
nurse in a lady’s family; had suffered for twelve months with a pro-
lapse of the bowel. She stated, that this prolapsus was always much
increased by carrying the infant, or by raising any weight; and also
worse after defecation; that every three or four weeks she had bleed-
ing from the protruding parts; that she had been regular as to time
in menstruation, but very deficient as to quantity, and that the
discharge was of a dirty-brown colour. She had been under a course
of medicine for nine months, but had derived no benefit.

On passing my finger up the rectum, while she was standing on the
floor and leaning forward on the side of the bed, I felt a round tumour
the size of an orange pressing on the rectum just below the promontory
of the sacrum, moveable on pressure towards the vagina; this, on
examination per vaginam, I found to be an enlarged uterus retro-
verted, and thus mechanically acting upon the rectum. This pre-
vented free circulation of blood through it, and thus not only produced
piles, but also congestion of the mucous membrane,—hence the
prolapsus.

Treatment.—I first directed my attention to the condition of the
uterus ; applied leeches; enjoined rest in the recumbent posture ; gave
saline aperients; ordered simple and unstimulating regimen, and the
bichloride of mercury, with tincture of bark twice a-day. The result
of this treatment, at the next menstrual epoch, was a considerable im-
provement in the character of the discharge; the same treatment
was continued another month with increased benefit.

On Dec. 16, I prepared her for the necessary operation, by giving
her a dose of castor oil at night, and an enema of warm water on the
following morning. Having placed her under chloroform, my assistant
separating the nates, I passed an armed needle, with a double ligature
of well-waxed twine, through the prolapsus, and tied it in two sepa-
rate portions; and then, having well smeared the surfaces with oil, I
returned them within the sphincter, which firmly contracted, leaving
the two ends of the ligatures without. Gave two grains of opium,
and ordered one grain every four hours.

17th. Had some sickness during the night, and vomited, after which
she slept well. There is no pain about the anus. To continue opium
every six hours.

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152 DISEASES OF THE RECTUM RESULTING FROM

18th. Has had a good night. Some pain in the rectum for a short
time, leaving no permanent discomfort. Diet: broth, light pudding,
and milk.

20th. The ligatures came away, and the bowels were relieved by
castor oil. :

22nd. Complained of a sharp cutting pain after the last dejection.

23rd. Examined, and found an ulceration or fissure within the
sphincter, and an inflamed external pile.

26th. I placed her under chloroform, and first cut off the external
pile, and then divided the fissure in the manner directed by Mr.
Copeland, and which I shall more fully describe in case XLIV. I then
examined more carefully, and found, exactly opposite the fissure,
a small wart-like substance, with a long slender pedicle. This fell
within the fissure—which it may be it had produced, and kept up
a-constant state of irritation. Having removed this by the scissors,
I applied a piece of lint dipped in oil to the incised surfaces, and gave
grs. ij. of opium. — oe ee

27th. Is free from pain; pulse quiet, and no fever. Removed the
lint, and did not again apply it. From this time she progressed
favourably, and in one fortnight was quite well. During the past two
years she has had no return of the disease, but has continued in the
same situation, performing well all its duties.

Practical Remarks.—This case again surely proves the truth of my
preliminary remarks, as showing the predisposing cause of the pro-
lapsus—viz., the condition of the uterus, its mechanical pressure on
the rectum, and the increased flow of blood to the bowel at the men-
strual epoch on account of the deficient discharge from the uterus.

Case XLITE.—Prolapsus Ani. H., et. 42, married; had been
married 11 years, and had no children; had long suffered from bearing
down of the womb, and at each menstrual epoch there was very defi-
cient excretion. Her health was generally impaired: she had long
been treated for uterine derangement, but had never allowed an
examination. On ‘consulting me, I immediately inquired if she
suffered from piles, or bearing down of the bowel; and, on her reply-
ing that she had suffered from prolapsus of the bowel for several years,
preventing her from riding on’ horseback, or sitting long in one posi-
tion, I inquired further, whether, at the menstrual epoch, there was
any bleeding from the protruding bowel. She replied that she lost
a great deal of blood at those periods, and that the parts were more
painful and sensitive then than at other times. This patient never
had an evacuation from the bowel, except from medicine, which she
took every night. I directed her to remain in the horizontal posture,
either on her side or on her abdomen; attended to her general health,
administering steel and quinine, and using the cold douche to the
uterus. Under this treatment she rapidly improved; and on finding
that after two months there was a freer menstrual discharge, I applied

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CERTAIN CONDITIONS OF THE UTERUS. 153

ligatures to the prolapsus of the bowel. The disease was permanently
cured; the patient was restored to good health, and in the course of a
few months became pregnant for the first time in her life; and I
delivered her of a healthy child at the full period of gestation.

Practical Remarks.—This case points out the importance of inves-
tigating both the uterus and rectum in such conditions of the female,
for it will be observed, that instead of the rectum alone being investi-
gated, as was done in the two preceding cases recorded, in this the
uterus alone had been treated, and the result was equally unsatisfac-
tory. I could adduce very many cases which have come under my
observation of a similar kind, where patients have been treated for
months and years for uterine disease, but no attention having been paid
to the condition of the bowel, no good has accrued. If this were the
proper place, or did space admit of it, I could show that the cause of
sterility in many females would be found to arise from these conditions
of the rectum, in connexion with those of the uterus. I need not,
therefore, enlarge upon the importance of thoroughly investigating all
such cases.

Casz XLIV.—Fissure of the Rectum.—E. P., et. 29, unmarried, of
pale complexion, and of anxious countenance, consulted me, complain-
ing of headache, great depression of spirits, lassitude, and want of
appetite. She had not menstruated for three months, arid complained
of a heavy bearing-down pain in the womb, particularly on standing,
or when lying on her back. She suffered from constipation, never
having relief from the bowels except from taking medicine. She
always dreaded the act of defxcation, because she suffered such ex-
cruciating pain a few minutes afterwards, She described the pain at
the time of defecation as like sand passing over a raw surface, and the
pain which supervened upon the action of the bowel was of a deep,
cutting nature, almost intolerable.

On passing my finger within the rectum, I immediately discovered
an irritable ulcer, in the centre of which was a narrow elongated
fissure, terminating just within the orifice of the anus. On with-
drawing my finger, I found on it a streak of blood corresponding
with the length of the fissure. On the opposite side of the bowel was
a pendulous tumour about the size of a small pea, with a long thin
pedicle. On examination per vaginam, I found a fibrous tumour
growing from the superior lip of the os uteri, extending up the cervix
about an inch, whilst the os and cervix uteri, enlarged by this body,
were tilted back upon the rectum, thereby interfering with its func-
tions. I ordered leeches to be applied twice a week to the os uteri,
prescribed tinct. ferri muriatis, and warm hip-baths. The catamenia
returned at the end of a fortnight, and continued for some days,
although scantily. I then removed the tumour from the os by ex-
cision, and as soon as she had recovered from the effects of the opera-
tion, which she did in a month, proceeded to the treatment of the
fissure in the following manner. Placing the patient on her side on

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154 DISEASES OF THE RECTUM RESULTING FROM

the edge of the bed, with her knees flexed on the abdomen, I passed
the forefinger of my left hand up to the ulcer, and directed along
it with my right hand a straight probe-pointed bistoury, beyond the
very extremity of the fissure; then turning the cutting edge towards
the sore, and securing the handle of the instrument with the thumb of
my left hand, I withdrew my finger and the instrument at the same
time, thus dividing the ulcerated surface as well as the fibres of the
sphincter muscle. The result was, as will generally be the case, per-
fectly satisfactory, the patient being at the end of three months from
the commencement of the treatment restored to health.

Practical Remarks.—I am indebted to my friend Mr. Copeland for
both the knowledge of this disease and the simple method of treat-
ment, which is almost invariably successful ; at least, out of upwards
of 100 cases which I have myself treated in twenty years, I have not
seen it fail once. Another practical fact is connected with the
pathology of these diseases. My own impression is, that the pedun-
culated tumour above described falling down upon a highly vascular
mucous surface, produces, in the first instance, irritation, secondly,
ulceration, and thirdly, fissure of the lining membrane of the bowel,
each contraction of the sphincter after defecation increasing or aggrava-
ting the ulceration. My reasons for believing this are, that I seldom
find this condition of the rectum without finding one or more of
these peculiar bodies, which I need not say should always be removed
at the time of operation. It is very easy to detect this disease by
digital examination. If the surgeon is consulted at the commence-
ment of the disease, he will simply find an irritable, ulcerated surface ;
but if consulted at a later stage, he will find the fissure, which resem-
bles very much the crack often found in the lip of the mouth, or in
the palm of the hand in cases of psoriasis ; still in whichever of these
two conditions he finds the patient, the treatment to be pursued
should be the same. I will also add, that it is always advisable to
give opium just after the operation, so as to prevent the bowels from
acting for some days.

Case XLV. Constipation—Mrs. T——. aged 38, mother of six
children ; complained of persistent constipation, except when she
was taking steel medicines ; that she suffered pain after each action
of the bowels; that much mucus came away with and after the
dejections ; that she had pain in the back, great bearing down both
of the bowel and womb, with profuse leucorrheal discharge, and that
she had lost much flesh. I found her face anxious, and of a dark dusky
hue. She suffered also from dyspepsia, headache, and general lassitude.
I requested permission to examine the uterus, believing the cause of
constipation arose therefrom ; but for a long time this lady resisted
the proposal ; however, I was at last permitted to make an examina-
tion, and found, as I expected, an enlarged and prolapsed uterus,
within two inches of the outlet of the vagina. On using the speculum,

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CERTAIN CONDITIONS OF THE UTERUS. 155

the os was seen to be inflamed, enlarged, and ulcerated. On examin-
ation per rectum, I found, three inches up, a solid, heavy body
(which was evidently the fundus of the uterus) pressing on the bowel,
so as to prevent any feculent matter passing in a solid state; the
lining membrane was covered with much slimy mucus. She stated
that she was always suffering pain in the bowel, as well as in the
womb; that the pain in the rectum was of an aching, wearying
character, making her feel faint and sick ; that the sensation of the
womb was like a heavy weight, feeling as if it would escape when
walking. I applied caustic to the os, ordered the cold douche night
and morning, with directions to recline on the stomach for several
hours ; to wear constantly during the day one of my perineal bandages,
to take internally steel, and zinc combined with extract of conium at
bed-time ; and to have the bowels relieved by an enema of warm
water every other night. Whenever she was lying on her stomach,
she was quite free from pain; after two months’ treatment, this
patient perfectly recovered ; and by the simple precaution of relieving
the bowels by an injection just before going to bed, she has continued.
well up to the present time.

Practical Remarks.—I think that any treatment, applied simply to
the bowel, for relief of the constipation, would in this case have
failed, unless the exciting cause had been found to have arisen from
the condition of the uterus. It is worthy of serious attention, that
she was perfectly free from pain both in the bowel and the womb
when reclining on the stomach. Another practical fact, worthy of
observation in this, and all the other affections of the rectum, is, that
by relieving the bowel at night immediately before retiring to rest, the
greatest’ relief is afforded; and it is the best way to prevent a
return of disease, because the natural determination of blood to
the bowel, at the time of defecation, as well as the congestion
of the mucous membrane, and the relaxation of the muscles,
are all relieved by the recumbent posture followed by sleep.

Case XLVI.—Fistula in Ano.—E. C., aged 32, married, lady’s
maid, consulted me, complaining of feeling generally ill, of pain on
her right side in the hepatic region, of indigestion, headache, and
general lassitude. She had an anxious countenance, a dusky-brown
complexion, depression of spirits, a tendency to melancholy, and felt
scarcely able to perform the duties of her situation. The following is
an account of her past history :—She had been married nine years ;
she suffered greatly from the first commencement of sexual inter-
course, having had from that period pain in the womb of a dull aching
kind, which increased more or less for twelve months. At the end
of this time, she experienced a heavy bearing-down pain, which par-
ticularly affected the rectum. She had lived apart from her husband
six or twelve months at a time, because of suffering so much pain, not
only at the time of connexion, but for some weeks afterwards. Be-

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156 DISEASES OF THE RECTUM RESULTING FROM

fore marriage, she had been healthy, active, and in robust health ;
but this gradually failed since marriage. In the third year of her
wedded life, she began to experience difficulty in defecation, as if
something prevented the bowel acting ; and was obliged to take some
aperient medicine two or three times a-week to insure relief. This
difficulty was soon followed by an aching, wearying pain in the bowel
itself when she was walking or sitting; then she became subject to
troublesome internal hemorrhoids, which were always more painful,
and occasionally bled a little at the menstrual epoch; menstruation
itself being regular as to time, but scanty in quantity. After some
time, she suffered from a throbbing, deep-seated pain in the bowel,
which terminated in a fistulous opening ; and then, for the first time,
applied to a surgeon, who operated for the fistula. During the next
three or four years she underwent two or three more operations on
the bowel, the precise nature of which she could not explain; but
although relieved at the time by each operation, still the relief was not
permanent, constipation and difficulty of defecation continuing.

Examination—On examining the anus, I discovered a fistulous
opening extending an inch up the bowel; and on passing my finger
up the rectum itself, found the uterus pressing heavily upon it. On
examination per vaginam, I felt an enlarged hypertrophied uterus,
tilted back upon the utero-vaginal septum, so as to press the rectum
flat upon the sacrum.

Treatment.—I treated the uterine affection on the principles already
described, with the same marked result. I then performed the usual
operation for fistula, and, after the parts were healed, directed her to
evacuate the bowels at night instead of the morning. The result of
the whole treatment was most satisfactory ; the patient recovered
her former good health and spirits ; and, when she lately called upon
me, I did not recognise her, she had become so stout, and looked so
cheerful and happy.

Practical Remarks.—Perhaps no case could more clearly illustrate
my preliminary remarks than this. Here was disease of the rectum:
of several years’ standing, distressing the patient, and rendering life
hardly endurable, considering the duties she had to perform ; and,
although she had the best attention paid to those diseases, and had
been relieved of each form of suffering by operation, still, the exciting
cause not having been discovered, no permanent benefit accrued from
treatment ; whereas, no sooner had the uterus been relieved, than she
was perfectly cured by the last operation, and has continued well ever
since. I could easily multiply these illustrations by quoting cases from
‘my note-book, and show that stricture, irritation of a dysenteric cha-
racter, &c., constantly arise, either from mechanical pressure of the
uterus, or from suppression, partial or entire, of the menstrual dis-
charge ; but, as the limits of this chapter will not admit of such

extension, I shall rest the proof of my preliminary propositions on the
cases now recorded.

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CERTAIN CONDITIONS OF THE UTERUS. 157

DISEASES OF THE RECTUM RESULTING FROM OTHER CONDITIONS
OF THE UTERUS AND ITS APPENDAGES,

In the preceding observations I have chiefly directed atten-
tion to the maladies of the rectum dependent on a tilting or
bending of the uterus forwards or backwards, or on the subsi-
dence of that viscus from enlargement. But it will be at once
perceived that other conditions of the uterus than those named,
may cause it to mechanically interfere with the functions of the
lower bowel. Among such may especially be noticed fibrous
tumours or polypi developed within the uterus, which will not
only drag it from its normal position, and cause its enlargement,
but also themselves act as mechanical causes of disease on the
neighbouring viscera. What fibrous tumours developed within
may do, those from the exterior of the uterus may do likewise, or
even more completely; and equally injurious with the foregoing
are the true pelvic tumours, particularly those originating in the
recto-vaginal cul-de-sac.

Another cause of suffermg in the rectum depends on the
presence of ovarian tumours, chiefly when in their early stage,
and still contained within the pelvis. This effect of cysts of the
ovary is particularly noticed in the chapter on ovarian dropsy.

Just as by the pressure of a displaced uterus, so uterine and
pelvic tumours give rise to false stricture of the rectum, some-
times to fissure and fistula, and oftener to piles. It is needless,
however, to enter into descriptions of how each morbid produc-
tion exerts its injurious effects; it will suffice my purpose to
have called attention to the frequent mutual dependence of
uterine and rectal disease; and to have shown the necessity of
bearing this in mind, when we are called upon to treat females
for any disease of the lower bowel, especially when the lesion
proves intractable. When this relation is once discovered, the
course of treatment will be obvious; every form aimed at any
local symptom will be entirely vain, whilst the fons et origo mali
remain untouched.

As the rectum behind, so the bladder in front is obnoxious

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158 DISEASES OF THE RECTUM, ETC.

to injury from its relations with the uterus. The disordered
micturition in pregnancy is well known; that in ovarian dropsy
is hereafter pointed out; whilst of that seen in displacements of
the uterus, and in the case of tumours attached to that organ
and its dependencies, the varieties are mostly described in the
descriptions of those diseases in works on surgery and mid-
wifery.

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CHAPTER XIII.

ON OVARIAN DROPSY, OR ENCYSTED DROPSY
OF THE OVARY.

Tus form of dropsy has for a long period been recognised,
and has received, especially of late years, the attentive study of
many eminent practitioners of medicine. By the majority it
has been deemed incurable, and susceptible only of palliative
treatment. Its pathology is still unsatisfactory, little having
been done to elucidate it. The history of the operations will
be given when they come severally to be described.

The disease consists in the development and progressive
growth from the ovary of one or more cysts, the lining mem-
brane of which has the property of secreting fluid in oftentimes
an almost indefinitely large quantity; where but one cyst exists,
the tumour is said to be unilocular, where several are found it
is multilocular. -

Origin and Structure of Ovarian Cysts.—Cruveilhiér;
Seymour, Paget, and others, believe the origin of the cyst or
cysts to be from one or more enlarged Graafian vesicles. Mr.
Paget* says (p. 57), “ Among the cysts formed by growth of
natural cavities or obstructed ducts, we have surpassing proli-
ferous power in the ovarian cysts from Graafian vesicles.” Dr.
Robert Lee’s account} of a dissection of an ovarian tumour,
points to the same source. In the language of others, there is
a cystic degeneration of the ovary; in which a morbid formative
power displays itself in the production of cysts, themselves

* Lectures on Tumours, 1853.
+ Clinical Reports of Ovarian and Uterine Disease, p. 23, 1853.

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160 ON OVARIAN DROPSY, OR ENCYSTED

capable of growth and of developing others. Mr. Paget* calls the
cysts, with reference to this power of development, proligerous,
and with respect to its direction (which he assumes to be
internal), endogenous.

The cysts, sacs, or cells developed i in an ovarium have three
coats—an external peritoneal, a middle fibrous, and an internal,
also fibrous, but smooth and capable of secreting, though not of
absorbing fluid. This last coat consists, according to Dr. Lee,
of two distinct membraneous layers, like the wall of a Graafian
vesicle. Dr. Hughes Bennett describest a delicate membrane,
covered. by epithelial cells, as existing on the free surface of the
internal wall. The middle coat, when sufficiently thick, may be
separated into several distinct strata.

Thus, it seems that, in most ovarian cysts, the true sac is
derived from a dilated Graafian vesicle, and in its progressive
growth involves itself with the fibrous or true coat of the ovary,
and possibly with more or less of the stroma, and over all is
covered by the peritoneum.

This applies to the true, or proliferous ovarian cysts, but another
form of compound cyst is well described by Mr. Paget, thust:—
“Tt is not unfrequent to find many small cysts formed
apparently by the coincident enlargement of separate Graafian
vesicles. These lie close, and mutually compressed; and as they
all enlarge together, and, sometimes, by wasting of their parti-
tion walls, come into communication, they may at length look
like a single many-chambered cyst, having its own proper wall
formed by the extended fibrous covering of the ovary. Many
inultilocular cysts, as they are named, are only groups of closely
packed single cysts; though, when examined in late periods of
their growth, and, especially when one of the group of cysts
enlarges much more than the rest, it may be difficult to dis-
tinguish them from some of the proligerous cysts. ef

It is in the middle tunic, as indeed its origin would indicate,
that the vessels of the sac are found. These sometimes are
small and few; at others much enlarged and numerous; they are

* Op. cit.
+ Exinburgh Medical and Surgical Journal, vol. Ixv., p. 402.
£ See op. cit., p. 22.

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OR ENCYSTED DROPSY OF THE OVARY. 161

always derived from.the proper vessels of the ovary. In thus
deriving its blood directly from the part from which it springs,
an ovarian tumour differs from an hydatid cyst; unlike which,
too, it has no such peculiarly independent existence, and no
acephalocysts in its contents. It may be here remarked that
hydatids of the ovary are very rare.

The walls of an ovarian cyst vary much in consistence and
thickness in different cases, and even in different parts of the
same sac. Also, in a mass of cysts, similar variations are often
met with in the several individual ones. An increased thicken-
ing may be due to simple hypertrophy of the tissues, but more
frequently to a morbid process established in the walls. Thus
they may become thickened and indurated throughout, or only
in parts, by inflammation, or by tubercular, or by cancerous
deposit. On the other hand, inflammation may soften and waste
them, or render their consistence friable and lacerable; or
ulceration and even gangrene may be set up, and perforation
follow; or lastly, they may undergo calcareous degeneration.
Cases have been narrated where the tunics have attained an inch
in thickness. In a tumour dissected by Mr. Stockwell*, where
dropsy had been perceived only three years, and tapping but
once resorted to, the anterior wall was one inch and a half thick ;
the posterior rather less. In one of Mr. Wilson’s cases,t two
thick bands stretched across the front of the sac, which were
found to be offsets from the broad ligament, and to contain the
several vessels. Often, on the contrary, the tumour has very
thin and flexible walls, and a whitish, shining, or glistening
appearance. The walls are, however, in all cases thicker at the
part where the cyst is attached to the ovary, whether it be so
by a pedicle, or by a broad base. The thickening of a sac
chiefly takes place in its middle wall; the peritoneal, however, is
often thickened and rendered opaque.

The lining membrane most frequently shows the result of
morbid action. This it may do by partial or by general inflam-
matory injection; by adherent flakes of lymph; by the oozing
out of pus; by a granulated or a puckered surface; by softening,

* Provincial Medical and Surgical Journal, No. 2, 1851, p. 38.
+ Tbid., p. 35, 36.
M

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162 ON OVARIAN DROPSY,

and by various coloured spots. A fibrinous exudation may
entirely line a cyst, and, as pointed out by Professor Simpson*,
become vascular, and eventually give rise to hemorrhage within
the sac. An alteration of the lining membrane generally
happens after a cyst is opened; for, as a rule, the qualities of the
fluid subsequently secreted are changed.

On the growth of a cyst, from the ovarium, the latter, in most
cases, wastes; but it will occasionally happen that its substance
or stroma undergoes hypertrophy, increasing in quantity and
hardness, and assuming a fibrous or fibro-cartilagmous consist-
ence. This has been considered by some to be a scirrhous
transformation, though any evidence of malignancy is wanting.
It may be met with at only one portion of a tumour; or,
where several sacs co-exist, it may intervene between them, and
in a slighter degree appear only as thickened septa.

According to Dr. Lee, the ganglionic nervous structures
enlarge when compound cysts are formed in the ovaries.

Formation of Multilocular or Proliferous Cysts —It is common
to find growing from the inner wall of an ovarian cyst many
smaller ones, as if by a process of internal gemmation. Dr.
Hodgkin + adopted this idea of internal cell growth, and
applied it generally to explain the formation of multilocular
ovarian tumours. In this he has been ably followed by Mr.
Paget, who defines the process as one of endogenesis, but, at
the same time, shows that the new cysts are occasionally shot
forth from the external surface,—by exogenesis, and that, as
above described, some compound tumours have no such
proliferous origin, but consist of a mere agglomeration of inde-
pendent vesicles.

“Respecting” (writes Mr. Pagett) “ the mode of generation of
the endogenous cysts, it could only be supposed that they are
derived from germs developed in the parent cyst walls, and
thence, as they grow into secondary cysts, projecting into the
parent cavity; or disparting the mid-layers of the walls and
remaining quite enclosed between them; or, more rarely,

* The Monthly Journal of Medical Science, Vol. XV., 1852, p. 526.

+ On the Morbid Anatomy of Serous Membranes.
t Op. cit. p. 60.

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OR ENCYSTED DROPSY -OF THE OVARY. 163

growing outwards and projecting into the cavity of the peri-
toneum.”

My own Sheceons tend to confirm these views of the
endogenetic formation of ovarian cysts. In many cases I have
found vesicles, of various sizes, proceeding from the lining |
membrane, and apparently quite unconnected with the external
fibrous envelopes. Dr. Robert Lee would explain the formation
of a compound tumour in another manner, as will be best
shown by quoting from his account* of the dissection of a large
cyst. He thus proceeds :—

“ Imbedded in the middle coat (of the large sac), near the
root, is another and much smaller cyst, with a lining membrane,
and likewise composed of two distinct layers. From the pre-
paration, it is seen that a thin stratum of the middle coat is
interposed between these two cysts, and that they are indepen-
dent of each other. But the smaller cyst, though not adherent
to the outer surface of the larger, has grown so as to encroach
on the cavity of the latter, the lining membrane of which the
smaller cyst has protruded before it. From this dissection it
is obvious that the smallér cyst did not grow from the inner
surface of the larger, nor from its outer surface, but that, in the
progress of deyelopment of the smaller cyst, it pushed before it
a portion of the lining membrane of the larger, and thus ac-
quired the layer of reflected membrane from the inner coat of
the larger cyst, by which it is invested.”

A similar account is given of a group of small multilocular
cysts at the base or root of the great cyst in the middle fibrous
coat, “which,” (says Dr. Lee) “ contain similar fluid, have all the
same structure, bear the same relation to one another as the
two cysts above described, and have evidently been formed
independently of each other.”

As a consequence of this dissection, Dr. Lee arrives at the
following deductions, viz., “that in some, if not all, cases of
compound or multilocular ovarian cysts, the cysts are formed
independent of each other ; that the smaller cysts do not grow
from the inner surface of the larger cysts, as has been supposed,

* Lee, op. cit. p. 22, 23.
m 2

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164 ON OVARIAN DROPSY,

but are formed in the stroma of the ovary, external to each
other, and that the smaller cysts encroach upon the cavities of
those more advanced cysts with which they are in contact,
and thus in a mechanical manner acquire reflected portions of
their membranes.”

Every pathologist will call to mind the frequency with
which small cysts, with transparent, watery contents, are met
with in the ovaries, sometimes giving those organs an appear-
ance resembling a bunch of currants. Now we can readily con-
ceive the formation, out of such a collection, of the non-proli-
ferous tumours of Paget; or in some cases of an encysted disease
like that described so well by Dr. Lee; but the latter writer en-
deavours to prove too much by his one case by urging it as decisive
against endogenous growth in all. Some forms of compound cysts,
especially where the secondary growth depends from a pedicle,
—such as that represented by Mr. Paget, at p. 60 of his work,
do not seem explicable on Dr. Lee’s hypothesis; and it must
also be remembered that endogenous cell-growth is witnessed in
other organs than the ovary.

Growth of Cysts—Multilocular ovarian disease is much more
common than unilocular. The latter may be strictly so from
the original development, or from the growth of a single cyst,
or otherwise, it may be a secondary condition, the result of the
coalescence of several cysts, to which indeed there is a natural
tendency. <A single cyst may go increasing per se to a size
equal with multilocular tumours, If secondary cells grow in its
interior, they may hang from it “ in large, lobed, warty-looking
masses, and nearly fill its cavity,”* or, springing from broader
bases tend to subdivide it, and destroy its original unilocular
character. The same effect is produced by exogenous develop-
ment from the wall of the cyst. On the other hand further inde-
pendent cysts may spring from the ovary, as represented by
Dr. Lee, and form at once a truly multilocular tumour.

Where other cysts form externally to a principal one, they fre-
quently feel like hard appended tumours, from being but partially
developed. The growth of such seems frequently to be only

* Paget, op. cit. p. 60.

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OR ENCYSTED DROPSY OF THE OVARY. 165

arrested, for on the subsidence, by tapping or otherwise, of the
large one, they will at once increase. The hardness perceptible
in some appended cysts is occasionally due to their distension
by denser fluid. The number of cysts which may form in an
ovarian tumour is almost infinite, but many will continue
small, or their. growth remain in abeyance, or several may
become large sacs together or in succession.

- Direction of Growth.—The direction of growth will be mainly
‘that of least resistance. Where several independent sacs exist
they pack themselves variously, according to their relations at
their origin, their order of development, and the direction of
least resistance to their growth. It so happens sometimes, that
the disposition of the sacs gives the impression of disease in
both ovaria, or of the transition of the dropsical effusion (after
paracentesis) from one side to the other.*

Mostly the tumours press upwards and forwards in the abdo-
men, but occasionally are felt to be most prominent in the
recto-vaginal cul-de-sac.

In consequence of the sacs enlarging in the direction of least
resistance it is, as Dr. Simpson observes,t that “we have the
largest cyst or cysts in the mass generally, if not always, placed
Jirst, at the upper or abdominal extremity of the tumour,—and,
secondly, on the anterior part of the abdominal tumour, rather
than on its lateral or posterior parts; the cyst or cysts in front
growing more readily, because they are less resisted in their
growth by the abdominal parietes in front, than the cyst or
‘cysts placed towards the sides or back of the tumour, inasmuch
as these latter are repressed by the denser fabric of the lateral
and posterior walls of the abdominal cavity. It is in conse-
quence of this pathological arrangement that, by the operation
of paracentesis abdominis, we are usually able to evacuate the
largest cyst or cysts in the mass ; and in consonance also with
the same law, the contents of such more prominent cyst or
cysts are usually far more fluid, and become more easily capable

* See case by Mr. Hunt, Lancet, Vol. L., 1846 ; and Cases 2 and 5,
published by me in the same Journal, Vol. L., 1846, p. 371 & 373.
+ “Monthly Journal of Medical Science,” Vol. XV., 1852, p. 365,

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164 ON OVARIAN DROPSY,

but are formed in the stroma of the ovary, external to each
other, and that the smaller cysts encroach upon the cavities of
those more advanced cysts with which they are in contact,
and thus in a mechanical manner acquire reflected portions of
their membranes.”

Every pathologist will call to mind the frequency with
which small cysts, with transparent, watery contents, are met
with in the ovaries, sometimes giving those organs an appear-
ance resembling a bunch of currants. Now we can readily con-
ceive the formation, out of such a collection, of the non-proli-
ferous tumours of Paget; or in some cases of an encysted disease
like that described so well by Dr. Lee; but the latter writer en-
deavours to prove too much by his one case by urging it as decisive
against endogenous growth in all. Some forms of compound cysts,
especially where the secondary growth depends from a pedicle,
—such as that represented by Mr. Paget, at p. 60 of his work,
do not seem explicable on Dr. Lee’s hypothesis; and it must
also be remembered that endogenous cell-growth is witnessed in
other organs than the ovary.

Growth of Cysts—Multilocular ovarian disease is much more
common than unilocular. The latter may be strictly so from
the original development, or from the growth of a single cyst,
or otherwise, it may be a secondary condition, the result of the
coalescence of several cysts, to which indeed there is a natural
tendency. A single cyst may go increasing per se to a size
equal with multilocular tumours. If secondary cells grow in its
interior, they may hang from it “ in large, lobed, warty-looking
masses, and nearly fill its cavity,”* or, springing from broader
bases tend to subdivide it, and destroy its original unilocular
character. The same effect is produced by exogenous develop-
ment from the wall of the cyst. On the other hand further inde-
pendent cysts may spring from the ovary, as represented by
Dr. Lee, and form at once a truly multilocular tumour.

Where other cysts form externally to a principal one, they fre-
quently feel like hard appended tumours, from being but partially
developed. The growth of such seems frequently to be only

* Paget, op. cit. p. 60.

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OR ENCYSTED DROPSY OF THE OVARY. 165

arrested, for on the subsidence, by tapping or otherwise, of the
large one, they will at once increase. The hardness perceptible
in some appended cysts is occasionally due to their distension
by denser fluid. The number of cysts which may form in an
ovarian tumour is almost infinite, but many will continue
small, or their growth remain in abeyance, or several may
‘become large sacs together or in succession.

Direction of Growth.—The direction of growth will be mainly
that of least resistance. Where several independent sacs exist
they pack themselves variously, according to their relations at
their origin, their order of development, and the direction of
least resistance to their growth. It so happens sometimes, that
the disposition of the sacs gives the impression of disease in
both ovaria, or of the transition of the dropsical effusion (after
paracentesis) from one side to the other.*

Mostly the tumours press upwards and forwards in the abdo-
men, but occasionally are felt to be most prominent in the
recto-vaginal cul-de-sac.

In consequence of the sacs enlarging in the direction of least
resistance it is, as Dr. Simpson observes,+ that “we have the
largest cyst or cysts in the mass generally, if not always, placed
_ first, at the upper or abdominal extremity of the tumour,—and,
secondly, on the anterior part of the abdominal tumour, rather
than on its lateral or posterior parts; the cyst or cysts in front
growing more readily, because they are less resisted in their
growth by the abdominal parietes in front, than the cyst or
‘cysts placed towards the sides or back of the tumour, inasmuch
as these latter are repressed by the denser fabric of the lateral
and posterior walls of the abdominal cavity. It is in conse-
quence of this pathological arrangement that, by the operation
of paracentesis abdominis, we are usually able to evacuate the
largest cyst or cysts in the mass; and in consonance also with
the same law, the contents of such more prominent cyst or
cysts are usually far more fluid, and become more easily capable

® See case by Mr. Hunt, Lancet, Vol. I., 1846 ; and Cases 2 and 5,
published by oo in the same Journal, Vol. L., 1846, p. 371 & 373.
+ “Monthly Journal of Medical Science,” Vol. XV., 1852, p. 365,

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168 ON OVARIAN DROPSY,

of albumen. Secretion of this kind is, according to my expe-
rience, the rule in unilocular cases, or in those having but few
cells, and of not long standing, and not previously punctured.
This pale liquid may also be limpid, or be mixed with more or
less mucous matter, sometimes in quantity sufficient to give it
a gelatinous or ropy consistence. At other times the cystic
fluid is coffee-coloured, or thick, as if mixed with coffee-grounds ;
and when like this, has been by some considered peculiarly
diagnostic of ovarian disease. This variety likewise will some-
times be met with in ovarian tumours when first tapped, and
may recur; but it appears oftener after the first tapping. The
peculiar colour may be assigned to the presence of altered blood.
The dark-coloured gelatinous fiuid sometimes discharged, is
most probably derived from the gangrenous softening of the in-
ternal septa of the cyst. I have met with opaque contents, of a
yellowish-white colour, which under the microscope appear to
consist almost entirely of fat-globules, and which, when allowed
to stand, form a semi-solid, greasy mass. Cysts containing
such matter seem to be accompanied in their formation by un-
usually great pain and disturbance of the system. Occasionally
I have evacuated from a cyst a black, ink-like liquid; at times
a gruel, or custard-like one; and, in some instances, a mixture
of fluid with semi-solid, brain-like matter.

After tapping, an unhealthy state of the sac is apt to ensue,
and an ichorous, or putrid, fluid escape; or purulent matter
form and discharge, with or without fetor and gases from de-
composition. But pus also occurs in unopened sacs from spon-
taneous inflammation, and also, as Dr. Bennett supposes, from
the formation of pus-corpuscles in the gelatinous contents.

A cyst, after being once evacuated, rarely again secretes
fluid of the same character as hefore. As above remarked, the
very fact of emptying the sac seems to change the character of
its secreting membrane. Even if an alteration of colour be not
met with, there is generally one in the consistence. The change
from a clear to a more or less opaque, or to a mucilaginous
liquid, is common on a second tapping. Not unfrequently the
transition is still greater, and a second emptying of a cyst
produces a coffee-coloured, or gruel-like, or a flaky discharge.

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OR ENCYSTED DROPSY OF THE OVARY. 169

The semi-solid, brain-like, and flaky substances may be com-
mingled with either variety of liquid contents.

The quantity of contained albumen varies much in the fluid
of ovarian cysts. Dr. Druitt* writes, “The contained fluid
generally contains about eighteen grams of albumen to the
ounce ;” but I have met with instances where the proportion
has been so great, that, on boiling, the fluid has set almost as
solid as white of egg. The excess of albumen I consider an
unfavourable circumstance in any case, and one calculated to
modify our prognosis and treatment, as pointed out in the
subsequent section on diagnosis.

It may be stated generally, that an increase of density in the
dropsical fluid, (associated as it is with an augmentation in the
animal and saline constituents,) whether that increase manifests
itself by a mucilaginous consistence, a more plentiful production
of flaky, or gruel, or brain-like matter, betokens a more de-
praved or morbid condition of the cyst, and indeed of the
general health, and consequently a condition less amenable to
cure. However, I am disposed to believe that, in some few
cases, such a morbid change may take place in the secreting
membrane of the cyst, from the effects of great distension or of
pressure, and of repeated paracentesis, that its secerning powers
may be to a great extent, or perhaps entirely, lost, and the cyst
consequently remain as an inert mass within the abdomen.

An instance of this nature was, I think, presented in a
case of Mr. Bryant.+ On the occasion of the third tapping, a
fluid of the consistence of gruel was evacuated, having to the
eye a near resemblance to a purulent discharge. Subsequent
to that time, the previously enormous sac remained nearly in-
active, with dimensions greatly shrunk. If this view be correct,
some prospect of benefit is attamable even in cases otherwise
desperate.

Besides albumen, chemistry reveals other constituents in
ovarian fluid, as fatty matter, cholesterine, and various alkaline
salts, chloride of sodium, sulphate of lime, and soda, &. An

* The Surgeon’s Vade Mecum, sixth edition, 1854, p. 465.
+ Lancet, Vol. II., 1849, p. 9.

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old analysis, by M. Jules Fontenelle,* detected, in eight pints of
brown and turbid fluid, 6 parts of fibrine, 97 of albumen, 34 of
congealed gelatine, a little phosphate and chloride of sodium.

Under the microscope are seen various small corpuscles, and
numerous‘large and compound cells filled with granules, together
with fat-globules and delicate plates of cholesterine. Dr. Hughes
Bennett} states that “the flocculi often floating im ovarian
fluid, are patches of epithelial membrane, more or less united
together by granular matter. Sometimes it is filamentous,
with granular cells and other products of inflammation. The
jelly-like matter, when consistent, presents all the characters of
coagulated liquor sanguinis.” In considering the diagnosis of
ovarian dropsy, I shall have again to refer to the microscopical
as well as the chemical characteristics of the fluid, and will
therefore here enter no farther on the subject.

The quantity of fluid which may accumulate in an ovarian
tumour is certainly astonishing. As much as 120, and even
140, pounds of liquid are recorded to have been withdrawn from
one sac. In a case I have described,t I drew off 93 pints
at one tapping. Moreover, it is well known that a cyst once
emptied secretes more rapidly than before. The last case
quoted shows this. The first enormous quantity removed was
the result of four years’ accumulation; but, after its discharge,
49 pints were secreted and evacuated within two months, and a
further 52 pints after the lapse of little more than three
months.

History affords many instances of this rapid and repeated
production of ovarian fluid, when paracentesis was generally the
only method of relief attempted. To quote one or two in
illustration, “ Mr. Martineau drew off nearly 500 pints in a
twelvemonth; and from the same patient upwards of 6600
pints by eighty operations, within twenty-five years.Ӥ Dr.
Copland adds, || “In a case under the care of my friend, Mr.

* Archives Générales de Médecine, Tom. IV., p. 257.

+ Edinburgh Medical and Surgical Journal, Vol. LXV., 1846, p. 40.
{ Lancet, Vol. IT., 1849, p. 9.

§ Copland, Dictionary of Practical Medicine, Vol. I. p 664.

|| Op. cit. Vol. IL. p. 928.

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Worthington, of Lowestoft, the quantity of fluid taken away by
him amounted to nearly as much as in the case detailed by
Mr. Martineau.”

In examples of this sort we must suppose the enormous bulk
of fiuid drained from the system contained little animal mat-
ter—albumen; and that the sac after being opened even re-
peatedly continued to secrete, contrary to the rule, a similar
thin, aqueous liquid.

Occasionally, actually solid tumours are produced in con-
nexion with the cysts, both internally and externally, and soft
or hard cancerous formations more rarely appear about and
between them.

“Tn rare instances,” says Dr. Copland,* “sebaceous matters,
with long hair, have been found in the same ovarium that con-
tained large dropsical cysts, and even in the same cyst with the
watery collection ; the cyst in which the hair and fatty substance
had been formed, having subsequently become the seat of drop-
sical effusion.” Another uncommon mixture is that with hydatids.

One or both ovaria may be affected: the latter circumstance,
however, is rare, at least so far as the production of large cysts
is concerned; but it is not uncommon that, where encysted
dropsy of one ovary exists, cysts in an early stage are present in
the other. The two ovaries are not equally prone to disease,
the left one being the more so.

Dropsy of the Fallopian Tubes——Besides true ovarian cysts,
springing from the substance of the ovary, other similar ones
occasionally proceed from the Fallopian tubes, or from the broad
ligaments, and may attain nearly or quite equal dimensions
with the first. Such cysts are unilocular, and more amenable to
treatment than the true ovarian form. Unfortunately, however,
sufficiently distinct signs are wanting to diagnose between the two
varieties. The contents of these non-ovarian sacs are clear when
first tapped, and have little or no albumen.

Causes of Ovarian Dropsy.—Under this head not ale can
be stated with certainty. The generally admitted predisposing
causes are—the scrofulous habit; debilitating causes in general;

* Op. cit. Vol. L p. 654.

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and excessive or too frequent menstruation. The exciting
causes are not well understood: no definite cause often can be
assigned by the patient, its onset being so gradual and insidious;
and even when its origin is attributed to some particular circum-
stance, the statement must be received with caution. Among
exciting causes are enumerated external violence, over-exertion,
venereal indulgence, mismanagement in labour or in miscarriage,
cold, checked menstruation, or leucorrhcea from any cause,
uterine irritation, or inflammation; and the operation of the
emotions, as fright, anxiety, &c.

The formation of cysts does not as a general rule occur until
the sexual functions of the ovary come into exercise at puberty;
but it may appear first after the cessation of the menses, whether
de novo, or only upon a germ of morbid action developed in
previous life, it is impossible to say.

“ Although,” says Dr. Copland, “chronic cases of it are
found in very old females, yet it rarely originates at an age
much above fifty.”

Cases are related of ovarian dropsy occurring in the 13th
and 14th year, and I have related one case* of its existence in the
15th year, and before menstruation was established; and a
second, of its appearance at puberty. Taking those cases, of
which I have the histories, ovarian disease made its appearance
in by far the majority between 21 and 40 years of age. The
average age at which the disease was discovered is about 26;
hence, so far as my collection of cases will warrant the deduc-
tion, the tendency is greatest during the period of the highest
functional activity of the ovaria; and does not arise so frequently
in further advanced or middle life, as is mostly represented by
writers. It is not uncommon among the unmarried, and the
larger number of diseased married femalest have, according to
my experience, borne no children though several years married.
But Dr. F, Churchill believes} that those who have borne children
are more obnoxious to it than the unmarried.

In aconsiderable number, ovarian disease has been ushered in

* Lancet, Feb. 19th, 1848.

+ Lancet, Vol. IT., 1849, p. 10.
{ On the Diseases of Women, 1850.

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OR ENCYSTED DROPSY OF THE OVARY. 173

soon after the birth of children; the process of parturition, or the
pregnant state, seeming to have been in some way instrumental
in developing it. With reference to this, I may remark that,
during the menstrual flow, and the periods of conception and
delivery, the ovaries are in an excited condition, and therefore
the more liable to take on diseased action under the operation
of any existing external cause; and thus a reason appears for
the observed fact, that the commencement of ovarian disease is
often traceable to such periods. Of the instances of married
ladies without children, it is a common observation, that such
persons are particularly prone to disease of the ovaries; pro-
bably from the partial and insufficient excitation of those
organs—i. e., the natural and sufficient stimulus to reproduc-
tive action may be wanting, or they may be incapable of taking
it on; in either case, the stimulus they undergo may con-
sequently serve only to kindle morbid or abnormal action. This
notion derives countenance from those examples of encysted
dropsy where the sac contains hair or other organized tissue.

It is supposed that the disease may take its rise from ovaritis;
this may be sometimes the case, but yet, as Dr. Copland
observes,* “there are numerous abjections to this view; for
even when the tenderness and pain in the region of the ovaria,
accompanying its commencement, are greatest, there is also
a frequently recurring and copious menstruation, indicating an
excited, rather than an inflamed state of these organs.”

Symptoms and Course of the Disease——The onset of ovarian
dropsy is frequently so very insidious, that the early symptoms
are unobserved by the patient, or referred to some other cause,
and it is not till the disease has unmistakeably shown itself in a
more or less advanced stage that medical aid is sought for, and
directed to its cure. Owing also to this non-recognition of the
disease at its origin, it is difficult to fix on the symptoms
peculiar to it at that period; the patient may probably remem-
ber, at some past time, having suffered pain in the region of the
ovaries and uterus, and, perhaps, tenderness on pressure, with a
feeling of fulness; or the malady may have crept on unheeded
till a visible increase of the abdomen reveals it, the patient
being unable to remember any previous definite symptoms.

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In not quite half of my cases, pain, lancinating and paroxysmal,
occurred ; but in the others it was not mentioned as present,
although the probability is, that the dropsical enlargement did
not come on without some, which might, at the time, be very
readily assigned to any other cause but the true one, and be
subsequently forgotten.

Again, it may be remarked, with respect to those instances
of the absence of pain, that more were married women, of
mature age, in whom we might consequently expect the morbid
process to proceed with less suffering than in young unmarried
women, or in those married ones in whom pregnancy or partu-
rition seems to act as a predisposing cause. And, in general,
we may assume that the pain will be in direct ratio with the
activity of the morbid process established.

I believe, therefore, we may fairly infer that, as a rule,
ovarian dropsy is ushered in by the occurrence of pain; that
this pain will be less in married females who have borne no
children than in others, and especially if they have advanced
near middle age, and the disease be slow in its progress.

In the first stage of encysted dropsy it is common to have
irregularity of the menses, a too frequent recurrence, or an ex-
cessive flow; but suppression is rare. In the after stages
menstruation is frequently continued, and even regularly so; an
exception to this must be made where the tumour is invaded by
cancerous disease.

So soon as the dropsical tumow growing from the ovary
acquires a moderate size, and is still confined within the limits
of the pelvis, it will mostly be a source of annoyance by its
pressure upon, and interference with, the functions of neigh-
bouring organs. Thus, from pressure on the bladder, irregu-
larity in the discharge of urine, and occasionally actual stoppage;
from contact with the rectum, constipation by obstruction, and
hemorrhoids; or instead of mechanical, sympathetic disorders
may afflict those organs, and be evidenced by sundry disturb-
ances of function. It is fortunate if these evils be assigned to
their true cause, for it is more likely they will be accounted
accidental, or assigned to some remote cause.

. By its progressive growth, the tumour rises out of the pelvic

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into the abdominal cavity, and in so doing stretches the Fallo-
pian tube and broad ligament. Other symptoms now become
evident, varying, however, according to the state of the patient’s
health, the nature of the tumour, the rapidity and direction of its
growth, the occurrence of inflammatory action, distending its
cells by further effusion, and attaching its walls to adjoining
tissues, or the setting up of malignant disease. As I shall
presently have to detail at much length the symptoms in con-
nexion with diagnosis, it is unnecessary to describe them here as
isolated phenomena.

It should be mentioned that impregnation may occur even
after ovarian dropsy has made considerable progress.

Course of the Disease—This differs greatly in different ex-
amples. In one of my cases, et. 15, the disease progressed to a
fatal end in eighteen months from the time of its first dis-
covery; whereas, in another, twenty years elapsed from its
appearance until active treatment was attempted. Mr. Mar-
tineau’s extraordinary case lived twenty-five years, although
tapped about eighty times.

J. P. Frank met with a case where ovarian dropsy com-
menced at 13, and yet the patient reached the age of 88 years.
Dr. Druitt says,* he “is at the present time, (1853,) attending
a lady aged about 57, of tall commanding figure, in whom an
ovarian tumour of immense size has existed for more than thirty
years.” The very reverse of this prolonged duration is conveyed
in the statement of Mr. Safford Lee,+ that he has seen a small
ovarian cyst progress so rapidly in a fortnight, as to acquire a
large size, obstruct the breathing, and severely impede the vital
functions. Dr. Frederic Bird, from a knowledge of fifty cases,
found that four died within one year from the commencement
of the abdominal enlargement, twelve within two years, twelve
within three years, ten within four years, and all the others
within ten years.

The rate of increase of a cyst is as various, and the circum-
stances of the tumour being unilocular or multilocular, appears

* Surgeon’s Vade Mecum, p. 465.
+ Lee on Tumours of the Uterus.

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176 ON OVARIAN DROPSY,

to have no direct nor constant relation with its rapidity of
growth. The fact that, after tapping, the fluid accumulates in
almost all cases much faster than before, has already been
recorded. No doubt can be entertained that, apart from the
actual activity of the ovarian disease, the state of the patient’s
health will influence very much the rapidity of secretion of
cystic fluid—i. e., the more sound, ceteris paribus, the constitu-
tion, the less the morbid exhalation of fluid. Hence the value
of those tonic remedial agents recommended in the treatment of
ovarian dropsy.

The character of the cyst, its size and quickness of develop-
ment, and other circumstances belonging to it, each and all
regulate the degree in which the health of the patient may
suffer. In general, the chief complaint before the tumour is of
very great bulk, is of its mechanical inconvenience, its weight,
the dragging from the loins, the feeling of fulness, and pain
in the back produced ; but eventually it interferes with and
oppresses the functions of various organs, some immediately
and others by sympathy, and if relief be not afforded, or be given
too late, the patient sinks. One of the most troublesome con-
comitants is irritability of the stomach, constant and exhausting
vomiting, only relievable by diminishing the swelling. The
bowels are also rendered irregular in their action ; obstruction
or local congestion may be produced by pressure; or irritation
may set up diarrhoea ; the kidneys, by the pressure, secrete less
than they ought, may suffer congestion, and become a prey to
organic disease. When the cyst presses chiefly upwards, it
interferes especially with the action of the diaphragm, causes
wregular action of the heart, and renders the breathing short
and difficult.

From these extended and injurious effects of the ovarian
tumour, the almost constant marasmus and exhaustion seen in
the last stages are explicable; as also the irritative or hectic
fever towards the close of life. Among other results of the
progress of the disease are oedema of the lower extremities,
and less frequently ascites.

Dr. Burns presents* the following sketch of the course of

* Burn’s Midwifery, p. 139.

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OR ENCYSTED DROPSY OF THE OVARY. 177

ovarian dropsy :—“In the course of the disease, the patient may
have attacks of pain in the belly, with fever, indicating inflam-
mation of part of the tumour, which may terminate in suppu-
ration and produce hectic fever; or the attack may be more
acute, causing vomiting, tenderness of the belly, and high fever,
proving fatal in a short time: or there may be severe pain
lasting for a shorter period, with or without temporary ex-
haustion, and these paroxysms may be frequently repeated. But
in many cases these acute symptoms are absent, and little dis-
tress is found until the tumour acquire a size so as to obstruct
respiration, and cause a painful sense of distension. By this
time the constitution becomes broken, and dropsical effusions
are produced. Then the abdominal coverings are sometimes so
tender that they cannot bear pressure; and the emaciated
patient, worn out with restless nights, feverishness and want of
appetite, pain and dyspneea, expires.”

There is a remarkable difference in the toleration—so to
speak, of the malady in different women. In some the func-
tional disturbances are early and excessive when the tumour is
still of no great magnitude; whilst in others, the lesser mechanical
effects of the swelling are almost alone complained of until an
extensive enlargement of the cyst—after, it may be,along period—
has occurred. Cases are recorded of tumours, with contents,
weighing from 50 to 120lbs., and even upwards; and others
where their weight has been such as to drag down the distended
abdomen to a level with the knees. This variety in tolerance
will much depend on the varied nervous impressibility of women,
although the state of the general health, the rate of the growth
of the tumour, its nature and contents, must have considerable
influence.

In place of the dropsical enlargement progressing to the
destruction of life by mechanical interference with important
functions of the thoracic and abdominal viscera, other events
may ensue. The tumour may disappear by evacuating itself
by rupture through some organ, or, as some believe, by spon-
taneous absorption. “ Dr. Baillie mentions an instance of the
spontaneous disappearance of a tumour, after it had existed
thirty years, the patient remaining subsequently in good health.”

N

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(Copland, loc. cit.) Although not a solitary example, this is,
however, a rare one. A singular instance of the progressive
wasting of an ovarian sac occurred to Mr. Norman, of Bath,*
in a patient on whom ovariotomy had been attempted, but
was not carried out on account of extensive adhesions. A
small quantity of discharge escaped from the wound, “ but too
small to admit of supposing it came from the tumour,” and
Mr. Norman observes, that to account for the very great and
progressing diminution of size must be a matter only of con-
jecture. Since the publication of the case, I have heard from
that gentleman that the woman is quite well, is married, but
has not become pregnant. In the paper quoted, Mr. Norman
also records the spontaneous disappearance of ovarian tumours
in several cases known to him and to friends ; and he seems to
regard such a termination as more common than generally
supposed. The bursting of a cyst is not uncommon, but it often
hastens on the fatal termination. The danger, nevertheless,
depends much on the outlet through which the fluid makes its
way; and this will be regulated by the seat of the previous
adhesions of the walls of the cyst, by the relative thickness of
those walls, and the changes in structure and strength that the
inflammatory process may have effected in them, and, in fine,
by the direction of least resistance. For the tendency to burst
may be determined not simply by the over-distension of the
cyst, or by mechanical pressure or injury, but also by a weaken-
ing of some part of the wall of a cyst, through a morbid pro-.
cess, or by other cause. It is not very uncommon for a sac, after
being once punctured by a trocar, to again and again empty.
itself through the same outlet, the adhesions of which are dis-
solved by the pressure of re-accumulated liquid. Such a case
I have put on record in the Lancet (Case 2, vol. i., 1849).

An ovarian cyst may empty itself into the peritoneal cavity,
into the large intestines, the bladder, or the vagina, through the
Fallopian tube (see p. 167), or externally through the abdominal
wall. The discharge into the peritoneum is, of these several
modes, the most dangerous; though, I believe, less so than
generally imagined. The peril will vary according to the

'* & Provincial Medical and Surgical Journal,” No. 1, 1851, p. 7.

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OR ENCYSTED DROPSY OF THE OVARY. 179

character of the escaped fluid; it will be the less when that
fluid is bland and non-irritating, and the greater when it is
mixed with the products of diseased action within the interior
of the cyst. Sufficiently numerous cases of recovery are known
to forbid a necessary fatal prognosis when the contents of an
ovarian cyst are effused within the peritoneum; the fluid may
be absorbed, and the peritonitis lighted up be mild and
readily subdued, and even the yet more gratifying result ensue
of the destruction of the cyst itself by obliteration. Indeed, in
the operation, hereafter detailed, of cutting out a portion of the
cyst and returning the remainder into the abdominal cavity,
the subsequent secretion of fluid and its effusion into the
peritoneal cavity are even contemplated as parts of the
procedure.

Dr. Blundell, in his lectures on midwifery, adduces an in-
stance of recovery from rupture of a cyst into the peritoneum.
Dr. Simpson, of Edinburgh, states* that he has seen several
cases, and narrates one.t+

Many examples of rupture through one of the mucous
canals are recorded. In one of my cases, published in the
Lancet (vol. i., 1849), the tumour, it would seem, ruptured in-
ternally three times ; and on the last occasion discharged its
contents through the urinary passages. Dr. Seymour mentions
one where the fluid escaped by the vagina and intestines at the
same time, and the patient recovered. Dr. Simpson gives (Joc.
cit.) the history of a patient in whom the cyst ruptured from
time to time, and emptied itself per vaginam ; and he afterwards
refers to the rare communication of the interior of an ovarian
sac through a Fallopian tube with the interior of the uterus.
Dr. Coplandt says, he saw a case “in which adhesion of the
tumour took place to the parts adjoining the puncture by which
its contents had been drawn off. The cicatrix ulcerated, and
the fluid was afterwards discharged by degrees through the
opening, and the patient recovered.”

* “The Monthly Journal of Medical Science,” vol. xv. p. 527,

et seq., 1852.
+ See some remarks by Dr. Simpson, quoted in section on tapping.
t “Medical Dictionary,” vol. i, p. 655.
nN 2

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The issue of the cystic contents through a mucous canal, or
through the external parietes, is much more favourable than
into the peritoneum, and not attended by any such immediate
danger to life. If the sac can collapse, a natural cure may
result forthwith ; if not, it may shrink, and though continuing
to secrete for some time, may ultimately wither; or, again, it
may expand with fluid as much as before, discharging it at
intervals, or almost constantly. The result will much depend
on the size and nature of the opening, as well as on the collap-
sibility of the sac, and on the exclusion or admission of air into
its interior. The destruction of a sac with dense thick walls
may likewise follow from suppuration established in them after
its evacuation.

The following case of ruptured cyst, narrated by Dr. Simpson,*
is sufficiently remarkable to justify its insertion :—“ A patient,
now aged 56, the mother of five children, and naturally of a very
robust and strong constitution, had up to the end of last year
been tapped for ovarian dropsy forty-four times by myself and
others. Latterly the paracentesis was required every few weeks,
and an enormous amount of fluid was always evacuated. I have
repeatedly seen above four gallons of fluid drawn off at a single
tapping. Last winter, this patient slipped in walking upon a
frozen path, and so violently struck the abdomen and ovarian
tumour against the ground in her fall as to rupture the cyst.
Since that time, however, no new tapping has been required.
The abdominal swelling, though still large, is considerably less
than it was at the time of the fall, and does not increase in size.
For a time the fluid of the cyst evidently escaped freely into the
cavity of the peritoneum, and was as regularly absorbed from it.
Latterly there has been apparently much less, or indeed, no per-
ceptible amount of fluid in the cavity of the peritoneum. For
several months the patient’s skin was in an almost constant state
of diaphoresis—a result which, to her, appeared the more strange,
as for years previously she had never been able to excite any
perceptible degree of perspiration. This tendency to spontaneous
diaphoresis has latterly increased. The urinary secretion was
often previously affected and greatly diminished as the ovarian
tumour enlarged. Since the fall and rupture of the cyst, the

* “ Monthly Journal of Medical Science,” vol. xv., p. 528.

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OR ENCYSTED DROPSY OF THE OVARY. 181

kidneys have continued to act very freely and uninterruptedly,
the urine secreted being now always clear and limpid.”

An extraordinary case, where death resulted from the twisting
on itself of the pedicle of an ovarian sac, is related in the
New York Journal of Medicine, for March, 1851. The twisted
pedicle appeared to have caused the fatal peritonitis. The
tumour internally was intensely congested.

The probable occasional discharge of an ovarian cyst
through the Fallopian tubes has been referred to in a preceding
page (p. 167).

Diagnosis of Ovarian Dropsy.—Encysted dropsy of the ovary
has been mistaken for pregnancy, and pregnancy for ovarian
dropsy; the latter a much more serious error, as it may lead to
fatal treatment. Ascites, tumours of the uterus, distension of the
bladder, fecal and flatulent accumulations in the intestines, and
indeed almost every kind of enlarged abdomen, have been con-
founded with ovarian disease; and, conversely, the last has been
mistaken for each and all of these conditions. Such errors have
occurred to distinguished practitioners; and it must be admitted
that the diagnosis is often as difficult as it manifestly is
important. Its importance, indeed, can scarcely be exaggerated;
for whatever be the treatment, the knowledge not only of the
existence but also of the precise nature of: the ovarian malady,
is of the utmost consequence.

Signs of Ovarian Dropsy.—The signs of ovarian dropsy may
be divided into general and special, or local. They will, however,
vary according to the stage of the disease.

General Signs.—The general are evidenced by the condition
of the patient’s health and appearance; and taken in conjunction
with a suspected abdominal enlargement, are confirmatory of its
real nature. Among such general signs in the fully developed
disease, are, emaciation about the neck and shoulders, and a
peculiar expression of countenance. The latter is more readily
appreciable to the observer than any description can make it to
the reader:—The face is elongated, thin, and rather shrivelled;
anxiety and care are strongly depicted on the features; the
angles of the nose and mouth are drawn downwards, the lips
thinned, the cheeks furrowed; the eyes are remarkably defined,
the space between the eyelids and bony margin of the orbits

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being sunken and hollow; indeed, the whole areolar adipose tissue
of the face is atrophied; the complexion is pale, but without that
peculiar leaden aspect, or sallow or parchment-like colour seen
in malignant disease. It is mostly not till late in the disease
that oedema of the extremities is noticeable, that the abdominal
veins become prominent, or that the derangement of the digestive
organs, or the decreased quantity of urime is considerable. Some-
times, indeed, edema happens at an early stage, owing to
pressure on the veins of the leg, and is, consequently, seen on
the side from which the tumour originates. It is, therefore, at
once distinguishable from that cedema having a general cause.

Negative signs are deducible from the absence of symptoms of
cardiac or of renal disease; for im ovarian dropsy there is. little
disturbance of the circulation; and it is only when distension is
yery great that respiration is much embarrassed.

Disorders of the compressed viscera, and impaired nutrition
and consequent wasting, are among the signs of advanced ovarian
disease.

As implied in the first paragraph, these general signs are
apparent mainly where the disease has so far progressed as to
exhibit itself by an abdominal enlargement; for where the
enlarged ovary has not yet emerged from the pelvis, the
symptoms, except some of a sympathetic character, are local and
special.

Of the few general signs dependent on sympathy, are,
enlarged and painful breasts, surrounded by an areola, often
secreting a milky fluid, and at times even morning sickness.

Special and Local Signs.——The special and local signs of
ovarian dropsy are to be gathered from the patient’s account,
from inspection, palpation, and percussion of the abdomen, from
change of position, and by vaginal and rectal examination.

These signs vary considerably, according as the tumour
occupies the pelvis or the abdomen; just as in the case of the
impregnated uterus. In estimating the diagnostic value of
symptoms, we must bear in mind that encysted dropsy is an
advancing disease, and that, ceteris paribus, the larger the
tumour the more difficult the diagnosis. Before attempting a

manual examination of any sort, the bowels and bladder ought
to be emptied.

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OR ENCYSTED DROPSY OF THE OVARY. 183

‘ Local Signs in Early Stage-—The cyst, while still in the pel-
vis, is attended by not a few of the symptoms of early pregnancy,
and frequently gives rise to the belief of its existence. I have
mentioned the sympathetic enlargement, pain, and secretion of
the breasts, the appearance of an areola, and the occasional
occurrence of morning sickness. The patient has besides a
feeling of weight and fulness in the pelvic cavity, and the
menses are not unfrequently suppressed, though in the majority
of cases only irregular. In the course of its growth the sac is
apt to press on the rectum, impede the passage of the feces, and
so to cause distension of the intestines above, and enlarged veins
or piles about the anus. The pressure may likewise more or less
completely close the ureters, producing dilatation above; or it
may compress the neck of the bladder, and prevent the escape of
urine; or, again, may cause some degree of displacement of the
uterus. Such symptoms may concur or otherwise be met with
separately.

But the most certain evidence of a cyst in the pelvis is to be
obtained by a vaginal and rectal examination. To effect this,
the patient should be placed on her back with the thighs flexed
on the abdomen, so as to relax the muscles, and she should be
directed not to hold her breath. The finger being introduced
into the vagina or rectum, feels an enlargement in the
iliac fossa, low down about the ovary, occupying the pouch
between the vagina and rectum. It is a still better plan
to introduce the thumb into the rectum and the middle finger
into the vagina, when an elastic tumour of a rounded figure is
felt interposed between them, and fluctuation in it may be ascer-
tained if the sac be large enough and the walls not too thick,
as in general they are not in this stage. Such a tumour is not
very painful on pressure, and not immoveable like the uon-
ovarian solid or sanguineous tumours developed in the areolar
tissue of the recto-vaginal pouch. The vagina is generally found
to be drawn upwards, and the uterus raised, or thrown back-
ward towards the rectum, or bent forwards, or pushed to one
side—the opposite to that from which the tumour springs. “ If,”
says Dr. Churchill,* “ the finger be introduced into the rectum

* On the Diseases of Wamen: 1850.

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past the tumour, we shall find the fundus uteri, and be able to
distinguish it from the enlarged ovary. This is very necessary,
or we might conclude the case to be retroversion of the womb. —
In addition, it may perhaps enable us to decide whether one or
both ovaries be diseased.”

“There are three characteristics,’ says Dr. Blundell,* “ by
which recto-vaginal dropsy of the ovary may be known; a tumour
within the cavity of the pelvis, with the vagina in front, and the
rectum posteriorly; a fluctuation more or less palpable, and an
assemblage of symptoms, more numerous in some cases, of
smaller number in others, but most of them referable to irritation,
obstruction, and compression of the viscera within the pelvis.”

It should be remembered that a hernia may descend between
the vagina and rectum, and feel like a tumour in that region;
but in the absence of symptoms of strangulation we must dis-
tinguish it from an ovarian cyst by the effects of coughing, and
of change of posture, and by being unable to pass the finger
beyond the tumour. Again, the ovary itself, though free from
cystic disease, may descend into the same space, in which case,
however, examination causes uneasiness, and pressure severe pain.

A cyst of the ovary may, owing to arrest of, or to extremely
slow development, remain in the pelvis for many months, or
even for years. In general, however, it gradually increases,
and, retaining for a time its rounded outline and unilateral posi-
tion, ascends from the pelvic to the abdominal cavity in front of
the bowels, covered by the peritoneum. Now it is that it pro-
duces the abdominal enlargement and distension, and in its
continuous growth thrusts upward the diaphragm and liver,
thereby lessening the thoracic cavity, and compresses the sto-
mach, spleen, and kidneys. Hence follows a train of new symp-
toms referable to the effects of the tumour in its new position
on the several organs it comes into relation with ; but I have at
present only to deal with those signs—special and local—
applicable to diagnosis.

Special Signs of Cyst when in Abdomen.—Inspection—When
an ovarian sac emerges from the pelvic into the abdominal

* Blundell on The Diseases of Women, p. 108.

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cavity, the enlargement is first seen about the iliac region of
one side, and as it increases, this unilateral preponderance
remains visible mostly for a very long period. Ultimately
the excessive distension of the abdominal wall, or the develop-
ment of fresh cysts towards the opposite side of the body,
obliterates this diagnostic sign of unequal enlargement on the
sides of the abdomen.

To test the disparity in size of the two sides of the abdomen,
we may moreover have recourse to actual measurement ; although
the difference is generally too slight to render this proceeding of
much value. Just as in pregnancy, the distension renders the
umbilicus prominent. We likewise see that the abdominal
veins are enlarged and apparently more numerous ; those of the
legs also are oftentimes so in bad cases, and attended by cedema.

Percussion.—The growth of the sac renders fluctuation more
distinct on percussion: the tympanitic sound of the intestines
is heard more or less on one side the tumour, and a dull sound
over the tumour, varying according to its dimensions, but having
its limits generally well defined, and only slightly modified by
change of posture. Unlike what happens in ascites, the more
complete dulness of ovarian dropsy occupies the most prominent
part of the swelling; whilst over the superior and lateral regions,
especially on the healthy side, the clear intestinal sound will be
recognised, and the want of resonance in the tumour can be
distinctly traced into the pelvis. The fluctuation is more
resistant than in ascites; and the hydrostatic lime of level,
so characteristic of the latter disease, is never found.

By palpation, the character of the wall of the cyst may be
made out, whether smooth and even, or irregular and tuberose.
The multilocular may often be distinguished from the unilocular
sac by its inferior degree of fluctuation, and better still by its
unequal surface and consistence; for mostly the additional cysts
are less developed, and so feel solid or nearly so, or they have
denser and less fluctuating contents, and are smaller. The dis-
tinction on these grounds will be more readily made where the
new cysts are developed externally to the old one, as offshoots
from it. As before mentioned also, the unilateral origin of
ovarian dropsy is more evident when the disease is unilocular.

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A vaginal or rectal examination will often discover supple-
mentary cysts, not detected from the exterior of the abdomen,
and afford us other valuable information respecting the condi-
tion and relations or adhesions of the sac. On examining per
vaginam, the uterus will be found higher up than natural, or
otherwise displaced, and the os expanded.

The uterine sound supplies another means of diagnosis; but
I will defer an account of its use to a subsequent page.

On the eruption of the tumour from the pelvis, the feeling of
weight and distension in that cavity vanishes; and as the
urethra can be no longer compressed, but the bladder is, the
impediment to the discharge of urine is replaced by incon-
tinence. The bowels continue irregular, but the rectum is less
the seat of the mischief. The sympathetic irritation of the
breasts often continues for some time.

Recapitulation—tTo recapitulate :—When with a slowly in-
creasing abdominal tumour, there are such general signs as
emaciation, sunken or contracted features; the absence of
marked cedema of the legs, of the special symptoms of ascites,
or of those organic lesions productive of it; of any notable
impairment of the patient’s activity; of any great deterioration
of the functions of life, and of the characteristic signs of preg-
nancy, we may suspect ovarian dropsy to exist. When percus-
sion reveals fluctuation, and in every change of posture the
fluid is detected at the most prominent part of the tumour,
whilst the intestinal sound is present only on one side, and the
dull sound extends into the pelvis, ovarian dropsy may be more
than suspected, it may be presumed to exist.

When in an earlier stage an examination per vaginam et
rectum discovers an elastic tumour in the recto-vaginal pouch,
loose in position, and probably distinctly fluctuating, without
the presence of the symptoms of hernia, or of the pain of a
prolapsed ovary, then we may be almost certain that it is a
dropsical ovarian cyst, and by watching, the progressive increase
of the tumour strengthens the conviction. Likewise it should
be remembered that, when there is only one cyst, the tumour is
generally more perceptible on one side the body, and its sur-
face feels more equal; but that when there is a plurality of

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eysts, the unilateral character of the tumour is liable to be lost,
the symptoms to be more or less obscured, and the fluctuation
less distinct.

Lastly, we must ever bear in mind the many deranged con-
ditions of organs and functions which may be and have been
confounded with encysted dropsy, and which I shall presently
describe seriatim.

Microscopical Diagnosis—When the existence of cystic disease _
of the ovarium has been made out, some more intimate know-
ledge of the nature and condition of the cysts it has been hoped
to gain by means of a microscopic examination of the fluid
withdrawn by tapping. Dr. J. Hughes Bennett, in a paper on
Ovarian Disease, published in the Edinburgh Medical and
Surgical Journal, (vol. lxv., 1846), expresses an opinion that such
examination is of great value, and seems disposed to rely, to a
very considerable extent, upon the indications so derived. He
thus writes: “ There can be little danger of our confounding the
fluid accompanying encysted ovarian dropsy with that found in
inflammatory or passive dropsies. In peritonitis we find primi-
tive filaments mixed with plastic or pus corpuscles, which can
never be mistaken for the large epithelial cells observed in the
fluid of ovarian dropsy. Jn accumulations of fluid caused by
diseased liver, I have not detected, when uncombined with
inflammation, any structures whatever.”

In the above remarks Dr. Bennett appears to lose sight of
the frequent occurrence of inflammatory products in ovarian
cysts, both of exudation and of pus corpuscles.

A few years ago I gave, in conjunction with my friend, Mr.
Nunn, considerable attention to this point, and am indebted to
that gentleman for the following able reswmé. In the conclusions
arrived at I entirely agree.

Mr. Nunn thus proceeds :—“ The fact that fluid withdrawn
from the cavity of the abdomen by the operation of paracentesis,
may be, in one instance, the result of transudation of the serous
part of the blood, in consequence of obstructed portal circula-
tion; in another, the product of inflammatory action of the
peritoneum ; in another, a part of the contents of an hydatid ;
and in another, the distending secretion of an ovarian cyst,

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might lead one to conceive the characteristics of each of these
different fluids would be such as would enable one to decide at
once upon the source from which each was derived; and that,
therefore, the nature of the fluid would be diagnostic of the
disease which gave rise to its production. In the present state
of our knowledge I do not think we are justified in asserting
that such is the case. What I believe to be the value of a
microscopical examination of the fluid is, that it may serve to
strengthen an opinion; but, alone, it ought not to decide one.
As an illustration of what I mean, I would instance a somewhat
analogous example: the presence of the prismatic crystals of
the triple phosphate in the urine indicates the existence of a
morbid condition, that may be either a local disease or a general
disorder ; a knowledge of the other symptoms is required before
it can be determined which of the two maladies is present; to
be in possession of the fact of there being that peculiar deposit
in the urine is, notwithstanding, of great importance.

“We must take into consideration these two points :—

“ First. What does the microscope reveal that is peculiar in
fluid of an ovarian cyst?

“Second. What are the fallacies to which a diagnosis, founded
upon a microscopic examination of the fluid, is obnoxious ?

“In respect of the first of these questions, I am inclined to
say, as the result of many examinations of different specimens
of ovarian fluid, that the most constant characteristic of such
fluid is its containing, in greater or less abundance, cells gorged
with granules ; and, in addition, circumambient granules having
the same measurements as those encompassed by the cell wall.
At one time I considered the size of these granules (if they can
properly be so called) was constant ; but subsequent observations
have convinced me of the incorrectness of this conclusion—the
sizeof the gorged cells and of the granules varies greatly even
in the fluids from different cysts of the same ovary.

“Tt would be foreign to the subject to enter into a descrip-
tion of all the occasional contents of ovarian cysts; and I there-
fore only refer the reader to the annexed engraving, which will
in some measure illustrate the idea I wish to convey respecting
the gorged cells and granules.

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Fic. 14.
2%

0,

A B A B

A, In both figures represents the gorged cells.
B, Similarly the granules.

“Tn Fig. 14 it will be seen that both the cells and the granules
are formed on a much smaller scale than in Fig. 13.

“These drawings.were made from specimens obtained from a
multilocular encysted ovary, taken from a subject sent to the
dissecting-rooms of Middlesex Hospital. The fluids of the
different cysts were carefully kept distinct.

“ With regard to the second question, I would urge, in the
first place, that the phenomena of cell growth are at best but
imperfectly investigated, especially as bearing upon the physio-
logy of cells which owe their existence to a morbid action;
and that besides this, under certain circumstances, the ovarian
- fluid may not be contained within a cyst, as, for instance,
where the cyst has been at some time or other ruptured, but
may be mingled with peritonitic effusion, or the ordinary fluid
of ascites; and, moreover, we must recollect that lymph and
pus are not uncommonly found within an ovarian cyst.”

Exploring Needles—Dr. Simpson has suggested, as further
aids to diagnosis, the use of the uterme sound, and of the
exploring needle. The latter is nothing more than a very
slender silver trocar, with appropriate canula. The trocar is
tipped with a very short steel point ; and the tube of the canula
is open at one side for nearly an inch from its extremity, so as to
admit more easily of the escape, through the canal of the tube,
of any fluid in which its point may be placed.* Sometimes the
application of an exhausting syringe to the outer end of the
instrument is desirable, in order to produce the flow along its
tube of any more viscid fluid. Dr. Simpson introduces these
exploring needles to determine the solid or cystic character of a

* These exploring needles are represented in Vol. X., p. 197, of
the “Monthly Journal of Medical Science,” 1850.

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tumour, and by withdrawing fluid where present, to obtain
diagnostic signs by the microscope.

Of the advisability and utility of such an exploring instru-
ment I am convinced, and have frequent recourse to its use.
Indeed, I think it should be invariably employed before
attempting any further operative procedure.

Diagnostic Value of the Uterine Sound—Dr. Simpson pro-
posed the use of the uterine sound in 1843,* and its applica-
bility in the diagnosis of pelvic tumours has been acknowledged
by various eminent practitioners.

T have found this instrument especially useful in deciding the
diagnosis between fibrous tumours of the uterus and ovarian
dropsy ; a matter of much importance, and frequently of great
difficulty. I should be sorry to encourage an indiscriminate
use of the sound in uterine disease; for it will be but seldom
wanted to distinguish between most maladies, and as injury
may be easily inflicted by it, its introduction should be made
with great care.

In the excellent essay referred to, Dr. Simpson has chiefly
pointed out the utility of the sound, or bougie, in distinguishing
a uterine from a non-uterme tumour. He thus proceeds :—
“In other instances, where the tumour is not uterine, we have
repeatedly made ourselves and others certain of the fact, by first
introducing the bougie, and so far giving us at once a know-
ledge of the exact position of the uterus, and a control over its
movements, and then proceeding in one of three ways.—l. The
uterus may be retained in its situation with the bougie,
and then, by the assistance of the hand above the pubis, or by
some fingers in the vagina, the tumour, if unattached to the
uterme tissues, may be moved away from the fixed uterus.
2. The tumour being left in its situation, it may be possible to
move away the uterus from it to such a degree as to show them
to be unconnected. Or, 3. Instead of keeping the uterus fixed,
and moving the tumour, or fixing the tumour and moving the
uterus, both may be moved simultaneously ; the uterus by the
bougie, and the tumour by the hand or fingers, to opposite sides

* See his paper on its employment in Diagnosis in the London and
Edinburgh Monthly Journal for 1843, pp. 701 and 712. -

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of the pelvis, to such an extent as to give still more conclusive
evidence of the same fact.”

_ Again, as the same writer observes, the ovary normally lies
behind the uterus, being attached to the posterior surface of the
broad ligament ; hence an ovarian tumour will occupy a similar
position. Accordingly, if the sound show a tumour in front of
the uterus, the disease is certainly not ovarian.

For further valuable hints as to the varied applicability of
the sound in diagnosis, I must refer to the original paper from
which I have quoted the above remarks.

As Dr. Hughes Bennett observes,* “In cases of ovarian
dropsy the information thus arrived at is negative; but this
becomes of immense importance when the question arises, (as it
always does,) is the tumour uterine or ovarian ?”

Further on, when alluding to a particular case, he says, “ By
pushing the uterus from side to side, we are enabled to act
upon the ovaries, and to determine by the impulses communi-
cated to the hand, whether the tumour be on. the right or left
side, and to form a tolerable idea, in certain cases, whether it
be free or unattached.”

The use of the sound is applicable in every stage of encysted
dropsy, but with more advantage in the earlier.

Diagnosis of Adhesions—Having discovered ovarian dropsy,
the question of treatment will be further elucidated by ascer-
taining, if possible, whether the tumour grows free from a
single pedicle, or is attached by adhesions to the peritoneum
or to neighbouring viscera. To determine this, the patient
should lie in the horizontal posture, with the thighs flexed, so
as to relax the abdominal wall. The endeavour to move the
cyst from side to side is first to be made; and if this can be
easily done, it proves the absence of adhesions; next, the hand
being placed firmly on the relaxed parietes, if these are readily
moved over the walls of the cyst, there are no adhesions, at
least on the upper and lateral surfaces. Lastly, a third argu-
ment against the presence of adhesions is deducible when the
abdominal parietes, which are thin in this disease, can be

* Edinburgh Medical and Surgical Journal, 1846, p. 404.

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grasped and puckered up, and so moved over the cyst; and
when they can be gathered up readily without raising the cyst.
If these three indications are met with, we may determine there
are no adhesions.

Another plan, for which I am indebted to my colleague, Dr.
Sibson, is based on the extent to which the contents of the
abdomen are forced downwards during a deep inspiration, by
the descent of the diaphragm. If there be no adhesions in
front, the upper boundary of the ovarian tumour descends to
the extent of an inch during a deep inspiration, the space pre-
viously occupied by the tumour being now taken up by the
intestines ; consequently, if percussion be made over the upper
part of the tumour, during ordinary respiration, a dull sound is
elicited; but when the patient takes a deep inspiration, an
intestinal resonance is there perceptible.

Malignant Disease of the Ovaria.—It is not my intention to
enter into a description of this condition, except so far as it
bears on diagnosis.

Malignant or cancerous disease of the ovary is not so com-
mon as was formerly supposed, when dense fibrous, and some
forms of cystic growth were set down as cancerous. Indeed,
our more intimate knowledge of the pathology of cancer shows
that the ovary is comparatively but rarely invaded by it.

The cerebriform, scirrhous, and gelatiniform varieties have
been met with. Cruveilhier, in his Pathological Anatomy,
describes an areolar, or gelatiniform ovarian cyst, in which the
tissue of the ovarium is divided into cells or areole, and comes
to exactly resemble the areolate, or gelatiniform cancer of the
stomach.

Cancerous deposit takes place in the walls of the cysts, or in
tissue intervening between; or appears as an independent
growth from the ovary. The walls of cancerous ovarian cysts
are thick, but unevenly so at different parts, and irregular on
their surface. The same also is true of the false cysts, which
sometimes hollow themselves out in the centre of a cancerous
mass, whether that be scirrhous, fungoid, or encephaloid.

When an ovary is attacked by malignant disease, the increase
of the tumour is more rapid, the pain attending it much greater,

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often lancinating, the constitution is much more grievously
affected, the health and strength quickly destroyed, the func-
tions of the stomach and nutrition seriously impaired; the
system is altogether cachectic, and the complexion sallow. At
the same time, enlargement of the abdominal glands, the evi-
dence of cancer in other parts, the unevenness of the abdominal
tumour, and, from the thickness and density of its walls, the
indistinct or imperceptible fluctuation, afford further evidence of
the dreadful disease with which we have to deal.

The concurrence of most or all of the above symptoms ren-
ders cancerous ovarian disease not difficult to diagnose. The
prognosis is necessarily unfavourable ; and no treatment, except
that to relieve present suffering, is justifiable. Tapping, and
all active and depressing remedies, must be eschewed. Ina
case related before the Medical Society of London, in 1850, by
Mr. Nunn, the disease attacked both ovaries, and the female,
aged 62, died after several copious discharges of blood from the
rectum. “The right ovary presented the greatest evidence of
malignancy : the left contained within it several cysts; the fluid
in each of these cysts differed in its appearance from that in the
others. The gorged cells, which are said to be proper to
ovarian fluid, were found in all in greater or less abundance.
The right ovary was situated higher in the pelvis, and was the
most plentifully supplied with blood. The spermatic artery,
entering its upper part, was excessively tortuous. In addition
to this, branches from the right colic, superior and middle
hemorrhoidal, epigastric, internal iliac, and uterine arteries,
also assisted to feed the tumour; the ureter was involved in the
pedicle of this ovary. The uterus was dragged from the centre
to the side of the pelvis; and was so placed, that its long axis
was directed transversely. It presented, on being laid open, no
marks of disease, although malformed by being divided into an
upper and lower compartment. The os uteri was perfectly
healthy, and had the appearance of belonging to a virgin uterus.
The vagina and bladder were quite sound ; the rectum about an
inch and a half from its lower termination was perforated by a
circular opening, large enough to admit three fingers; other-
wise this viscus was healthy. The aperture formed the means

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of communication between the rectum and a highly vascular
cancerous lump, situated in front of the rectum, and behind the
vagina and uterus. This mass, if it originated in either of the
organs referred to, must have occurred in the outer covering,
since the mucous lining of all was, with the exception of the
aperture mentioned, as sound as it is ever found in persons of
advanced age. The cecum was thrown from its seat in the
right iliac fossa into the middle of: the belly, not by being
displaced by the enlarged ovary, but by means of the tension
of the peritoneum. Cancerous deposit was found in the breast,
and in several other organs.”

I have had several cases of malignant ovarian disease under
my own care; two such were patients in St. Mary’s Hospital,
in whom the cancerous disease enveloped both uterus and
intestines, as well as the diseased ovary. .

I will just observe, in passing, that the ovary is sometimes
the seat of the so-called cancroid disease, which has been defined
and fully described by Professor Hughes Bennett in his “ Treatise
on Cancerous and Cancroid Growths.”

Diseases liable to be mistaken for Ovarian Dropsy.—The im-
portance of a right diagnosis, the difficulty in arriving at one,
and the ease with which an error may be made, will be my
apology for dwelling more at length on this point than other-
wise might be necessary. The principal diseases liable to be
mistaken for dropsy of the ovary are,—

. Retroversion and retroflexion of the uterus.
. Tumours of the uterus: a, solid; 4, fibro-cystic.
. Ascites.

Pregnancy.

Pregnancy, complicated with ovarian dropsy.
Cystic tumours of the abdomen.
. Distended bladder.
. Accumulation of gas in the intestines.
. Accumulation of feces in the intestines.
10. Enlargement of the liver, spleen, or kidney, or tumours
connected with these viscera.
11. Recto-vaginal hernia, and displacement of the ovary.

CONAMARWWH

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12. Pelvic abscess.

13. Retention of the menstrual fluid from imperforate hymen.
14, Hydrometra.

1. Retroversion of the Uterus may be confounded with the
early stage of ovarian dropsy, when the tumour is situated in
the pelvic cavity between the rectum and vagina; but a careful
examination of the uterus will decide the point. In retrover-
sion the os uteri is thrown forwards and upwards, the womb is
immovable, the pain is urgent and distressing, and the bladder
is generally distended. Not so in ovarian dropsy.

Retroflexion of the uterus, which has been well described by
Dr. Rigby, more closely resembles ovarian dropsy; but, on
examination by the uterine sound, the displacement is reco-
gnisable ; and, by careful manipulation, the fundus of the uterus
can be restored to its natural position.

2. Tumours of the Uterus.—a. Solid Tumours, particularly
those with distinct peduncles, may at first be mistaken for ovarian
dropsy : but a careful examination, first of the uterus itself, and
then of the tumour, in which there will be detected neither
elasticity nor fluctuation, will mostly soon determine the point.
Still the difficulties of diagnosis are often very considerable, as
is illustrated by the many recorded cases of error, where the
solid character of the tumour has not been discovered until the
abdomen has been laid open with the intent of performing
ovariotomy. An instructive case of this sort has been pub-
lished by Dr. Myrtle,* who has likewise collected notes of
several similar instances.

This case of Dr. Myrtle was operated on twenty-five years
before death occurred by apoplexy. The operation was under-
taken by Mr. Lizars, and an account of it published} by him.
He states that, on opening the peritoneum, “a multiplicity of
convoluted vessels presented themselves, of various magnitude,

* Monthly Journal of Medical Science, Vol. XIL, 1851, p. 229.

+ Observations on Extraction of Diseased Ovaria, pp. 19, 20, (1825).
In this work is another case recorded by Mr. Lizars, where supposed
ovarian disease depended on a fibro-vascular tumour growing from the
fundus uteri.

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from the thickness of a finger to that of a crow’s quill... ...
On minute examination, they were found to be the blood-vessels
of the omentum majus, enormously enlarged, running on the
surface and into the substance of the tumour, which appeared
an enlarged ovarium.” The idea of extirpation was abandoned ;
but Mr. Lizars both punctured and made an incision into the
tumour, which proved to be solid and cartilaginous: it bled but
little. It was not till the autopsy proved the contrary, that
the belief in the ovarian origin of this tumour was subverted.
Much ascites co-existed with it, “and the difficulty of diagnosis
was to no small degree increased, on account of the peculiar
effect of the very strong adhesions, dividing, as it were, the
abdomen into something like two cavities longitudinally, the
firm fibrous tumour being in the centre.’ Both ovaries were
found healthy, and in their natural position; the tumour was
attached to the fundus uteri by a pedicle between two and three
inches long, formed by a fold of peritoneum. “The uterus was
so atrophied as to make but a slight inequality in the appear-
ance of the vagina and pedicle, and could be but little distin-
guished by the touch, as they were much of the same breadth
and thickness, and ran quite in the same mesial line.”

6. Fibro-cystic Uterine Tumours.—The diagnosis between these
very rare tumours and encysted ovarian disease, must be more
difficult than in the case of solid tumours. Indeed, I know of
no distinguishing marks between the two. The uncertainty
which must exist is illustrated by a case published by Mr.
Hewett, of St. George’s Hospital, in the London Journal of
Medicine, for July, 1850:—An unmarried female, et. 47, was
admitted into St. George’s Hospital, under the care of Dr. Wilson,
with great swelling and distension of the abdomen. The symp-
toms, which had existed about twelve months, had been at first
confined to the left iliac fossa, but had subsequently spread over
the greater part of the belly. Fluctuation was very evident in
various regions, and the disease presented all the characters of
ovarian dropsy. Cidema of the legs was present, as well as pain
in the region of the heart, and difficulty of breathing in going
upstairs. The general health had not been much affected, but

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of late she had lost flesh. The catamenia had been absent for
the last six months ; the urine was scanty and highly acid. She
was put on diuretics and good diet. After five days it was
found she had decreased two inches in circumference round
the abdomen, and that there was also much less swelling of the
feet. Under this plan of treatment she at first contrived to
improve slightly ; but the symptoms and consequent distress
having subsequently increased, Mr. Hawkins tapped the abdo-
men, and drew off fifteen pints of thick fluid, of a reddish colour,
and mixed, towards the last, with blood and some flakes of
lymph. After the operation, it was observed that the decrease
in size had occurred principally on the left side, and two masses
of solid substance were detected, which appeared to form part of
a tumour, rising from the pelvis. The operation was at first
followed by marked relief; but two days afterwards, symptoms
of low peritonitis appeared, and the patient died on the eighth
day after being tapped.
Examination of the body, eighteen hours after death.—The
cavity of the peritoneum contained a large quantity of dark-
coloured fluid, mixed with flakes of recently effused lymph, which
served to glue together the convolutions of the intestines. In
its lower two-thirds the abdomen was occupied by a large
tumour, which, rising out of the pelvis, had displaced the intes-
tines, and become attached by slight adhesions to the anterior
wall of the belly. The upper part of this tumour was composed
of large membranous-looking cysts, with thin walls, the interior
of which was inflamed, and filled with a quantity of thick, dark-
coloured fluid. It was one of these cysts which had been
tapped during life. Towards its lower part the tumour was
principally formed of a more solid substance, and filled with an
enormous number of cysts, varying in size from that of a pin’s
head to that of a large orange. These cysts, which are all
lined with a thin, smooth, delicate-looking membrane, were
filled with clear fluid, containing a large quantity of albumen.
The diseased mass was, at first, thought to be connected with
one of the ovaries; but both these organs were found to be
lying behind it, and quite healthy. On further inspection the

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tumour was traced to the right side of the fundus of the uterus,
to which part it was connected by means of a pedicle, two
inches in breadth, and an inch and a half in length, formed by
the fibres of the uterus, which were trained upwards some dis-
tance and then lost. Among these fibres were several vessels
of large size. Here and there, in the lower part of the tumour,
were scattered some spots of fibrous tissue, hard, dense, and
without any cysts. In the body of the uterus, deeply im-
bedded in its structure, there was a common fibrous tumour, the
size of a bean. There was no affection whatever of any of the
glands. The other viscera of the abdomen and thorax healthy.

_ 8. Ascites—may be, and is, more frequently mistaken for en-
cysted disease of the ovary; and, in truth, when the abdomen
is excessively distended, the history of the case is more to be
depended on than percussion and manual examination. Ascites
is usually the result of chronic peritonitis, of cardiac, hepatic,
or renal disease, and its appearance has been preceded by the
symptoms of such disease, and by much bodily ailment ; whereas
ovarian dropsy generally commences with only a little dis-
turbance in the pelvic viscera, the patient being otherwise
healthy. Moreover, in cardiac and renal dropsy there is not
ascites alone, but also anasarca; and we also derive additional
distinctions between dropsy of the ovary and any other about
the abdomen by negative evidence,—by the absence of the
peculiar and well-understood general signs of organic disease
of the heart, liver, or kidneys; by the inefficacy of drastic pur-
gatives, and of dinretics to produce any comparative diminution
of the tumour.

Sometimes there is a complication of the ovarian dropsy with
peritoneal effusion, when the ovarian cyst can generally be
detected floating in the surrounding liquid, and its attachment
to one or other ovary may be made out. An effusion of this
sort may be the consequence of the friction or irritation of the
ovarian sac against the peritoneum, causing chronic peritonitis.

In the early stages, percussion considerately used will deter-
mine the diagnosis. Want of resonance in the lowest part in all
positions, with tympanitic sound on the highest level in all
positions, indicates ascites. Manipulation also discovers a cir-

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cumscribed elastic tumour in the former malady, and a diffused
fluctuation in the latter, in which, too, the enlargement is more
equable in character, and uot harder at one point than another.
However, in the late stages of ovarian dropsy, when the belly
is enormously distended, fluctuation becomes more diffused, like
that in ascites, and the uneven and limited wall of the cyst may
not be discoverable.

4. Pregnancy is not unfrequently confounded with ovarian
dropsy ; that this should happen is not so surprising when it is
remembered that the commencement of the ovarian disease
sometimes affects many of the earlier symptoms of pregnancy,
(see p. 181), although the history of the case, its duration and
course, and a careful examination of the uterus—stethoscopic
and manual—will dispel the error. Stethoscopic signs will not
be available where the child is dead, and they may even lead us
into error; for in an ovarian tumour, besides veins meandering
over it, “arteries,” (says Dr. Churchill,)* “may also be felt
pulsating sometimes ; and in one such case I observed a distinct
‘bruit de soufflet,’ like the placental ‘souffle.’ when the foetal
heart is heard, all doubt will be dissipated. Manual examina-
tion will detect the well-known state of the os and cervix uteri,
if there be pregnancy, and by ‘ ballottement’ we may assure our-
selves of the presence of a foetus; whilst externally, the move-
ments of the child may be felt. Fluctuation in the tumour
will generally be an indication of an ovarian cyst; but, at the
same time, it must be remembered that, owing to dropsy of the
amnion, fluctuation may be perceptible in the enlargement of
pregnancy.”

The danger of confounding ovarian dropsy with pregnancy
cannot exist in cases of a standing much beyond the usual
period of gestation ; except, indeed, in those very rare instances
of extra-uterine foetation where the embryo has become encysted.
An interesting case of ovarian pregnancy of twelve years’ dura-
tion, with a perfectly mature foetus, is related in the Monthly
Journal of Medical Science, vol. xiii., 1851, p. 478.

A case lately came under my notice, where pregnancy had been

* Op. cit.

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presumed by more than one medical man; but the patient,
finding herself not to increase in size, whilst various constitu-
tional symptoms multiplied, consulted me, when, using a uterine
sound, I concluded she was not pregnant, but suffered from an
enlarged ovarian cyst, with thick cheesy contents, a diagnosis
which subsequent tapping confirmed. I was suddenly sum-
moned to another patient supposed to have ovarian dropsy, but
found her on my arrival in premature labour at the fifth month.

5. Pregnancy complicated with Ovarian Dropsy.—This is
perhaps the most difficult of all to distinguish and determine.
By the usual methods of examination we may detect pregnancy,
but easily overlook the ovarian dropsy, unless this has been dis-
covered prior to conception. It is therefore very necessary to
learn the history of the patient, where there is unusual disten-
sion of the abdomen beyond that common during child-bearing.
Even if a dropsical swelling be recognised in addition to that of
pregnancy, it is not unlikely to be supposed ascitic in character ;
however, in ascites, the fluid will collect, or may be made by
position to do so, in front of the uterus, whereas in encysted
dropsy the tumour rises behind the uterus, and no change of
posture will cause any of its fluid to appear anterior to it. In
general, moreover, the uterus will be elevated by the cyst, and
its mouth pushed beyond the reach of the finger. When the
ovarian cyst is still in the pelvis, examination per vaginam et
rectum, will make known the presence of two tumours. Under
such circumstances the suffering from compression in the pelvis
is likely to be very great.

In the complication in question, it is the determination of
the existence of pregnancy which is of paramount importance.
If this be made ont, further proceedings will have to be regu-
lated by the period to which gestation has advanced, by the
size and relations of the tumour, and by its possible effects. on
the process of parturition. It is not my business, however, to
enter into the indications of management of delivery under such
circumstances of difficulty.

T have met with three cases of this rare complication. In
one, the lady was pregnant with her second child. I found her

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generally ill and weak, complaining of the enormous size of her
abdomen, and satisfied in her own mind that she should have
twins. At the proper period labour came on, and the child was
born without difficulty ; but on placing my hand externally, to
grasp the uterus, I could not feel it, for the pelvis was filled by
a white, soft, elastic tumour, and the uterus had ascended out
of the pelvic cavity, and was above this tumour, which I reco-
gnised to be an ovarian cyst. On endeavouring to reach the
uterus, to remove the placenta, and on pressing my other hand
externally over the uterus, I felt the tumour suddenly rupture,
and discharge its clear, amber-coloured fluid down the side of
my arm. The uterus now descended, the placenta was removed,
and a very tight bandage applied, and kept on for several weeks.
At a subsequent confinement not a vestige of this tumour could
be felt. In the second case, I pronounced my opinion to be,
that there was ovarian dropsy, independently of pregnancy.
This patient was safely delivered of a full-grown child, and sub-
sequently I tapped the cyst, removed sixteen pints of fluid, and
applied tight bandaging. In the third case, the patient was
delivered in the country, and came to me directly after her
confinement. Tapping and pressure were resorted to suc-
~ cessfully.

6. Cystic Tumours of the Abdomen.—Such are occasionally
developed in the sac of the peritoneum, or external to it in the
abdominal wall; or still more rarely in the omentum, the
mesentery, or from the kidney or liver. Such cysts are some-
times the result of hydatids. But whatever their nature, they
are frequently distinguishable with difficulty, or even not at all,
from ovarian cysts; those from the liver and kidney are the
most likely to be confounded with them. In seeking a diagnosis
where the tumour is of great size, we must rely chiefly on the
history of the case. We must learn at what point the swelling
first showed itself; what function has been most disordered ;
where pain has been the greatest.

The production of cysts from the kidney or liver is neces-
sarily attended by much disordered function, and by greater
bodily suffering than most forms of ovarian dropsy, whilst the

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site of the first signs of disease is quite different. Cysts of the
omentum and mesentery are very rare, and those of the peri-
toneum and abdominal wall hardly less so; in the two former,
more functional disturbance may be expected ; in the latter, the
resemblance to ovarian cysts is even closer, there is little con-
stitutional disorder, and, as in dropsy of the ovary, the swelling
is not uniform, and fluctuation not so diffuse and evident as in
ascites; it may be that in extra-peritoneal dropsy, the promi-
nence of the tumour is greater in front than in the ovarian
form.

Dr. Simpson described,* before the Medico-Chirurgical
Society of Edinburgh, an example of hydatids occurring in the
peritoneal cavity, and external to a large ovarian cyst. “ Their
origin was traceable to the peritoneal basement membrane, from
which they sprung; and in their course of growth they probably
projected into the cavity of the peritoneum, and subsequently
became detached.” The patient had previously been tapped
without the escape of any such fluid; the distension of the
abdomen was greater than Dr. Simpson had ever before seen ;
fluctuation was present, more particularly in the middle of the
swelling. It is very doubtful if an ovarian sac could be dis-
covered under such circumstances; and it must be confessed
that our diagnosis will be at best vague in most cases of cystic
abdominal tumours.

Mr. Harvey related a case of great interest at the London
Medical Society, of supposed ovarian dropsy. Ovariotomy was
determined on but not executed, and when the patient died, the
disease was found to be an hydatid cyst connected with the
liver, no ovarian disease whatever existing.

The following occurred to Dr. Buckner, of the United
States.t “The case having been diagnosed as ovarian, and
operation decided on, an incision nine inches long was carried
from umbilicus to pubes ; the tumour was then found to be not

* See Abstract in the Association Medical Journal, Feb. 10th, 1854,
p. 137.

+ Medico-Chirurgical Review, Jan. 1853, p. 293. The case quoted
from The American Journal of Medical Science, Oct. 1852.

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ovarian, but situated in the mesentery, between the lamine of
the peritoneum, and surrounded by small intestine. The ope-
ration was proceeded with, the tumour dissected out, and the
superior mesenteric artery, and other small arteries tied. The
patient recovered, and in spite of the great separation of the
mesentery from the intestine, no apparent bad consequence of
any kind ensued.” This is certainly the most hazardous feat of
operative proceeding I am acquainted with, in which our Trans-
atlantic brother has certainly gone a-head.

7. A distended Urinary Bladder has been mistaken for an
ovarian cyst. I once saw a case of this kind in a young un-
married lady, et. 23, from the country. She stated that she
had been under treatment for fonr months, for “ falling down
of the uterus,” but that during the last month she had become
very much enlarged in the body, and that her medical attendant
thought she was suffering from ovarian dropsy. I could feel a
round, smooth tumour the size of a foetal head, rising up from
the pubic region, with distinct fluctuation. She told me she
had passed but very little urine for some weeks, and then only in
very small quantities at a time. On examination per vaginam, I
discovered a retroverted uterus, the os and cervix pressing firmly
against the neck of the bladder. On replacing the uterus by
the uterine sound, and pressing on the tumour through the
abdominal wall, urine escaped through the urethra; I then
introduced a catheter, and drew off seven pints of dark, offen-
sive urine, and the tumour at once disappeared.

8. Accumulation of Air in the Intestines, especially if there
has been chronic peritonitis leaving some ascitic fluid, may be
mistaken for encysted dropsy. Such a case came under my
notice some time ago, when my diagnosis was verified by a post-
mortem examination. Mostly tympanitis is unmistakable.
Angesthesia by chloroform has decided the diagnosis at times.

9. Accumulation of Feces in the Intestines is another condi-
tion which has been mistaken for ovarian dropsy. I once saw
a case of simple encysted ovarian dropsy, which, in its earliest
stage, was considered by a very distinguished surgeon in London
to be an accumulation of feces. The case was treated by
tapping and pressure, and the result was a permanent cure.

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10. Enlargement of the Viscera of the Abdomen, especially of
the liver, the spleen, or kidney. I could illustrate this subject
by mentioning some curious cases of error in diagnosis, in con-
nexion with each of these organs, but I shall merely mention,
that in these cases we generally have severe constitutional
symptoms pointing out the nature of the disease. (See also
remarks on cystic tumours, p. 201.)

The excessive production of fat in the omentum and abdominal
parietes, has been confounded with encysted dropsy; such a case
is mentioned in Mr. Lizars’ work.*.

11. Recto-vaginal Hernia and Displacement of the Ovary
into the recto-vaginal space. The mode of diagnosing these
conditions of the parts has already been discussed. (See p. 184.)
Tumours also confined to that space—the retro-uterine of some
authorst,—may be distinguished from ovarian by the differential
signs already mentioned (p. 184.) of the latter.

12. Pelvic and Psoas Abscess may generally be detected
without difficulty, by reference to the past history of the case as
compared with the present condition of the patient’s health.
They generally occur in persons of a strumous habit, but may
be the result of injury or of accident, and are preceded by con-
siderable constitutional disturbance, the result of inflammatory
fever. A rapid pulse and a hot skin, loss of appetite, diminished
secretions, and one or more distinct rigors, are among the
general symptoms. The local signs are indistinct fluctuation,
throbbing, and especially great tenderness and intolerance of
manipulation.

13. Retention of the Menstrual Fluid from Imperforate
Hymen.—Mzv. B. Travers, jun., relates{ a case of this kind, which
was mistaken for ovarian disease. A young girl was admitted
into St. Thomas’s Hospital, under the care of the late Dr.

* Lizars, J., Observations on Extraction of Diseased Ovaria, Edin-
burgh, 1825.
+ See Union Médicale for May 31st, 1851, for M. Huguier’s
Observations. Also Dr. Tilt on Sanguineous Pelvic Cysts. Lancet,
Dec. 11th, 1852.
¢ Lancet, 1849, Vol. IL p. 387.

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Williams. The abdomen was much distended, and on examina-
tion the disease was supposed to be ovarian. An examination
per vaginam detected a fluctuating tumour, which, on being
punctured by a lancet, gave exit to a wash-hand basinful of
menstrual fluid. This girl’s health was bad, she was anemic,
emaciated, and did not sleep; there were other symptoms also,
to warrant the suspicion that organic disease might be present,
and he (Mr. Travers) thought the condition illustrated by this
case might be classed among those likely to be mistaken for
ovarian disease.

14, Hydrometra in many points will resemble the last. It
is a rare condition, and, like ovarian dropsy, causes no great
disturbance of the health. The history of the case will assist
us in distinguishing this form of dropsy from that of the
ovaries, but the use of the uterine sound suggests itself as the
readiest means of so doing.

TREATMENT.

General Observations.—A great variety of opinion has existed
in the profession on the propriety of interfering with a disease
which is seldom malignant in its character, and which occasionally
exists for many years without either destroying life, or materially
interfering with the general health. For many years the subject
attracted but little attention, and practitioners for the most part
contented themselves with either doing nothing, or with tapping
the patient occasionally when the degree of distension became
urgent. Of late, however, the subject has excited the attention
which it appears to merit, since it afflicts a very large number
of females at almost every age, tends, to say the least, to shorten
existence, and to render the subject of it, in a great degree, unfit
for the duties and pleasures of social life. Moreover, it has been
proved to be curable in so many instances, as to justify the
attempt to cure it in nearly all.

General Remedies.—The mere use of medicines internally to
secure the obliteration of an ovarian cyst, even at an early stage,
is almost hopeless, although conjoined with surgical means such
- may be of considerable avail. Ifa patient complains of uneasi-

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ness and pain in one iliac region, we may diagnose ovarian
disease, but until a cyst become evident in the pelvis, we cannot
be certain that we have to deal with that disease, and conse-
quently our remedies can be only of a general kind, and such
as will combat the apparent irritation, congestion, or inflamma-
tion. Yet when a cyst is developed, and we are fortunate
enough to discover it at its earliest epoch, medical means will
be rightly used to endeavour to arrest its further growth, and
to bring about its atrophy. Thus the application of leeches and
cupping, and counter-irritation, are indicated where active morbid
action is evident, or where the catamenia are wanting; and
when these are subdued, the preparations of iodine internally
and externally should be persevered in. Since, moreover, a
state of perfect health is inimical to the course of any morbid
process, the exhibition of tonics and of medicines to secure the
proper performance of the several functions, is called for. Of
the various tonics, the iodide of iron has enjoyed considerable
reputation. I have frequently given it in the various stages of
ovarian disease, and obtained much improvement of the general
health, but have never seen it produce any effect upon the
tumour, as some have thought to happen. Mercury, diuretics,
and purgatives, although under particular circumstances useful,
are rather to be avoided, on account of their prejudicial influence
on the health and strength; they have no such influence in
lessening ovarian dropsy, as is witnessed in ascites.

Dr. Watson has thus expressed himself respecting the
employment of remedies :— My position, as physician to a
hospital, has brought under my notice many cases of ovarian
swelling, at a very early period of its development. I have
treated such cases assiduously with the remedies of chronic
inflammation, frequent topical bleedings and the use of mercury,
till the gums were affected; with the remedies of ordinary
dropsy, diuretics and drastic purgatives; and with remedies
accounted specific, the liquor potassz, and the various prepara-
tions of iodine; and T must honestly confess to you that I am
unable to reckon one single instance of success.”*

* Principles and Practice of Physic.

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OR ENCYSTED DROPSY OF THE OVARY. 207

In the always desirable endeavour to recruit and sustain the
patient’s health, hygienic measures should be attended to; a
careful regimen, change of air and scene, gentle exercise, and
particularly, the avoiding of any sort of irritation of the uterine
organs. Attention to these matters is beneficial in all stages of
the malady; whilst, as above intimated, the application of
remedies must be regulated by the stage of the disease, the
symptoms, and the particular conditions arising from time to
time.

The following are the principal modes of surgical treatment
hitherto proposed and adopted. In speaking of them, I shall
have further remarks to make on the medical treatment.

Tapping, simply.
. Tapping, with pressure.
. Tapping, and injection of iodine into the sac.
4. Artificial oviduct.
a. external.
bd. per vaginam.
ce. per rectum.
5. Excision of a portion of the cyst.
a. by a small incision.
6. by a large incision.
6. Extirpation.
7. Other plans.

owe

1. Tapping—This operation is usually performed in the
course of the linea alba, the trocar being thrust in about midway
between the umbilicus and pubes. It has also been the general
practice to place the patient in the upright posture, resting on
the edge of a chair or a bed, to encircle the abdomen with a
broad bandage to be drawn tightly from behind by an assistant,
so as to keep up a supposed necessary pressure as the fluid
escapes, and to cut a hole through the bandage at the point
where the trocar is to be introduced.

Mode of performing the Operation—Now various objections :
attach to this mode of procedure, and I have for the last ten
years practised tapping the patient in the linea semilunaris, in

cit \

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the recumbent posture, and without the assistance of a bandage.*
Besides difficulties from the employment of the compressing
bandage, such as drawing into folds and altering its position as
the abdomen collapses, there is a great tendency to syncope
from the upright posture,—a very inconvenient occurrence. Ou
the other hand, the supine position guards against faintness,
and, together with site of the puncture in the most dependent
part, admits of the most complete evacuation of the sac.

I place the patient on her side—that on which the ovarian
tumour has originated, with the abdomen hanging over the edge
of the bed. On puncturing in the semilunar line, the chief
care is to avoid wounding the epigastric artery, and any
enlarged vems which may be present. By previously emptying
the bladder, any danger of injuring it is obviated. Two other
possible accidents are thus mentioned by Dr. Simpson.+ “ The
uterus is sometimes elevated and drawn upwards in front of an
ovarian tumour, and has been fatally wounded by the trocar in
the operation of paracentesis.... All chance of injuring it
would be avoided, if a point in the cyst sufficiently fluctuating
and thin in its parietes, be selected as the site of the puncture.”
Again, “ Ovarian cysts have been occasionally found so turned
upon their axis, that the elongated Fallopian tube has stretched
across the front of the diseased ovary, and interfered with the
introduction of the trocar ; and a dense fibrous state of the cyst
at particular parts has led to the same mischance—the cyst thus
becoming merely displaced, and not perforated by the pressure
of the point of the instrument. A case of obstruction to tap-
ping from this cause is detailed by Dr. Bright in the Guy’s
Hospital Reports. The puncture, in consequence, must not be
made over a point which feels unequal and condensed in its
structure.”

It is sometimes desirable, and particularly so if the abdominal

* Dr. Simpson, of Edinburgh, has more recently advocated the
same plan, and has well set forth its advantages in a Lecture in the
Monthly Journal, Oct. 1852. Dr. Tanner also (Lancet, Nov. 20th,
1852) has set forth the advantages of this proceeding, and in illustra-
tion has narrated an interesting case.

' ¥ The Monthly Journal of Medical Science, Oct. 1852, p. 363.

i

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wall be thick and fat, to make an incision through the integu-

ments before attempting to plunge the trocar with its canula
into the cyst.

The trocar and canula should be much larger (see fig. 15.)

Fie. 15.

 

than those in general use.* If the fluid be thin and transparent,
* This figure represents two-thirds of the size of the instrument I

generally use.
P

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it runs well enough through a small canula; but. if of treacly,
viscid consistence, it scarcely escapes at all, and if there are
albuminous flakes or cheesy matter, the tube becomes en-
tirely clogged up. Moreover, the very large instrument I use,
admits of free and rapid emptying of the cyst, and saves the
patient a tedious operation, it may be of an hour’s duration.
There is yet another advantage of a large trocar and the recum-
_ bent posture,—that two or three cysts in multilocular disease
can be successively punctured through the same canula by
simply withdrawing and reintroducing the trocar without
removing the canula. This advantage could be gained only in
the recumbent position, for in the upright the gravitation of the
cyst would not permit it. By turning the patient more on her
side, and by pressing on the abdomen, the evacuation of the
cyst may be rendered more complete. When the escape of
the fiuid has ceased and the canula is withdrawn, a pledget of
lint over the wound, which is to be drawn together by strips of
plaster, is generally sufficient to secure adhesion; where, however,
a larger wound has been made, a stitch is sometimes required.

Some surgeons have recommended tapping per vaginam as
preferable to paracentesis abdominis. I do not see what par-
ticular advantages the plan presents; it will be but rarely
practicable, as the sac seldom points in that direction, and it
will certainly be attended in the bulk of cases by greater diffi-
culties and dangers. In some instances, however, where it is
wished to establish a fistulous opening into the cyst, through
which it may constantly discharge and become obliterated,* this.
method may be adopted, if the cyst sufficiently points in that
direction.

Dr. Simpsont+ looks upon this mode of tapping as more
peculiarly applicable to unilocular cysts, and states that he
has “ more than once evacuated the contents of a dropsy of the
Fallopian tube, by introducing the small trocar, which forms the
usual exploring needle, in this position. In one of these cases,
the elongated sac formed by the distended Fallopian tube

* See subsequent section on the Production of an Artificial Oviduct.
+ Op. cit. p. 364.

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inflamed after its evacuation, and, in consequence, seemed
to become entirely obliterated ;” the patient in the end recover-
ing from her previously bad health, and becoming pregnant. In
this opinion Dr. Simpson may be very correct; yet the diffi-
culty will be to diagnose unilocular, and still more the Fallopian
form of dropsy, previously to putting it to the test of practice.

Many cases are on record in which paracentesis alone has
effected a cure. Most such were probably examples of cystic
disease of the broad ligament, or Fallopian sacs, and not actual
cases of cystic degeneration of the ovary, which probably are
rarely cured by this operation alone.

Dr. Simpson writes,* “T am acquainted with the history
of two cases in which the first tapping of an ovarian dropsy has
never been followed by any reaccumulation, the operation in
both having now been performed several years ago: and I
believe the secret of this very unusual termination in the two
cases in question, is ascribable to the circumstance, that the
perforation formed in the walls of the ovarian cyst by the trocar,
has remained permanently open, like a fistula, allowing of the
continuous drain of the ovarian fluid into the cavity of the peri-
toneum. Perhaps art will yet be able to imitate, both success-
fully and with certainty, in an appropriate set of ovarian cases,
this fortunate accidental termination.”

These cases of Dr. Simpson we may presume to have been,
if not Fallopian, unilocular cysts.

Whatever additional agents may be prescribed, they will be
found more active after paracentesis.

Dr. W. Hunter’s dictum was, “ that the patient will have the
best chance of living longest under it (ovarian dropsy), who
does the least to get rid of it;’? and Dr. Denman and other
eminent accoucheurs and surgeons have proposed to defer
tapping as long as possible. The objections to paracentesis are
that the fluid re-accumulates faster than before; that it is
altered in character for the worse as regards the system, and
that, by the probable entrance of air, inflammation is set up in
the sac, attended with great and immediate danger to the

* Monthly Journal of Medical on Dec. 1852, p. 528.
P

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patient’s life. These objections* have certainly great weight,
sufficient to deter from employing simple tapping with the hope
of attaining a cure, although resort to it be defensible where
nothing is left: us but to ameliorate temporarily the condition of
the patient. Hence,

2. Tapping with pressure should always be combined, both as
a matter of precaution when the origin of the cyst is obscure,
and as affording an increased probability of cure in any case.
Like every other simple operation, the application of pressure
may fail from inattention and carelessness. First of all, com-
presses of linen or lint should be so arranged as to present a
convex surface, adapted as nicely as possible to the concavity of
the pelvis. Over these compresses straps of adhesive plaster
should be applied so as to embrace the spine, meeting and cross-
ing in front, and be extended from the vertebral articulation of
the eighth rib to the sacrum. Over this strapping, either a broad
flannel roller, or, still better, a band with strings and loops which
tie in front, may be applied; or a well-made bandage, which
by lacing in front may be gradually tightened, as made at
my suggestion by Mr. Spratt, 2, Brook-street. These ban-
dages must be prevented from slipping upwards by a strap
around each thigh. Both the compresses and the bandages
will require watching and adjusting from time to time, lest by
unequal pressure, the bowels or bladder be subjected to incon-
venience. Also the crest of the ilium should be guarded with
thick buffalo skin or amadou plaster. :

The effect of pressure, before tapping, is fourfold in its opera-
tion. It sometimes retards the filling of the cyst; it may
prevent the increase of the tumour; it sometimes brings about
absorption of the whole contents; or, lastly, it may produce a
rupture of the cyst into the vagina, rectum, or peritoneum.
After tapping, pressure tends to prevent the refilling of the

* Dr. Atlee, of the United States, denies the generally received
opinion of the danger of tapping in ovarian dropsy. He says that the
experience he and his brother have had of this operation since 1828,
and the numerous inquiries he has made of surgeon’s in large practice,
convince him that death, or even serious symptoms, never result from
tapping, that life is usually prolonged, not curtailed, by resorting to
it, while, in several cases, even permanent recovery has resulted.—
American Journal of Medical Science, No. XXXVIIL, 1849.

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cyst, probably by compressing mechanically the blood-vessels
which supply the fluid. The use of pressure is countenanced
by its known good results in dispersing various tumours, or in
arresting their growth. When tapping, with pressure, is
resorted to as a means of cure, or even with the view only of
retarding the process of ovarian dropsy, medicines to stimulate
the functions of the various abdominal organs, to correct faulty
secretions, and generally to improve the health and strength,
should also be administered.

The use of tapping with pressure and auxiliary medical treat-
ment, I consider most: applicable to unilocular cysts without
adhesions, with clear and not albuminous contents, and where
time and the condition of the patient admit of its persevering
application. There are also cases of multilocular disease, and
others where adhesions exist, where pressure may do material
good, and retard the growth.

This plan of treatment I first suggested in 1844, and the re-
sults have been published from time to time in the Lancet, not
only by myself, but by other practitioners who have been in-
duced to give it a trial. For the particulars of those already
published, I must refer the reader to the Lancet.*

Besides those cases which have appeared in the Lancet, I
have had several others which have proved entirely successful.
Certainly, the result of some has disappointed me, where I had
hoped to have effected a permanent cure; but, even in such,
great benefit has been derived from the plan, the patients have
regained health and comfort, and the disease has for a time
been suppressed. Further, in some instances where ovarian
dropsy has reappeared, it has been in consequence of the de-
velopment of new cysts, an event to be wholly prevented only
by resort to extirpation of the entire diseased ovary.

I will here adduce the following cases of the successful appli-
cation of this mode of treatment.

Cass XLVII.—Ovarian Dropsy of several years? standing : cured by
Tapping and Pressure.—Miss E. B., xt. 24, came under my care in

* Dr. Murphy, at the Meeting of the Medical Society of London,

April 8th, 1854, mentioned having had a successful example of this
mode of treatment.

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July, 1848, at the recommendation of Sir B. Brodie and Drs. Bright
and Locock. From childhood she had a tendency to asthma ; and at
three years of age had diseased mesenteric glands, which left a
distended state of the abdomen for some time. After the establish-
ment of the catamenia her health much improved ; but in June, 1840,
she had a severe asthmatic attack, with fever, and copious expectora-
tion—hay-fever ; and this recurred every summer. In May, 1844,
a worse attack happened, and did not pass off till about the end of
July, when it was found that the abdomen,—always swollen during
these attacks,—instead of subsiding, actually increased. This was
attributed to over-indulgence with grapes when at Nice, and she was
treated for obstruction, with the effect of reducing the abdominal ful-
ness. After this time hay-asthma did not recur except in a mild
degree ; but her health became indifferent, and an increase of the
abdomen was apparent. She complained of a feeling of weight and
oppression in the stomach, and sought relief by aperients. On her
return to England, in 1847, her disease was recognised.

When I saw her, she was pale and debilitated. There was much
wasting, particularly about the neck, shoulders, and arms. The cata-
menia were mostly regular ; the stomach was weak, and she suffered
much from heartburn, and sometimes sickness.

The abdomen was enlarged to the size of a woman’s at the seventh
month of pregnancy. Fluctuation was most distinct, and I concluded
the cyst to be thin, and to proceed from the left ovary ; but it could
not be pushed over towards the right side of the median line, which
made me believe it adherent to the peritoneum.

August 14th. After some preliminary medical treatment, I pro-
ceeded this day to tap the sac. Dr. Locock, and Dr. Gardner, her
ordinary medical attendant, being present. Fifteen pints of a clear,
amber-coloured fluid escaped. Some slight faintness followed the

_ operation. I strapped the wound, and over it applied my usual pads
and bandage. <A diuretic mixture, and some alterative, aperient pills
she was previously taking, were ordered to be continued.

15th. Had had a severe asthmatic attack, which caused her to be
restless, and so loosened the bandages, which it was to-day necessary
to re-apply.

17th. To-day feverish and uneasy. Pulse 100; skin hot. Ordereda
saline draught every four hours, and pills of ext. aloesaquosum gr. iii. ;
ext. tarax. gr.iv. ; ferrisulph. gr.i., in pil. i. : to be taken every night.

18th. Urine free, but alkaline and thick. To omit preceding
draughts, and ordered an acid mixture in lieu of them.

20th. The urine is now of natural acidity: to discontinue the acid
mixture.

24th. Has taken a diuretic mixture, and pills, composed of blue
pill, aloes, and hyoscyamus. She is gaining flesh ; appetite very good ;
is allowed wine daily. The recumbent pesture in bed is strictly
maintained. Bowels regular.

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26th. Sir B, Brodie visited her with me, and, on examining the
stomach, could find no indication of the cyst, and considered the
progress satisfactory.

Sept. 5th. The catamenia have appeared at their proper time.
Has continued to go on well. Pressure is kept up by the pads, strap-
ping and by a flannel bandage. Kidneys and bowels act freely.

Oct. 6th. Has continued to improve, gaining in flesh and strength.
Is to go to the country for change.

Novy. 7th. Sir B, Brodie wrote me to say he had seen Miss B. at
the sea-side ; that she was going on as well as could be desired, and
that on a very careful examination he could discover no dropsy, and
no trace of a cyst. The treatment is persevered in. At the end of
another month the patient returned to London, when her health
appeared excellent, and no vestige of the disease was discoverable.

Feb. 2nd, 1849. Dr. Gardner saw her, and expressed himself
satisfied of the cure of the dropsy. Again, on April 4th, he visited
her with Dr. Locock and myself, when, by a careful examination, no
disease could be detected.

Some months after this, on repeating an examination, Dr. Locock
and myself were sufficiently satisfied of the complete cure of the
ovarian disease, that permission was given her to marry.

May, 1854. I have the great satisfaction of adding to the preceding
history, the fact that she has continued well to the present time ;
that is, for a period of five years and a half, without trace of a
return of the malady. She was married in 1849, and I have attended
her in three confinements, and have after each delivery, when the
abdominal wall is in the most favourable state for complete examina-
tion, been unable to discover any vestige of ovarian disease.

Cast XLVITI.—Miss L., eet. 30, came under my care, Sept. 9, 1847.
Complained of having suffered for many years; the stomach was
considerably enlarged, but ovarian disease had not been suspected.
She was much emaciated, especially about the chest and shoulders.
Menstruation had always been regular ; the bowels torpid ; the urine
free. Digestion impaired, and appetite bad ; and she is altogether
much debilitated.

On examination, I found a cyst about the size of a child’s head,
distinctly fluctuating. This I at first took to be a simple cyst ; but a
subsequent examination showed a solid tumour beneath it, pressing
towards the rectum and the right side, and interfering with the action
of the bowel. At the same time the uterus was pushed over to the

left side. : df :
Ordered a cinchona draught, and pills containing aloes, blue pill,

and hyoscyamus. ; : :

Sept. 29th. Her health being improved, I this day, with the assist-
ance of my brother, Mr. George Brown, tapped the cyst in the median
line, and drew off five pints of a clear, transparent, and slightly albu-

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minous liquid. No syncope followed. The usual pads and bandages
were then applied to exert pressure over the abdomen. A saline,
diuretic draught was ordered ; the pills, as before, continued.

30th. The kidneys and skin have acted freely. I had, during the
night, to re-adjust the bandage on account of its painful pressure over
the ilium.

Oct. Ist. On a vaginal examination to-day, I found on the right of
the displaced uterus a hard tumour pressing on the rectum, and
evidently beneath the cyst, and apparently connected to it. In size
it was about equal to a small fist, and painful when pressed. On
removing the bandage, it could be felt through the abdominal wall.
Owing to the pressure, as applied, causing pain in this tumour, with
impediment to the passage of the feces and sympathetic vomiting, I
adopted the use of two pads, stuffed with bran, and over these placed
tightly a flannel band. This band being made to fasten by loops,
could be made as tight as needful.

13th. A fortnight after the tapping, she had pain and cedema of the
left leg, which a stimulating embrocation and friction dispersed. She
was ordered a mixture containing sulphate of iron, and pills of aloes
and blue pill. The bowels act regularly, and the urine is copious.
She is evidently gaining flesh, and in good spirits, having previously
been exceedingly desponding.

21st. Examined carefully, but could feel no return of the fluid..
The tumour was perceptible more in the centre than heretofore.
The catamenia are regular.

December. Has continued the application of the pressure as ordered.
No return of the dropsy traceable. Her health has much improved.

Jan., 1848. She left town this month for Brighton, having received
instructions on no account to discontinue the use of the bandage.

March 29th. I received a letter from Mr. Phillpotts, of Brighton,
the lady’s ordinary medical attendant, saying, “I examined Miss L.
a few days ago, as she complained of the pressure of the bandage.
There is no return of the fluid in the ovarian cyst; and, indeed, I
could detect no enlargement of the ovary itself. I recommended her
to continue the use of the bandage, substituting an air-compress for
the one in use, and slackening the bandage itself. She is in other
respects in much better health, and takes more exercise.”

March, 1849. This patient has been staying in town for some weeks.
She is quite free from any symptoms of the ovarian disease.

April, 1854. I am now pleased to be able to state that this patient
has had no return of the local disease, and that she is in every respect

uite well; free from the constitutional disturbance which so much
embarrassed and enfeebled her health prior to her being submitted to
my treatment.

Dr. Hamilton mentions having cured seven cases by patting
for a long time daily on the tumour, compressing by a bandage,
by the internal exhibition of a solution of muriate of lime, and

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by the use of warm baths. Long continued friction, with
moderate pressure, and the exhibition of iodine, is another
plan which has had its advocates.

3. Injection of Iodine.—It has been proposed both in England
and France, to attempt the cure of ovarian dropsy by injecting
a solution of iodine into the cyst, after having evacuated its
contents by tapping ; the object being, like that of the operation
for hydrocele, to excite adhesive inflammation of the walls of
the cyst. The plan has been resorted to in Paris with success,
and though I have not had an opportunity of trying it, I regard
it as well worthy of the consideration of the surgeon. It will
scarcely be admissible in true multilocular disease, and in uni-
locular the danger will be considerable of the inflammation
proceeding too far. The comparative merit of this plan with
others, and the question how far the inflammation set up is
controllable, are points to be decided only by experience. Since
the above was written, the following able review of this practice
has appeared.*

“ Dr. Simpson has, within the last year, injected into dropsical
ovarian cysts, subsequently to tapping, the tincture of iodine, of
- the Edinburgh pharmacopeeia, undiluted, in seven or eight cases.

He has usually thrown into the cyst two or three ounces of the
tincture. In some cases he has allowed a portion of the in-
jected fluid to re-escape ; in others, has retained the whole of it.
From these cases he drew the following conclusions :—

“1. In none of the cases of ovarian dropsy, treated with
iodine objections after tapping, has he yet seen any consider-
able amount of local pain follow the injection, with one excep-
tion; in most instances no pain at all is felt; and in none has
constitutional irritation or fever ensued. In the one exceptional
case, considerable local irritation followed, and the pulse rose to
110; but the same phenomena occurred in the same patient
after previous tappings, without iodine being used.

“2. While the practice seems so far perfectly safe in itself,
it has by no means proved successful, as in hydrocele, in pre-

‘venting a reaccumulation of the dropsical fluid; for in several
instances the effusion into the sac seems to have gone on as
rapidly as after a simple tapping without iodine injection.

* Monthly Journal of Medical Science, May, 1854, p. 467,

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in the middle hypogastric region, encroaching on the iliac
regions, but more so on the left one, and rising nearly to the
umbilicus. At its upper part it felt round like an inflated
bladder, and fluctuation was perceptible. The hardness and
extent of the swelling prevented my discovering any appended
tumours.

“ Although two diseases which appear to be of the same
kind may not be exactly alike, yet there may be such an analogy
between them that one may serve to direct the treatment of
the other. Recalling, therefore, to my mind the characters of
the cyst I previously dissected, I concluded it to be desirable
to open the tumour to a great extent, along the linea alba.
For if the cyst were not emptied, it would extend itself more
and more; and if only emptied by tapping, it would refill very fast.

“M. de la Peyronie, with whom I saw the patient, advised
for the present, tapping only so’ as to ascertain, on the col-
lapse of the walls of the cyst, the existence or not of hard
tumours at its sides, and afterwards to take such a course as I
judged best. TI yielded to his advice; but the patient did not
agree to ours, and she returned to Vernon. The cyst filled and
extended more and more in such a manner, that four months
afterwards, that is, in January, 1737, the tumour extended itself
to the diaphragm, and even raised the xyphoid cartilage, em-
barrassing the respiration much, fatiguing the patient by its
weight, and by the most acute pains. The symptoms were
accompanied by much fever, by want of rest, by frightful
wasting, and a continual wish to make water; besides which,
the patient’s bowels were very confined, and yielded nothing but
by injections. The sad condition in which she was, made her
at last resolve to submit to all that was judged needful to be
done for the relief, and M. Aubé, surgeon of the town, tapped
her on the right side, considering the dropsy to be ascites. For
this he must not be blamed, since it is very difficult, not to say
impossible, to recognise ovarian dropsy by external signs when
the cyst extends over the whole belly; and it cannot be dis-
tinguished under the finger from ascites, except when, being but
little extended, its limits are discoverable. M. Aubé drew off
fifteen pints of a bloody liquid; the patient was relieved; but

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the cyst soon refilled, and at the:end of February, @.e., seven
weeks after tapping, the patient’s condition and symptoms were
the same as before the operation. I was now requested to go
to Vernon. The patient suffered such acute pain, that, to
relieve her, she was tapped a second time in the right side, the
day before my arrival, and M. Aubé thought good to leave the
tube of the trocar in the wound. He this time only drew off
twelve pints of bloody fluid; I saw the blood in little clots at
the bottom of the vessel.

“In examining the abdomen, nearly a spoonful of purulent
fluid, coloured by blood, escaped through the tube. I easily
distinguished through the integument the entire cyst, which,
though less extended upwards than before the paracentesis, still
rose to the breadth of four fingers above the umbilicus. The
left iliac region appeared occupied by a scirrhous tumour, of
about six inches in length and four in width, attached to the
cyst, and raising the integuments externally. Its almost round
figure and its situation countenanced the supposition of its
being the enlarged and scirrhous ovary, such as is often seen.
The rest of the hypogastric region was rather prominent, with
the skin covering it healthy. Around the retained tube was a
circle of inflammatory swelling, of some two or three inches
wide. When I saw this patient six months before, the hypo-
gastric swelling had but an eighth part of its present bulk, and
I had then hoped to be able to obtain a radical cure by promoting
suppuration in the sac, and with that view proposed the large
incision. Circumstances, however, were now changed, the cyst
was so extended as to push forward the xyphoid cartilage, and I
could not hope for the same success. I thought it, however,
right to extend the existing opening, in order to prevent re-
accumulation in the cyst; and to favour the gradual drawing of
the wall towards the point from which it started, and which
seemed to me to be near the fold of peritoneum covering the
bladder.

“‘T should have wished to have opened the cyst as nearly as
possible in the median line, but the collapse of its walls obliged
me to make use of the opening made by the trocar. Not to
lose the route of the tube, before withdrawing it I introduced a

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thick piece of catgut, as a bougie, and afterwards a grooved
director in the same course ; then removing the bougie, I carried
the bistoury the entire length of the director, and cut outwards
and downwards towards the pubes, thus making an opening four
inches long. JI carried my finger all round inside the incision,
but could on no side feel the furthest walls. I dressed the wound
simply with pledgets of lint, keeping the edges moderately apart.

“ As I could not reckon on arresting the formation of fluid
in a sac which had .twice become filled in so short a time, and
as it was necessary to facilitate the escape of the results of sup-
puration and prevent the closure of the wound, I clearly fore-
saw the necessity of retaining the tube in it for some time.
Accordingly, I made a tube of sheet lead, of a diameter propor-
tionate to the size of the wound, into which I introduced it
obliquely. As the wound contracted, I decreased the size of
the tubes. For more than four weeks many shreds of membrane
escaped through the tube, the pus in the interval of the dress-
ings was always rather red. Morning and evening the surgeon
injected the sac by the tube. First he employed detersives, and
afterwards stimulating lotions. At length the pus lost its red
colour, and at the end of five months, 7. e., in the beginning of
August, the tube was dispensed with, and only a small fistulous
opening was left, through which some drops of pus continued to
ooze. But although the walls of the cyst approached, no union
took place.

“Tf we observe that the disease came on in consequence of
the suppression of an evacuation which had become habitual, so
far from regarding the oozing through the fistulous opening as
an evil, it will be looked upon as a resource of which nature
availed itself.

“From the date of this fistwlous opening being made, the
dropsy terminated. However, as the cyst. contracted, the
scirrhous tumour gradually increased ; the integuments over it
became cedematous and thick, and at length pus slowly formed,
accompanied by many symptoms. At the end of September,
eight months after the opening of the cyst, the surgeon, feeling a
fluctuation which seemed to him to extend throughout the
hypogastric region, wished me to go to Vernon, which I did.

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The fluctuation was not equivocal, and I judged from the touch
that the pus was under the muscles, in the cellular tissue which
surrounds the bladder, although it was felt to rise to two fingers’
breadth below the umbilicus. Between the umbilicus, the
fistulous opening, and the place where the pus terminated, which
included a space of from two to three inches in extent, I felt
under the integuments something denser than in the rest of the
abdomen, which I judged was the cyst spoken of. I carried a
very blunt probe obliquely through the fistulous opening, but it
penetrated no further than the width of three fingers, and I
could not make it move in the cyst, which I therefore concluded
was very narrow. The principal thing to be done was to
evacuate the pus. For this purpose I made, four fingers’ breadth
above the pubis, a transverse incision, following the course of
the swelling. By this incision I divided the right rectus muscle
partially, and the left one, together with the oblique and trans-
verse muscles of the same side, entirely; and in so doing could
not avoid the epigastric artery. I stopped the bleeding by holding
the vessel between the fingers until the pus was evacuated, and
afterwards tied the artery. Two pints of purulent fluid were at
once discharged, and subsequently about a pint escaped from the
bottom of the left iliac region, presenting a different character,
being white, thick, viscid, clotted, and of bad smell. I passed my
hand to the bottom of the wound, and found no trace of the
tumour which was there six months before. It had suppurated
away, and in process of so doing, had apparently involved the
cellular tissue about the bladder. Almost immediately the walls of
the abscess collapsed ; and I filled the vacant space with very soft
lint. The various symptoms forthwith declined and gradually
disappeared. Two days after, I left the patient to M. Aubé,
who dressed the wound judiciously; and this healed in seven weeks.

“The patient enjoyed tolerably good health for four years
afterwards, when she died from the same cause as the dropsy
originated from, a fact the post-mortem examination will show.

“The cyst appeared as if torn, but was closed at the bottom
of the fistulous opening, which had remained open. The
jejunum and ilium were adherent to it, and in connexion with
them was a group of scirrhous tumours, consisting of the

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mesenteric glands. The hypogastric region was filled with
scirrhous tumours of different sizes, adherent to each other, and
placed on either side of the bladder.

“ This observation may lead to some useful reflections on the
cure of this species of dropsy, and perhaps of some others.
Firstly, ovarian dropsy is found nearly always based upon a
scirrhous tumour, of which therefore it is only a symptom.
Every cyst is always full, however small it may be, and the
more liquid collects, the more it extends in every direction.
Secondly, its bulk presses on all the parts it'touches, and the
more it extends, the more it compresses them, which impedes or
deranges their functions. Thirdly, in extending itself, the cyst
is rendered adherent to all the viscera upon which it rests.
Fourthly, if the cyst has been emptied by an operation, and the
opening closes immediately, it fills anew, and in less time than
before; and the third time it refills still faster, i. e., in less time
than on the second occasion. Fifthly, if the opening be made
in the cyst in such a manner that it does not close, the walls
approach each other in proportion to the elasticity that is left
in them; and they are further approximated by the compression
of surrounding parts, just as the uterus which has been dilated
in pregnancy, contracts after delivery. Sixthly, in proportion
as the walls of the cyst are brought together, the vessels which
empty the liquid into the cavity are compressed ; therefore less
liquid flows into it, as after delivery the discharges diminish in
proportion as the uterus contracts. Seventhly, the opening
made by the trocar closes in twenty-four hours, and as the cyst
fills itself quickly, its walls approach each other but very little
between one tapping and another. But if it is opened by a
large incision, the walls have time to come very near together.
Eighthly, the walls of the cyst approach each other, but cannot
unite, hence the wound remains fistulous. Ninthly, if the cyst
has been extended and dilated in such a manner that it is
adherent to all parts of the abdomen, it is difficult and almost
impossible that it should collapse entirely, owing to these
adhesions. From what is above stated, it may be concluded—
Firstly, that ovarian dropsy can only be cured by a tolerably
large opening of the cyst. Secondly, that it must be opened

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early to prevent its very great extension. Thirdly, that it is not
enough to tap simply with the trocar, but an opening must be
made in the sac so large that its interior may suppurate and
modify itself before the opening becomes contracted. Although
this mode of cure I propose may seem but palliative, as the
wound remains fistulous, I regard it as necessary, since it prolongs
the life of the patient, who has nothing more to fear, except the
scirrhous tumours, for which, indeed, pathology may hereafter
find remedies; finally, it is not impossible but that it may result
in a radical cure. Here is an observation which proves it.

“Case B.—Of Ovarian Dropsy, treated by incision, and cured
without fistula—An unmarried woman, aged 44, had been for
two or three years ill with obstructions in the abdomen, for
which she had seen many physicians. During this illness she
menstruated irregularly, then ceased entirely, At length the
abdomen began to enlarge; her water became lateritious and
scanty ; fever came on; she had very frequent vomitings ; the
uterus became very painful; and she was tormented with wind
and constipation. At last she was declared dropsical, and I
was requested to tap her. This was in 1746. I drew off
fifteen pints of muddy fluid, mixed with blood, of such a stench,
that the whole house was infected with it. The abdomen being
empty, I easily distinguished through the integuments in the
left iliac region an unequal scirrhous tumour, fixed in its
position, and seemingly the size of a small melon. The symp-
toms diminished after tapping; the urine became natural and
more copious. The quality of the liquid drawn off made me
conjecture that it was ovarian dropsy, but I had no proof of it
till the end of eight or ten days, when, the cyst being half-
filled, I easily distinguished its limits; in a part of its circum-
ference it seemed to adhere to the scirrhous tumour. In three
weeks the cyst was nearly filled again to the same extent.
Then, knowing the nature of the disease, which I could not
decide the first time, because the cyst extended all over the
abdomen, I thought that simple tapping with the trocar would
not be right, but that the cyst must be hindered from refilling.
I then made an incision in it, so large, that it could not con-

Q

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tract promptly, in the linea alba, a little below the umbilicus,
so that the bottom of the cyst approaching gradually the
scirrhous tumour upon which it was formed, the wound always
answered to its cavity. Almost as much similar liquid as at

the first time, and as offensive in smell as that drawn off three

months previously, was discharged. I put a tube in the
wound to hinder it from contracting too much, and that I
might be able to inject the cavity. However, new symptoms
arose ; the fever increased, accompanied by a species of delirium,
also by frightful nausea, and almost continual sickness; the
patient vomiting immediately all that she swallowed. As
Spanish wine was the only thing she could retain, she was
sustained by it alone, taking six or seven ounces a day, for five
weeks, during which all her symptoms continued with the same
violence. During this time there was discharged every day by
the tube eight or ten ounces of red liquid, muddy, and as
offensive as on the day of the operation ; and twice a day I
made injections in it of barley water and honey of roses. At
last, at the end of three weeks, the fluid which passed lost
a little of its red colour, and pus was detected in it One

morning twelve to thirteen ounces of pus escaped, much whiter ©

than before. I thought the tumour was beginning to suppu-
rate, and that it emptied its matter into the cyst; for, on touch-
ing it, it seemed considerably diminished in size. Two days
after, the violence of the symptoms abated, and then gradually
ceased. ‘The interior of the cyst suppurated well, and the pus
daily lost its red colour and its offensive smell. Its quantity
diminished, so that at the end of six months only a spoonful
at the most was discharged in the day by the tube, which was
kept in and occasionally cleaned. Doubtless the walls of the
cyst gradually contracted. Things continued in the same way
for more than two years; at last the patient having one day
taken out the tube to clean it, could not replace it, and the
wound closed entirely. With time, menstruation returned, and
continued regularly. Of all the cases of ovarian dropsy I have
treated by such an incision, this is the only one in which I
have seen the cyst close itself entirely.”

Treatment.—In January, 1850, I had the pleasure of bring-

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OR ENCYSTED DROPSY OF THE OVARY. 227

ing before the notice of the profession what I conceive to be an
improvement of this operation of Le Dran; the variation
consisting chiefly in making the opening in the semi-lunar in
preference to the mesial line. I was led to propose this deviation
by reflecting on a case published by Mr. Bainbrigge, of Liver-
pool, who had performed Le Dran’s operation in two cases, the
first of which, I believe, terminated fatally; but the second,
subsequently published in the Provincial Medical and Surgical
Journal, was successful. In the latter case, Mr. Bainbrigge
made an incision in the median line, midway between the um-
bilicus and the pubes, intending to stitch the sac to the
external wound, which was to be kept open by the introduction
of a pledget of lint, so as to admit of continuous evacuation of
the contents of the ovarian cyst as fast as formed. As it hap-
pened, however, Mr. Bainbrigge found the previous adhesions of
the sac so complete, that the sutures proposed were unneces-
sary. The patient was then placed in a prone position, and so
kept for some weeks. The result proved quite satisfactory.

It will be observed that here the prone posture was main-
taimed (as necessary for a free escape of the discharge) for a
lengthened period. Now, it struck me on reflection that
such an operation might be performed with greater chance of
success, and with much less inconvenience to the patient, by
making the incision laterally in the semilunar line, where, in-
deed, I ordinarily introduce the trocar in tapping an ovarian
cyst. An opportunity of carrying this idea into practice soon
after occurred to me, when the advantages IT had reckoned upon
were fully realized.

Casz XLIX.—Miss R., aged 39, introduced to me by Dr. Richard
Bright, came under my care in May, 1847, labouring under ovarian
dropsy. The cyst was multilocular ; for one sac yielded to the com-
bined effect of tapping, mercurials, and pressure; but a second
appeared six months afterwards, which was punctured, February,
1848, and yielded seven pints of a mucilaginous viscid fluid. The
abdomen again enlarging in the following July, three cysts were
punctured, the oldest one discharging a milky, highly albuminous
fluid ; the second, a transparent, but also albuminous serum ; and the
third, of small size, a non-albuminous fluid of a straw colour ; the
entire quantity evacuated amounting to eleven pints. Although

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relief followed, the eysts re-filled, and pain and other symptoms of
suppurative inflammation supervened. At the commencement of
October a fourth tapping drew off a clear, light-coloured, and after-
wards an offensive, purulent fluid, in all sixteen pints. After this,
the accumulation of fluid returned with greater rapidity than ever,
when, with the concurrence of Mr. Fergusson and Dr. Sibson, I
decided on the following operation :—

Oct. 11th. Assisted by those gentlemen, and Mr. Nunn, (chloro-
form having been administered by Dr. Snow,) I placed the patient in
the horizontal posture near the edge of the bed, and made an incision
two inches in length about half-way between the umbilicus and the
anterior and superior spine of the ilium, dissecting carefully down to
the peritoneum. I next made a second (shorter) incision at right
angles with the first, extending from its lower termination inwards
towards the median line. The flap thus formed was dissected back,
exposing the peritoneum with the subjacent whitish cyst appearing
through it. Introducing a large-sized trocar at the angle at which
the two incisions met, I withdrew nine pints of fluid, containing pus
and flocculent matter ; and, before removing the canula, divided the
peritoneum in the line of the longer incision ; and having reflected it
on each side, stitched the cyst to the tendon of the external oblique
muscle, taking care not to include any portions of muscle or of perito-
neum. The next step was to remove the canula, and, with a pair of
scissors to divide the cyst midway between the sutures; a piece of
lint dipped in oil was then inserted and secured by strapping ; lastly,
the external wound was partially closed at its extremities by stitches.

For the first five days after the operation, the progress of the patient
was very satisfactory; but on the 16th (the sixth day), a redness of
the surface, extending from the wound to the back, became visible;
and on the following day sickness occurred, and continued to do so sub-
sequently. The discharge from the wound had previously been free, but
I now thought it advisable to inject, twice a day, a portion of lotion
containing two drachms of tincture of iodine to a pint of water; but
the discharge becoming shortly very offensive, I substituted an injec-
tion of chloride of lime. At this period, much exhaustion and rest-
lessness were present, together with frequent faintings and considerable
dyspnoea, and the discharge from the cyst became most profuse, thus
diminishing the little remaining power. The patient sank rapidly,
and died on the 9th of November, a month after the operation.

A post-mortem examination was made on the following day in the
presence of Mr. Nunn and other gentlemen. There was much
emaciation. On opening the thorax, the diaphragm was found to
reach as high as the third rib, and the base of the heart to lie between
the first and second ribs. The right lung was thrust upwards by the
liver, which was raised to a level with the third rib. Firm and ex-
tensive pleuritic adhesions existed. The right lung contained more air
than the left, which though crepitant, was much congested, and also con-

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OR ENCYSTED DROPSY OF. THE OVARY. 229

tracted and shrivelled, each lobe being capable of containing but little air.
Little or no fluid was present in the pericardium. The heart was very
fat; the auricles remarkably small, as indeed was the entire organ.
The right auricle contained coagula, The right ventricle was soft and
flabby, whilst the left was thicker and harder than natural, its
columnz carnes dense, and its chords tendinex very firm and rigid.
Valves healthy. The diver not only rose high in the chest, pushing
the right lung up to, or above the third rib; but it was also much
enlarged and rounded, the right lobe resembling in figure and size, a
foetal head. Its parenchyma was highly vascular and exceedingly
soft. Spleen normal; stomach much distended with flatus; kidneys
very much enlarged, softened,-pale, and easily broken down by the
fingers. The ovarian cyst was found generally adherent to the abdo-
minal parietes in the neighbourhood of the lateral incision. On
removing the cyst, we found on its posterior surface an ulcerated
opening of no very recent date, through which a communication existed
with the interior of a smaller cyst, and through this with several
others, also small, some of which appeared to have been more recently
formed. The contents of these several cysts varied in character ;
some being dark, thick, and offensive, the lining membrane studded
with ossific points; others, more recent, straw-coloured or purulent.
Uterus normal, except at its posterior surface, where it was indurated
by many fine nodules.

The issue of this case was unfortunate, but the untoward
result offers no testimony against the propriety of the operation,
inasmuch as it was a consequence of general bodily disease.
The engorged and enlarged liver, the abnormal condition of the
kidneys, the congested, puckered, and adherent lungs, com-
pressed into half their original bulk, and last, not least, the
diminished size and diseased condition of the heart, afford ample
explanation of the fatal issue. The frequent faintings occurring
upon any change of position or sudden movement, indicated
serious organic changes in the chest; and Dr. Sibson, when he
saw the patient before the operation, had diagnosed displace-
ment upwards, and diminished power of the heart. This
diagnosis the autopsy confirmed and satisfactorily accounted for
the dyspnoea and the constant tendency to syncope.

So far, then, from regarding the operation as the cause of
death, we all agreed that, taking into consideration the exten-
sive and serious visceral lesions, the multilocular character and
long standing of the ovarian disease itself, the debility of the
patient, and the pressure sustained by the thoracic viscera, the

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operation was so far successful as that life was considerably
prolonged by it. Had the powers of the patient persisted suffi-

ciently, we may conclude that the cysts would have been
destroyed by suppuration.

Case L, was that of a married woman, the mother of four chil-
dren, who having been found to be labouring under ovarian dropsy by
her usual medical attendant, Mr. Evan B. Jones, was taken by him to
Dr. Tyler Smith, who requested me to see her in April, 1850.

I found that she had been tapped by Mr. Jones about seven weeks
previously, immediately after the birth of her last child, when twenty
pints of fluid were withdrawn. The sac had subsequently filled again
very rapidly: she was compelled to keep her bed, but unable to lie
down from fear of dyspnea.

She stated it was several years since she detected a swelling in her
right iliac fossa, that she was told it was ovarian dropsy. Since its
appearance, however, she has had several children. After she was
tapped, a hard body could be felt, apparently within the cyst.

On examination, the cyst seemed thin; and, deeper in the right
iliac fossa, a solid tumour could be felt, which I thought might be an
undeveloped or contracted cyst. Fluctuation was distinct.

This patient was most desirous that some further operation should
be attempted, but her extreme debility and generally bad state of
health, promised but an indifferent or untoward result.

However, I determined to try the plan of making a lateral incision,
and of stitching the sac to the abdominal wall. On the 18th, I
accordingly proceeded to operate, assisted by Mr. Nunn, Mr. Jones,
and Mr. Henry Smith. Having made an oblique incision, similar in
position and size to the first in my previous operation, and thereby
reached the peritoneum, I found it on almost every side adherent to
the subjacent sac. Withdrawing about twenty pints of fluid, I at once
proceeded to stitch the sac to the aponeurotic tendon of the external
oblique muscle. This being completed, I opened up the cyst by
scissors, midway between the stitches—just as in my former operation.
On introducing my finger, I felt the solid mass (before detected from
the exterior), which was yielding to the touch, and seemingly within
the empty cyst, and was in fact an undeveloped cyst.

The following day she was doing remarkably well, and continued
progressing favourably for a fortnight. Unfortunately, however, at
the end of this period, having previously removed from her bed to a
sofa, she exposed herself to wet and cold by lying close to an open
window. The consequence was a severe cold attended with fever,
which lasted several days. Then the abdomen began to enlarge in the
region of the cyst, and the previously free discharge diminished con-
siderably.

On introducing my finger in the wound, I found that adhesions had

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OR ENCYSTED DROPSY OF THE OVARY. 231

been set up between the walls of the cyst and the solid tumour con-
tained in it: whereby the cavity of the sac was now divided into two
compartments, only one of which could empty itself through ‘the
opening ; the other had consequently become distended by the accu-
mulation of its secretion. I was able, however, to break down these
recent adhesions by my finger, giving liberty to the imprisoned fluid.
To avoid the recurrence of this event I introduced a pledget of lint,
so that it should lie across the tumour, or between it and the ad-
joining wall of the cyst.

From this period the patient went on remarkably well, suffering
indeed every two or three weeks from attacks of bilious vomiting,
with headache and prostration. At the end of May she changed her
residence to the west end of London, as more advantageous, and her
health so improved, that she was enabled to take walking exercise
almost daily.

In July the large cyst was extruded en masse through the external
opening, in a putrid condition. After its separation it required much
care to prevent the closing up of the wound; the discharge, too, was
now trifling, and caused the patient no inconvenience. To keep the
orifice free, a pledget of lint had to be introduced daily.

At this period the operation was considered by the several medical
men who visited her, (among whom were Mr. Fergusson and Mr. Ure,)
as perfectly successful. In fact, the patient walked about and rode
several miles a day.

In August, Mr. Ure saw her, when she was suffering from one of
her severe bilious attacks, and from the cedema of her face, surmised
the existence of kidney disease. Her health, which had long suffered
from her intemperate habits, now began seriously to give way: in-
cessant vomiting would occur for three days together, and incomplete
paralysis of the left side supervened, Some relief followed the use of
general and topical bloodletting, but exhaustion soon more clearly
manifested itself, and she sank, after having fallen into a comatose
condition four or five days previously. :

A post-mortem examination was made the next day, with the
assistance of Dr. Tyler Smith and Mr. Nunn. The following are the
notes made on the occasion.—Body well developed, with a consider-
able quantity of subcutaneous fat. No existing peritonitis apparent
on opening the abdomen. The cavity of the pelvis contained an ounce
and a half of puriform fluid, lying partly in front and partly behind
the uterus. This pus had evidently escaped from the mass of the
right ovary, the vesico-vaginal and recto-vaginal pouches being
healthy. : ;

A cyst capable of holding an orange occupied the right ovary, (see
Prare IX.,) and was situated just below the broad ligament,—its inner
side within an inch of the uterus, its outer in contact with the brim
of the pelvis. This cyst communicated by means of a fistulous canal,
13 inch in length, with the external opening made in operating. The

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back and under part of the cyst was disorganized and soft, and at one
part lacerated, allowing the free escape of its contents upon the
slightest pressure. Through this lacerated opening, the puriform dis-
charge in the pelvis had evidently escaped; and without doubt this
laceration had occurred in the progress of the autopsy, for had it pre-
viously existed, the sac would have been much more completely
emptied, and some signs of recent peritonitis have certainly been met
with.

The left ovary and ligaments were healthy. The surface of the
uterus was rather red and vascular, but unaffected by peritonitis. In
the course of the fistulous canal were three or four small cysts varying
in size from that of a currant to that of a grape. The structures about
the wound and the fistulous canal were pale, firm, and healthy. The
kidneys, soft, large, and pale; the liver remarkably yellow; the brain
unusually pallid and soft.

That the case just recorded was (so far as the operation itself was
concerned,) successful, will, I think, be generally admitted. The fatal
symptoms were other than those dependent upon the operation, and
death did not take place till four months after it. The great sac had
been entirely expelled, and we may conclude that if the patient’s
general health had not failed, it would have been followed by the dis-
charge or destruction of the small one found after death.

Cast LIL—Miss W., eet. 41, was always observed to be of large
size in the abdomen from her childhood, but enjoyed good health,
with the exception of suffering occasional bilious attacks. In 1848,
her health was not so good; there was much indigestion and gastric
disorder, with a sensation of heat in her throat proceeding from the
abdomen; but it was not till March, 1850, that she sought medical
advice, at which time she consulted a physician, who declared her to
be labouring under ovarian dropsy. She remained under that gentle-
man’s care until June, her abdomen in the meantime increasing to

double its former size. Wishing for further advice, she consulted
another physician, who prescribed some medicines and recommended
her being tapped.

In July she was visited by me, when I found her suffering con-
siderably from the pressure of the ovarian tumour upon the thoracic
viscera. The general appearance of the abdomen and careful, manipu-
lation, convinced me that this was a case of multilocular ovarian
disease, with extensive and firm adhesions. The inference, therefore,
was, that the operation of extirpation could not be resorted to,
that pressure would be unavailing, and that the patient’s condition
demanded speedy relief, She had of late suffered frequent and severe
pain in the right side of the tumour, and was herself most desirous to
submit to an operation.

On the ist of August, Dr. Snow having put her under the influence
of chloroform, I proceeded to the operation, assisted by Mr, Nunn,

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OR ENCYSTED DROPSY OF THE OVARY. 233

and other medical friends. The incision was made in the left side,
and in the usual position, and the peritoneum being reached and
divided, I found very firm adhesions over its right side incapable of
being broken down. The multilocular character of the disease, as
previously diagnosed, was rendered evident, and two cysts were
opened on the present occasion, and a highly albuminous fluid eva-
cuated. Many other smaller ones were left untouched. I do not
here recapitulate the several steps of the operation, which were in all
respects the same as in the previous cases.

On the day following the operation, inflammation was set up in
the sacs, but was recovered from in three days; bleeding and other
antiphlogistic remedies having been employed. After the subsidence
of the inflammation, she became free from pain and progressed favour-
ably ; expressed herself much relieved, took food, and was in good
spirits. The wound also developed healthy granulations. In ten
days more, however, the discharge became offensive, and its debili-
tating influence on the system manifested itself rapidly; the feeble
powers of the patient not being able to sustain the drain, and the less
so, on account of its unhealthy character, which tended to produce a
typhoid state. She consequently sank on the 25th of the month.

A post-mortem examination was made on the 27th.

On opening the abdomen, the cyst was found generally adherent on
its right side, but free from adhesions behind, On attempting to rup-
ture some of the adhesions low down, the walls of the sac gave way,
and a quantity of pus escaped. The cyst rested by a broad base on
the left ovary. The right ovary was enlarged, and contained a small

st.

The liver was adherent, and pushed upward to the third rib, The
left lung was adherent to the pleura-costalis in its upper third. On
cutting into the cyst, it was found to be made up of many, some large,
others smaller cysts.

The cause of death in this third case must be admitted to have been
exhaustion from the copious and offensive purulent discharge from
the cyst, hastened in its operation by the debilitated state of the
patient. We must also attribute the fatal result in some measure to
the circumstance of the discharge having become offensive, and the
recognised noxious or poisonous influence exerted by any fetid collec-
tions of fluid within the body.

The state of the patient previously to the operation was such, that
life could not have long continued, and I think that the operation
itself, directly or indirectly, had little to do with shortening it.

In such inveterate cases, of long standing and multilocular,
having extensive adhesions, and where the health is broken
down, my present conviction is not to interfere by any operation.

Although the three cases last related terminated fatally from

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one unfortunate circumstance or another, the principle of the
operation has so frequently been successfully carried out, as to

justify its repetition in a favourable case. In Paris the opera-
“ tion has been performed several times with success; adhesion
of the sac to the abdominal parietes having been effected by
pinning the cyst to them some days before making the opening.
For this information I am indebted to Dr. Ferguson. I have
also heard from Mr. A. Ure, a report of a case successfully treated
by the lateral incision in Germany; and in the “ Provincial
Medical and Surgical Journal” (1850), an instance is recorded
of “an ovarian tumour cured by incision, followed by suppura-
tion,” by Dr. Prince, of St. Louis, Missouri.* An operation
which has been extensively acknowledged, not only in this
country, but im France, Germany, and America, has certainly
claims upon the attention of surgeons.

Artificial Oviduct,—per vaginam, or per rectum.—tIn the
foregoing observations and cases, the formation of a fistulous
opening into the sac through the abdominal parietes has alone
been considered; but the same may be effected through the
vagina, or through the rectum. However, the establishment of
an artificial oviduct through either of those canals will be of less
extended application, and only warrantable when the cyst is
most evident in the recto-vaginal space, and is distinctly fluc-
tuating, and where a long trocar and canula can be employed,
and the latter be left. As to the requisite position of the cyst,
it will be recollected that the direction of growth is rarely
towards the recto-vaginal cul-de-sac. (See p. 184.)

The operation per vaginam has,I understand, been several times
performed at St. Bartholomew’s Hospital with success. I regret
T have not the precise facts and statistics. That per rectum has
also been resorted to in some instances, and obtained favourable
results. I have, as yet, not had experience of either of these
varieties of the operation in question; but I regard them as
likely to be, under circumstances such as above indicated, more
desirable than that through the abdominal wall. Moreover, I
should, ceteris paribus, prefer perforating the vagina.

* Abstracted from the “American Journal of Medical Science.”

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OR ENCYSTED DROPSY OF THE OVARY. 235

5. The Excision of a portion of the Cyst, for the cure of
ovarian dropsy, was first recommended and practised with |
success by Messrs. Jefferson, West, and Hargraves. Their
operation consisted in making a small opening, about an inch in
extent, seizing the cyst, withdrawing the fluid, and excising as
large a portion of the sac as could be drawn through the open-
ing. It will be seen that this operation is applicable only to
simple cases, and that the smallness of the opening precludes the
possibility of ascertainmg, during the operation, either the
degree of vascularity of the cyst, or the extent of its adhesions.
Reflecting that there is no greater danger in an opening of two
or three inches than in one of only an inch, Mr. Wilson, of
Bristol, proposed and practised with some considerable success,
a similar operation by a larger incision, which enabled him to
tie all the larger blood-vessels ramifying in the cyst which were
divided by the knife. To this plan I give the preference, for
the above reasons, and for another, not less important,—viz.,
it enables the operator, by taking out of the wound one or more
pieces of the cyst, and cutting it or them irregularly, to avoid
dividing the bloodvessels, and the consequent necessity for liga-
tures. Also, should necessity arise, it affords room and space
to tie a bleeding vessel with twine, to cut it off very close, and
leave it.

The excision of a portion of the cyst is an operation more
free from danger than complete extirpation, and less tedious in
its results than the formation of an artificial oviduct. But it
has a limited application. The conditions likely to favour its
success, are :—The cyst unilocular, its walls thin, and possessed
of little vascularity, very few or no adhesions, the fluid only
slightly albuminous, and of light specific gravity. When these
favourable circumstances coexist with unimpaired general health,
or very little ailment, then only should this operation be per-
formed. If pressure had been tried without success, or was
interdicted by the existence of prolapsus uteri, or by any other
objection, an additional reason to try this operation would exist.
Now, by preferring the longer incision, and being prepared to
extirpate the whole cyst if necessary, the surgeon will be able to
explore the parts to ascertain which operation is most eligible.

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For instance, if the walls of the cyst are found thicker and more
vascular than was expected, it will be safer to proceed to extir-
pate the entire cyst, after tying its pedicle, than to run the risk
of profuse hemorrhage by cutting out a portion. Or, if the
cyst is found to be thin, unilocular, unattached, and unvascular,
and the fluid thin, then the plan of excising a portion may be
adopted with reasonable prospect of success.

The operation consists in excising a portion of the cyst,
returning the remainder into the abdomen, and then, closing the
wound. with sutures, to allow any fresh fluid secreted by the
remaining portion of the cyst, to escape into the cavity of the
peritoneum, there to be taken up by absorption and discharged
by the kidneys. This method of treatment was suggested to
my mind (before I was aware that it had been previously prac-
tised) by reflecting upon the numerous cases on record in which
spontaneous recovery has occurred after an accidental rupture of
the cyst and subsequent copious discharge of urine. One case
especially impressed me with the importance of attempting such
an operation; namely, that of a young lady who had been long
treated by Dr. Henry Davies for ovarian dropsy. In this case
spontaneous bursting was followed by complete disappearance of
the disease, and non-recurrence of dropsy. She died ten years
afterwards of inflammation of the dura mater. On the post-
mortem examination it was found that the cyst had collapsed
and shrunk, and that a fissure of some size existed, which was
probably the original rent through which the cyst had burst.

The January (1851) number of the late “ Provincial Medical
and Surgical Journal” contained an interesting and highly prac-
tical communication from Mr. J. Grant Wilson, on the value of
excising a portion of the cyst as a means of curing ovarian
dropsy. He practised it in three cases, and in two was suc-
cessful.

Unlike my proceeding, he advises the drawing out of as much
of the cyst as can be readily extracted, without displacement of
the other contents of the abdomen. He also makes it a
principle of the operation, to cut off the cyst, not close to the
wound, but from one and a half to two inches beyond it, so that
when the portion of cyst has been removed, the cut margins can
be carefully examined, and each of the vessels be secured by fine

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OR ENCYSTED DROPSY OF THE OVARY. 237

silk; and he directs the ends of the ligatures to be cut off close
so that none may hang from the wound.

For the cases, which are highly instructive, I would refer my
reader to Mr. Wilson’s own description in the periodical named.

In one of Mr. Wilson’s cases,* the sac from which he had
excised a large portion, slipped back into the abdomen before he
could tie its vessels, which were numerous and large, and by
hemorrhage into the peritoneal cavity, acted as the chief cause
of the fatal result. To obviate so disastrous an occurrence for
the future, that gentleman contrived an instrument, having two
branches, each seven inches long, which could be so screwed
together, as to hold the cyst firmly between them. Figures of
this instrument are given in the journal quoted.

I have never felt the want of such an appliance, and should
think it would be in the way of the operator. The vulsellum
forceps and proper assistance are alone necessary to guard
against an accident of the sort.

I shall first relate the particulars of one case in which the
endeavour to imitate nature, by excising a portion of the cyst
and leaving an opening in it, proved eminently successful. I
shall then illustrate, by two other cases, the difficulties which
may be encountered in this operation. The first case is thus
related in the case-book at St. Mary’s Hospital:—

Casz LII.—Jane T., wt. 47, admitted Feb. 13, 1852, into the
Victoria ward at St. Mary’s Hospital, under Mr. I. B. Brown.
She is a thin spare woman, of somewhat sallow complgxion. She
stated that the catamenia first appeared at the age of 14, after which
they occurred at regular periods up to the age of 19, when she had a
child; she believes she had a natural labour, and she got about in
three weeks after. Since this, the catamenia having regularly appeared,
the amount of secretion however has gradually lessened. About
nineteen years ago, whilst lifting a heavy piano she strained herself,
and soon afterwards prolapsus uteri came on ; she then also noticed
that her abdomen began to get larger; when the enlargement first
appeared it gave her the idea of a lump, commencing on the left side ;
three years ago she was in St. George’s Hospital for eight weeks, and
afterwards for seven weeks an out-patient, without deriving any
benefit. During the last six months the swelling has increased much
more rapidly; before that period the growth having been rather slow.
At times has had shooting pains about the abdomen, sometimes

* « Provincial Medical and Surgical Journal,” Jan. 22nd, 1851, p. 36,

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confined to the left side, and to the space between her shoulders. She
has complete prolapsus uteri, which she has considerable difficulty in
returning, the uterus coming down on the slightest movement, even
on turning in bed. During her stay in St. George’s, she wore
pessaries. The abdomen is considerably enlarged; the -tumefaction,
however, does not extend uniformly and completely up to the scro-
biculus cordis; percussion gives a dull sound over the front of the
abdomen, but is resonant on the sides; less so, however, on the left
than on the right. Fluctuation extremely distinct. The general
health was attended to, and a cutaneous eruption which appeared was
removed, and on March 10th Mr. Brown judged her to be in a fit
state to undergo the operation.

March 10th. Having been placed under the influence of chloroform,
an incision four inches long was made through the integuments along
the linea alba, commencing about an inch and a half below the
umbilicus. The transversalis and afterwards the peritoneum were
then divided, and the cyst, covered by the visceral layer of the
peritoneum brought into view; its surface covered by ramifying
vessels. The hand passed round the tumour encountered no adhesions.
Cutting through the peritoneum, avoiding and pushing aside the
vessels, the cyst was then punctured by a large trocar, and about
sixteen pints of clear limpid fluid withdrawn, leaving a small quantity
behind. Lastly, the cyst having previously been seized by the vul-
.Sellum forceps, a portion of it comparatively devoid of bloodvessels was
cut out, its size being about four inches by three, but with an irregular
outline. The omentum protruded a little, and had to be returned:
the edges of the wound were then brought together with four or five
interrupted sutures, care being taken to pass the needle deeply, so as
to include the whole of the abdominal parietes, except the peritoneum
itself, and to let the edges of the peritoneum come closely and evenly
together. Two or three fine sutures were placed through the skin in
the intervals between the deeper ones, so as to ensure perfect union.
She was ordered two grains of opium immediately, and one grain every
three hours: a pad of wet lint was placed over the wound, and a broad
bandage round the abdomen.

6-45 p.m. Has been sick, has a little pain, pulse 110, full and
strong, skin moist, lips rather dry.

9-40 p.m. Pulse 120, hardand jerking. Respiration 32; some tym-
panitis and pain on pressure, greater in the left iliac fossa ; has some
thirst ; bled from the arm to twenty ounces; pulse was lowered to 80 ;
two grains of opium immediately.

12 p.m. Pulse 108, softer; respiration 28; less tympanitis.

2pm. Is asleep, has passed a nearly fluid, dark coloured motion.

11th, 8-30 a.m. Pulse 110, rather hard ; respiration 30 ; there is
more tympanitis, somewhat less tenderness on pressure; tongue rather
white and dry ; venesection sixteen ounces ; the pulse did not diminish
in frequency, but became softer ; five grains of calomel and two grains
of opium immediately, and to be repeated in six hours if needful:

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_ 4m. She has been asleep since the last note, and is so now. There
is more tympanitis, but not much tenderness of abdomen ; the wound
looks quite healthy; pulse 120 full; tongue rather white and dry,
with red edges; repeat the calomel and opium immediately ; has
passed about a pint and a half of high coloured urine.

11:30 p.m. Much the same; pulse 108, rather hard; countenance
placid, skin cool, tongue moister ; bled from the arm to thirty ounces.
Repeat the calomel and opium.

12th. Feels easier; pulse 100, strong; complains of flatus, abdo-
men tympanitic, wound healing by the first intention. Blood drawn
rather buffed and slightly cupped; skin moist. Citrate of potash
twenty grains, carbonate of ammonia three grains, camphor mixture
and water each half an ounce every five hours. Passed a pint and a
half of urine.

1l pm. Pulse 108, hard and jerking; more tenderness and tym-
panitis, tongue more furred in the centre: has passed a little more
urine ; respiration 36. Bled from the arm eighteen ounces ; pulse
become softer, 128. Respirations 30; less tenderness on pressure and
on coughing. Repeat the calomel and opium directly, and in six hours.

13th. Has passed about a pint more urine, which is rather thick ;
specific gravity, 1022; not albuminous; its quantity greater than
fluid taken. She has had a restless night; face flushed ; tongue
coated with a creamy fur; gums not much affected. She suffered
greatly during the night from flatulence, which was relieved by
passing a tube into the rectum. Pulse 120; respiration 30; more
tenderness and tympanitis; skin moist. Repeat the calomel and
opium every four hours, and omit the mixture. This afternoon she
feels weaker.

14th. Omit the calomel and opium. To have some strong beef tea.
Pulse 108, easily compressible. A leather plaster was applied over the
abdomen yesterday; there are now less distension and less flatus.
Sutures removed ; union perfect, except that one edge slightly over-
laps the other ; tongue clearing; has passed half a pint more urine
than she has taken fluid.

15th. Abdomen getting quite flaccid ; pulse 112, compressible, no
tenderness. After the above the bowels were relieved three or four
times, which rather weakened her. Motions of a dark colour, and
fluid; she has had some griping; tongue cleaner. To have port
wine, 2 oz, and a mutton chop. Take aromatic confection, 20 grs. ;
sedative solution of opium, 10 drops; sal volatile, 10 drops; chalk
mixture, 1 oz. every two hours. Quantity of fluid taken and urine
voided, equal.

16th. Pulse 120; feels better; abdomen smaller; tongue much
cleaner ; bowels open once, no tenderness ; urine voided, one pint,
less than fluids taken.

17th and 18th. Improving ; more fluid voided than taken.

19th. Pulse quiet, rather feeble ; bowels regular. Fluid taken and
voided equal, 1 grain of quinine, 5 drops of sulphuric acid, and

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13 drachms of tincture of cassia, and 1 oz. of camphor mixture three
times a day.

20th. Abdomen getting quite flaccid ; bowels open ; tongue clean ;
looking much better.

21st. On the right side, and below the cicatrix, a solid, irregular
substance can be felt, evidently the remains of the cyst. She is
getting stronger.

22nd. To sit up a little.

25th. Has a little griping pain in the abdomen. 1 oz. of decoction
of bark, and 3 grs. of carbonate of ammonia, three times a day.

29th. The tumour not so easily felt. To have 2 oz. of compound

senna mixture. Milk diet.
April 3rd. No increase of abdomen; feels well; simple diet ;

mutton chop.
6th. Discharged.
Sept., 1853. She is still well, and equal to her duties as a servant.

April, 1854, Has during the past year gained in flesh and strength,
and continues to perform her duties as a domestic servant,

It will be seen that acute inflammatory action was set up
in the cyst and in the peritoneum, and that the most energetic
means were required to overcome the urgent symptoms.

This case offers some important practical points for consider-
ation, which T shall very briefly notice :—

1. The nature of the cyst—unilocular.

2. Why not attempt a cure by tapping and pressure?

- 8. How do we explain the subsequent condition of the
patient ?

4. Why do we expect that the cyst will not refill, or, at all
events, fluid collect in the peritoneum ?

1. The cyst was evidently unilocular, and the walls thin;
and it was also evident by the usual diagnostic signs, that there
were no adhesions; and on a small trocar being introduced, it
was found that the fluid was very slightly albuminous.

2. It was, in fact, just the case which I should have selected
for the treatment by pressure ; but this patient had so persistent
a prolapse of the uterus, that the slightest exertion extruded
that organ, and no perineal support would retain it within the
vagina. I was therefore convinced that any well applied pads
and pressure would have the effect of increasing the prolapsus.

3. This patient’s condition, after she was convalescent, was,
the remaining portion of the cyst continued secreting, and
as a certam quantity, about a pint, accumulated, it escaped

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into the peritoneum, absorbent action was set up by that
membrane, and the kidneys excreted the fluid. This would
probably go on for some time, till the cyst became altered in
condition, becoming more hardened, and assuming eventually, it

might be, a calcified character, and consequently a less amount
of vitality.

4th. It was therefore to be expected that the kidneys and
peritoneum would continue to carry off the fluid secreted, and
that the cyst would gradually undergo a process of degeneration
as above alluded to; a result which has now been happily

realized.

Case LITI.—E. H., a lady, aged 58, sent to me by Dr. Locock
the mother of several children, had a large multilocular cyst. I
dissected down to the cyst in the semilunar line, cut through its
walls, which were very thick, and excised a portion. After the escape
of a highly albuminous fluid, to the extent of twelve pints, it was
found that a second large cyst existed, the fluid of which I evacuated,
and then closed the wound. A sharp attack of inflammation super-
vened, which was treated by bleeding, with calomel and opium, and
the patient did well. The first cyst has collapsed, and is easily felt
through the abdominal parietes ; but the other has frequently filled ;
but now (1854) it fills at a much slower rate, and the patient is in
good health, and able to walk and drive out as formerly. I should
observe that I kept up very steady and firm pressure after each
tapping ; and I believe that this has mainly prevented the cyst from
filling so fast.

The subjoined table exhibits the gradual improvement which

has occurred in the decreased morbid activity of the cyst.

, Tapping. Pints.
March 13th, 1851 SOP ae shane 2389
June 5th si Dik 26
July 22nd 5 Od 26
Sept. 26th 7 ag 30
Nov. 12th 5 5 28
Dec. 26th she 6 28
Feb. 19th, 1852. 7 28
» mrt he gg acs ee, ee Ee es 24
June 19th Glande ye tay Cele ales. Bp ae aS
Aug. 26th a bem cae ee AM Sg goo ES
Oct. 25th je) Beige a Sg ey Hl
Dec. 23rd ioe oe! Be Go oe
April lst, 1853 ©... . . 130.0. 2. =. «285
July 14th, Gg ee ee ee Pe ace ae
Dec. 16th lice aie Ae cit gD Gen cr Sah He

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As these sheets are passing through the press, I observe that
the operation of partial ovariotomy has been performed by
Mr. Crouch, of Bruton, Somerset, the particulars of which are
published in the “ Association Medical Journal,” (Jan. 20th,
1854.) In this case the cyst was very thick and vascular, and
adherent to the surrounding structures in every direction. A
piece of the size of a crown piece was excised with a large pair
of scissors. ‘No fewer than seventeen small arteries required
the application of a fine ligature silk. Suppuration occurred
after the operation, which process continued until the period of
her death, sixteen weeks after the operation. Her health had
improved considerably before her decease, which was sudden
and unexpected. The post mortem examination proved that
matter had escaped from the tumour into the peritoneal cavity,
and the solid part of the cyst exhibited evident traces of can-
cerous deposit. The left ovary appeared healthy and only
slightly enlarged. The uterus had a small fibrous tumour
imbedded in its substance.”

6. Extirpation of the whole Cyst, or Ovariotomy.—This has
been looked upon as the last alternative; and the formidable
and hazardous character of the operation has deterred most
surgeons from attempting it. _ :

I do not profess to give a history of the operation of ovari-
otomy ; but may state, generally, that the idea of the entire
removal of the dropsical cyst occurred to several of the older
surgeons, of whom were Bonetus, Delaporte, and Van der
Haar; but was opposed by Morgagni, Sabatier, and others.
The first who attempted extirpation appears to have been
Aumonier, of Rouen, in 1782, and he was successful. Of later
celebrities in favour of it may be mentioned Dieffenbach,
Martini, Siebold, and Lizars; and, on the other side, Sir C.
Bell, Liston, W. Hunter, and Seymour.

At the present day, I think I may safely state that the
number of those who recognise ovariotomy as a legitimate
operation, is on the increase; and, undoubtedly, it is more
frequently than ever performed. It would be useless here to
enumerate the whole array of names of those who have prac-
tised the operation, or who approve of it; but in my ensuing

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observations on its expediency, the opinions of several distin-
guished surgeons will be referred to.* I may at once advance
the proposition that, even if the authorities in favour of ovarian
extirpation were less numerous and less eminent than they are,
the statistics of the procedure would commend it to our atten-
tion, as one far more satisfactory than are several others unani-
mously approved of by surgeons.

This point was well put forward by Mr. G. Borlase Childs,
in a paper read before the Medical Society of London} since I
have had this chapter in preparation. He made remarks to
the following effect: that the mortality after ovariotomy could
not be considered large, when it is remembered how common it
is to delay the operation to the last—undoubtedly, a prin-
cipal cause of its failure, as reference to recorded cases would
show ; and that errors in diagnosis sometimes committed, form
no argument against the operation. Mr. Fergusson, no mean
authority, in his work on “ Practical Surgery,” (8rd edition,
page 792,) says, “ My personal experience in the operation last
referred to (ovariotomy) has been comparatively limited; yet,
though prejudiced against it in my early education, I now feel
bound to state that the removal of such formidable disease by
one or other of the various proceedings as first executed in this
country by Mr. Lizars, and now practised Dr. Clay, Dr. F.
Bird, Mr. I. B. Brown, Mr. Walne, and others, is not only
justifiable, but, in reality, in happily selected cases, an admir-
able proceeding.”

Dr. Druitt,t after candidly stating the objections to the
operation, produces the following comprehensive summary of
particulars favourable to it. He says, “ On the other hand, in
favour of the operation, it may be argued: first, that the mor-
tality occurring from this is not larger than from many other
surgical operations; second, that as no other plan of treatment
can effect a radical cure, but by this, women, relieved of a burden

* The chief British Medical Practitioners who have performed
ovariotomy are :—Messrs. Clay, Lane, Walne, Frederick Bird, Crouch
of Bruton, Borlase Childs, and Tanner.

+ April 8th, 1854. See Report in the Journals.

+ Surgeon’s Vade Mecum, sixth edition, p. 467.

R 2

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which made life miserable, have married and borne children ;
third, that if favourable cases only were submitted to operation,
the mortality would be very small, and that increase of ex-
perience would lead to the selection and discrimination of
favourable cases; fourth, that if the surgeon, in order to com-
plete his diagnosis, makes a small incision to ascertain the ex-
istence of adhesions, and closes it again with suture, if he finds
this to be the case, no great harm is likely to result; in fact
this, which is sometimes raked up as an opprobrium against
operators, is a prudent and legitimate measure. Lastly, it is
by far the most merciful plan of treatment, if adopted early, in
patients otherwise healthy, with a still growing, but non-adherent
tumour.”

The whole question of operative interference has been very
fairly stated in an article in the “ Medico-Chirurgical Review”
for April, 1853, written by .Dr. Fleetwood Churchill, as a
critique on Dr. Robert Lee’s recent work “On Ovarian and
Uterine Disease.”

The remarks of the able reviewer are so apposite to my
present purpose, that I shall here reproduce most of them.
He writes: “The objections to the operation adduced by Dr.
Lee are,—1. The great mortality, which, according to his tables,
is 1 in 23. 2. The extreme difficulty of diagnosis, so as to be
sure the case is one which will offer no obstacles to the removal
of the tumour. 3. The possibility of prolonging life consider-
ably by other means. To this it is answered by the advocates
of the operation :—

“1, Undoubtedly, the mortality is very great—l in 2% ac-
cording to Dr. Lee, 1 in 3 according to others; but a mortality
nearly, if not quite as great, is not considered a fatal objection
to other operations. If we take the major amputations of the
limbs (primary and secondary) it appears that in Paris, accord-
ing to Malgaigne, the mortality is upwards of 1 in 2; in
Glasgow, it is 1 m 23; in British Hospitals it is ] m3}. As
to amputation of the thigh, Mr. Syme observes—‘ the stern
evidence of hospital statistics shows that the average frequency
of death is not less than from 60 to 70 per cent.” Of 987 cases
collected by Mr. Phillips, 435 proved fatal, or 44 per cent.

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OR ENCYSTED DROPSY OF THE OVARY. 245

Mr. Curling states, ‘On referring to a table of amputations, in
the hospitals of London, performed from 1837 to 1843, I find
134 cases of amputation of the thigh and leg, of which 55
-were fatal, giving a mortality of 41 per cent. Of 201 ampu-
tations of the thigh, performed in the Parisian hospitals, and
reported by Malgaigne, 126 ended fatally. In the Edinburgh .
hospitals, 21 died out of 48. Even if we take much larger
numbers, we find the mortality very high. Dr. Inman has
collected 3586 cases of ‘amputation generally, primary and
secondary, for accident or disease, and the deaths are 1 in 33,’
In 4937, published by Mr. Fenwick, the mortality is 1 in 33.

“The result of amputation at the hip-joint is still more
unfavourable. Mr. Sands Cox has shown, that of 84 cases, 26
were successful, and 58 unsuccessful.

* Again, take operation for hernia. Sir A. Cooper records
36 deaths in 77 operations; and Dr. Inman, 260 deaths in 545
cases. Or, the ligature of large arteries, of which Mr. Phillips
has collected 171 cases, of which 57 died; Dr. Inman, 199
cases, of which 66 died. Of 40 cases of ligature of the subcla-
vian artery, 18 proved fatal. Ligature of the innominata has,
we believe, been fatal in every case. So that, taking the mor-
tality at Dr. Lee’s estimate, it is not higher than that of other
operations, which are admitted to be justifiable notwithstanding.

“ But although these figures show that as high a mortality
occurs in other operations as in ovariotomy, we beg to remark,
that the necessity for the operation is much more urgent in the
former. In many cases it is the alternative of immediate
death. Further, the operation of ovariotomy is of two kinds—
by the long and short incision ; and the advocates of the latter
point to their statistics, which give a mortality of 4 in 23 cases,
ov nearly 1 in 6; whilst, according to Mr. Safford Lee’s tables,
that by the long incision is 1 in 3.

“9 he errors in diagnosis have been very great, and the
fair inference therefrom is, that the diagnosis is difficult and
obscure. But, unless it can be proved that all improvement in
this department is impossible, it is clear the argument cuts both
ways. If the present deficient diagnosis entails an increased
mortality, it is certain that every improvement will by so much

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reduce it. And we can see that it is possible that this may
occur ; for if all who have operated had the means of ade-
quately ascertaining the actual presence of a tumour, of being
sure that it is an ovarian, of determining the amount of ad-
hesions, and had been sufficiently attentive to the constitution
of the patient—it is clear that many of the recorded operations
would never have been undertaken, and equally clear that many
of the deaths would have been avoided, as a cursory glance at
Dr. Lee’s tables will prove. Moreover, it seems highly pro-
bable that a more accurate knowledge of the contents of these
cysts may lead to important results as to the selection of the
more promising cases for the operation, which may yet further
diminish the mortality; and, lastly, it is quite possible that
some beneficial modification of the mode of operating might be
adopted.

“3. With regard to the prolongation of life by palliative
treatment and repeated tapping, it is not easy to estimate the
exact gain: it would have been a valuable argument if Dr. Lee
had given us a collection of cases to show the amount of pro-
longed life thus obtained. If the patient be otherwise in good
health, and the ovarian tumour increase very slowly, it is true
that years may elapse, under careful treatment, without much
distress, or any necessity for measures involving risk. In such
cases, life will be best prolonged by letting the patient alone.
But with those that increase rapidly, and to such an extent as
to occasion inconvenience and distress, or to threaten life, some-
thing must be done to afford relief, and tapping has been the
ordinary means. We have, however, but few statistics to show
the results. .....

“ From this brief summary it appears, that the admissibility
of the operation will depend, not so much upon the rate of
mortality hitherto, as upon future improvements in diagnosis ;
and when we see men of high intelligence like Drs. Simpson
and Bennett, Southam, Walne, and Frederick Bird, devoting
themselves to this task, we cannot doubt that a decided and
practical advance will be made.”

In the main, I cordially agree with the foregoing observa-
tions and arguments of Dr. Churchill, and will add, that much

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has of late been done to improve our diagnosis of ovarian
dropsy 3 to lessen the danger of committing those grave errors
of which many of Dr. Lee’s collected cases afford examples.

Indeed, in forming an estimate of the value of Dr. Lee’s
tables in deciding on the mortality, or on the admissibility
of the operation of extirpation, it must be remembered that
not a few of the cases occurred some twenty or thirty, or even
more years ago, when pathology was more crude, and when
many sources of diagnosis now resorted to, were altogether
unknown. For example ;—the stethoscope, the uterine sound,
the speculum, and the exploring needle, are recent: inven-
tions; so—be its value what it may—is the achromatic
microscope, as applied to pathology and diagnosis. Then
again, I may safely affirm, that manual exploration of the pelvic
viscera was not carried out twenty years ago, with the same
care and discrimination as at present ; and lastly, the lesions
and the displacements occurring in the pelvic organs were, at
the best, imperfectly understood.

Further, the surgeons in these earliest cases had not the
benefit of example and of the experience of others in their
operations ; and if modern surgery have advanced,—especially in
the matters of dressing and after-treatment,—present and future
operators and patients may hope more favourable results from
ovariotomy.

These ancient examples will therefore be surely not deemed of
much weight, in appreciating that operation as it would be
carried out at the present day.

The value of Dr. Lee’s table of cases will appear still less,
when we reflect on the circumstances under which the operation
has frequently been performed. Setting aside those in which
the diagnosis has been faulty from want of sufficient attention or
experience, some underwent the operation as a ‘ dernier ressort;’
others with constitutions broken by the long continuance of the
malady, or by the existence of malignant disease, or by the
drain of albumen from the system by repeated tapping.

Finally, may I not assume without fear of contradiction, that
the operation as now performed is improved,—that the provi-
sions for securing success are better known and applied. Is it

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a trifling advantage that we can now operate on the patient with-
out pain to her, and with leisure and facility to ourselves ?

I believe the preceding remarks must prove that our statistics
of the operation of ovarian extraction are, per se, not at present
sufficiently accurate and precise to construct data upon, as to
the admissibility, or not, of that measure; yet that the weight
of argument is in the favour of its admissibility into practice as
a legitimate operation.

Another circumstance with regard to extirpation of a diseased
ovary is, that it is the only operation affording undoubted
security against the return of the malady. By it the disease is
literally extirpated,—the whole morbid mass is taken away ;
whereas, by the other operations, partially, or, as they are
called, undeveloped cysts may persist after the destruction of
the major ones, and in course of time develope and reproduce
ovarian dropsy; or, again, solid tumours may remain behind
after the disappearance of the dropsical sacs, and be a cause of
suffering and of death to the patient.

A very satisfactory case of ovariotomy happened to Mr.
Crouch, of Bruton,* where the patient was safely delivered of a
child two years after the operation. See the case of Miss B.,
hereafter recorded by me.

CONDITIONS RENDERING THE OPERATION OF OVARIOTOMY
JUSTIFIABLE.

1. The surgeon should be satisfied by most careful and
repeated examination,—that the tumour is ovarian; and those
with whom he may consult should take equal pains to form an
unbiassed opinion. The diagnostic signs it is not necessary
here to repeat. (See page 181.)

2. That the tumour is increasing, and that the disease will be
likely to progress to a fatal issue if allowed to take its course.

3. That such of the different modes of treatment already
described, as appear to be suitable to the case, excepting the
excision of a portion of the cyst, have been fairly tried without
lasting benefit.

* Medico-Chirurgical Transactions, Vol XXXV.

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OR ENCYSTED DROPSY OF THE OVARY. 249

4, That the tumour is not cancerous.

- 6, That the patient is not so reduced in her general health
and vigour, as to render her an unfit subject for a formidable
operation.

6. That there is no evidence of the existence of adhesions.

7. That the fluid is not highly albuminous.*

These conditions being present, the next question is, at what
stage of the disease should the Operation be performed? Should
we wait till life is brought into immediate and imminent
danger, so that any measure, however desperate, might be justi-
fiable, which presented the faintest prospect of affording relief:
—or should the earliest period be chosen after the necessity of
the operation has become unequivocally apparent? On this
question, a variety of opinion exists 3,some of the advocates for
the operation only approving of it as a forlorn hope; others,
believing with Dr. Druitt, that “it is by far the most merciful
plan of treatment if adopted early,” and that. “the reasons for
running the risks will be much the strongest in the case of a
young, healthy person, whose life, if spared, might be long and
valuable.” I am persuaded that on this question hang chiefly
the results, whether fatal or favourable, of the operation, and I
therefore adhere most strongly to the latter opinion. I con-
sider that the risks of the operation are becoming greater every
year the disease exists. The tumour and its coats and pedicle
are always growing, its chances of contracting adhesions are
multiplied, and the patient is getting older, and most probably
less able to endure the shock every year she lives. Indeed, I
should as soon be persuaded to delay the operation for strangu-
lated hernia till the symptoms of approaching gangrene became
apparent, as to delay to extirpate an ovarian cyst, when I had
once determined that it must be done. I believe that if early,
and otherwise favourable cases, were selected for operation, the
mortality would be very small. This opinion I give advisedly,

* Believing as I do that the highly albuminous condition of the fluid
exhausts the system ina similar way to that of albuminuria from
disease of the kidney, I consider that it contra-indicates an operation
as clearly as the latter disease. The nature of the contents may be
readily discovered by withdrawing a little by an exploring needle.

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after a thoughtful review of all the cases on record, as well as of
my own. After tapping and pressure have failed, and the cyst
begins to fill, the chances of success in ovariotomy, as well as
in the operations above described, will be, ceteris paribus, deter-
mined by the promptness with which the operation is performed;
and it is very important that it should not be deferred till the
strength of the patient is exhausted by the disease, or abdo-
minal or pelvic mischief has been done by the weight or pressure
of the tumour. I therefore differ from those who advise that
no operative procedure take place, until the tumour seriously
interferes with the healthy action of the abdominal organs.

In a paper recently read before the North London Medical
Society, by Mr. Erichsen,* that intelligent surgeon strongly
advocated the contrary practice. He recommended “ palliative
treatment, until the growth has begun to interfere seriously
with the comfort of existence, or with the healthy action of the
abdominal organs. When these injurious effects of pressure,”
he continues, “ have once fairly begun to manifest themselves,
the patient wasting, suffering much discomfort from her size,
with difficulty in breathing, repeated vomiting, gastric irrita-
tion, &c., then the question of relief from operation will neces-
sarily obtrude itself. * * * It is proper to perform it
when all other means of relief have failed, and when the patient’s
health is giving way under the extension of the disease.’ This
certainly is not the rule by which Mr. Erichsen, or any other
experienced surgeon, would be guided in a case of strangulated
hernia, fistula, polypus uteri, or any other disease, the tendency
of which is from bad to worse, and which ultimately may be
expected to destroy the health and life. The operation should
‘be performed, not when there is but one chance in three, but
when, with proper precautions, there are twenty chances to one
in its favour. I am glad to find Mr. Borlase Child entertains the
same viewst with myself on this point, as well as on most others
with respect to extirpation.

.

* Association Medical Journal, Jan. 13th, 1854, p. 37—39.

+ Recorded in a Paper read before the Medical Society of London,
April 8th, 1854. See abstracts of it, and the discussion in the Me-
dical Journals.

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OR ENCYSTED DROPSY OF THE OVARY. 251

PREPARATIONS FOR THE OPERATION.

As all important operations are liable to fail from the neglect
of little things, both in preparatory proceedings and in the
operation itself, the following suggestions, all of which are really
of moment, may be useful to those who are about to operate for
the first time.

1. If the weather be cold, the patient should have, ready to
wear, a flannel waistcoat, and a pair of flannel drawers: the
waistcoat should be put on before the operation.

2. She should have a warm bath the night before the opera-
tion, to cleanse the skin, and thereby ensure free perspiration
after the operation.

3. The bowels should be opened by a dose of ox-gall or castor
oil, and an enema, on the morning of the operation day.

4, A hot water-bottle should be prepared for her feet.

5. There should be a thermometer in the room, and the
temperature should be kept systematically at not lower than 66
degrees, nor higher than 70 degrees. A kettle should also be
boiling on the fire, so as to make it possible to insure a degree
of moisture in the air by the steam. This is especially requisite
when the wind is in the east, or the weather hot and dry.

6. If the operation take place on the bed which the patient
is afterwards to occupy, the lower part of it should be prepared
and guarded by a macintosh sheet and an old blanket, which
can be afterwards removed. There should be a hassock or stool
for the feet to rest upon. The feet and legs should be clothed
in warm stockings, and the hands and arms enveloped in a warm
flannel gown.

7. As the patient will have chloroform administered, she
should not take any food for some hours previous to the opera-
tion; and to avoid sickness afterwards, a supply of ice should be
procured for her to suck for two or three hours before the
operation. This is of much consequence.

8. There should be plenty of hot water in the room, in which,
in cold weather, both the operator and his assistants should
immerse their hands before touching the patient; and there

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should be from three to six basins of warm water ready for
immersing sponges or warming the flannels, &c.

9. The duties of each assistant should be clearly assigned and
understood before entering the room, so as to avoid confusion,
and also to save time, an important point when the peritoneum
is exposed.

10. Four or six large needles should be got ready, armed
with the best twine, well waxed, for the interrupted suture ; and
one large needle to carry the double ligature (also of twine, not
of silk,) for the pedicle. Several smaller ligatures for blood-
vessels should also be ready; and a flannel bandage to go round
the abdomen after the operation is completed; also a supply of
lint and a few adhesive straps.

11. Instruments. —One or two scalpels, a pair of scissors, a
pair of Vulsellum forceps, a pair of good common forceps,
tenaculum, trocar and canula of large size, together with the
needles and ligatures, should be ready on a tray.

Lastly,—As much will depend upon the after eine it
will be well to arrange beforehand that the operator, or some
other competent surgeon, should remain with the patient all
night. Indeed, she should not be left for more than two hours
at a time for the first three or four days.

MODE OF OPERATING,

The patient being placed conveniently on her back, and
brought under the influence of chloroform, an exploratory inci-
sion, from two to three inches in length, should first be made in
the linea alba. Having divided the peritoneum and reached
the cyst, two or more fingers should be passed over its surface to
ascertain if adhesions exist ;—if these are slight and recent, they
should, if possible, be broken down by the fingers; or if they
are few, and small in diameter, so as to bear division, they may
be first tied to guard against hemorrhage, and afterwards
divided ; but if they are spread out to a considerable breadth, it
is better to desist from any further procedure with a view to
extirpation. If, on the contrary, there are no adhesions, or only
such as can be easily broken, the incision should be enlarged to

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the extent of four inches, or more if necessary : the next step is to
tap the cyst or cysts with a proper trocar and canula, and in the
evacuation of the fluid, to take care that none of it escapes into
the cavity of the abdomen. Then, if there is only one cyst, and
that not thick nor vascular, a portion of it only may be excised,
in the manner described in the section “On Excision of a Portion
of the Cyst.” If the cyst, however, should be found to be thick
or vascular, or multilocular, it will be the safest procedure to
have recourse immediately to complete extirpation in the follow-
ing manner. The pedicle of the tumour is to be taken in the
left hand, and gently drawn outwards from the pelvic cavity,—
an assistant carefully keeping back by warm flannels the bowels
and omentum. The course of the bloodvessels in the pedicle
should now be carefully observed, so that the latter can be
safely punctured by a scalpel or bistoury, and through the open-
ing thus made an aneurismal needle, carrying a double ligature
of the strongest twine, be passed, and firmly tied on each side
of the pedicle. Mr. Wilson advises, that instead of passing a
ligature round the pedicle, each vessel should be tied separately.
This some regard* as an important improvement. This ligature
should be passed as near to the tumour as possible, so that, by
the entire length of the pedicle being preserved, the ligatured
end may be kept external to the abdominal cavity together with
the ligature, as recommended by Messrs. Duffin and Erichsen.
This done, the tumour should be removed by dividing the pedicle
half an inch from the ligature, which should be given to an
assistant and held at the inferior end of the opening. The
operator then closes the wound—and this, I need hardly say,
should be done, as in all operations exposing the peritoneum, as
soon as possible—by introducing deep sutures about an inch
from the incised edges, through the parictes of the abdomen,
taking care to avoid the peritoneum. These sutures should be
about half an inch apart. The edges of the wound should then
be more carefully brought together by superficial interrupted
sutures occupying the intermediate spaces between the deep
ones. It now only remains to prevent the end of the pedicle

_ * See Medico-Chirurgical Review, January, 1852.

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and the ligatures from returning into the abdomen. For this
purpose, a common director, with its convex surface turned
towards the abdomen, should be passed through the ligatures,
so as to be firmly held by them at right angles to the wound.
The ends of the ligatures should now be secured to the abdomen
by adhesive plaster, and the wound dressed with common water
dressing. This done, the abdomen must be supported by a
many-tailed flannel bandage, comfortably tight, the patient be
placed in bed, and warmth applied to the extremities. Two
grains of opium are to be at once given, and one grain re-
peated every three or four hours until pain is allayed. Ice,
milk, barley-water, or weak broths, should constitute the diet for
the first twenty-four hours; afterwards stronger animal broth
may be allowed, and wine, if the condition of the patient admit
of it. It is better, if possible, that the bowels should be con-
fined for four or five days after the operation. The bladder
should also be emptied every six hours by the catheter. The
temperature of the room should be carefully maintained for the
first week after the operation.

I have not enjoined the use of any particular length of inci-
sion; for this matter must, I am of opinion, be regulated by
the special circumstances of each case; the rule on the sur-
geon’s part being to extract the cyst with the least danger to
the patient, and through the smallest practicable incision with-
out incurring a risk of failure in the operation. A small in-
cision, of an exploratory nature, should be the first; if the
operation be proceeded with, it must be enlarged sufficiently to
admit the extraction of the apparent cyst, and further increase
will be very easy, if, by its peculiarly compound nature, its
position or relations, or other circumstances demand it.

The long, the median, and the short or small incisions, have
each had their advocates, and their relative advantages been
hotly debated ; and statistics have been adduced to show that
fewer deaths attend the smaller incisions. Such discussions I
regard as of little moment, and the attempt to fix a certain
length for the abdominal section in all cases, as frivolous. As
well might operative surgeons debate on, or endeavour to fix
the exact number of square inches the flap of an amputated

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limb ought to have, without reference to the muscularity or
fatness of the extremity, or to any other special circumstance
which ought to weigh in the management of each individual
case.

It is desirable, when the diseased ovarian mass of one side is
removed and before the abdominal incision is closed, to look at
the condition of the other ovary, which not uncommonly is also
diseased, and when such is the case, may be at once removed.
An instance of this sort is described by Dr. Peaslee, in the
American Journal of Medical Science, for April, 1851, in which
a cyst the size of a pullet’s egg was discovered on the right
ovary, and the whole organ was diseased. A double ligature
was passed through the broad ligament, and the ovary removed ;
the ligatures were drawn out through the wound at the nearest
point.

The dangers to be apprehended after ovariotomy are—a. The
shock of the operation; 6. Hemorrhage; c. Acute inflamma-
tion—peritonitis; d. Inflammation of a low or typhoid character.

a. Now that we have the benefit of chloroform, the dangers
from the shock of the operation are greatly lessened. But in
some of high nervous susceptibility and debilitated frame, the
shock may be fatal or severely felt, even although chloroform
has been employed during the surgical proceedings, and the
patient has not regained consciousness until they are over and
the wound dressed. Like similar cases from other operations,
these demand the use of stimulants, and other means of support.

5. Hemorrhage is, unfortunately, not so uncommon; the
source of it being mostly from the cut pedicle or supporting
base of the tumour. It will be seen, however, that in one of
my cases the fatal bleeding had its source in the divided vessels
of an adhesion; and it is this event which has induced me to
recommend the tying of any divided bands of adhesion where
they have any thickness, and do not readily break down before
the finger.—The tying of the stalk of the tumour, as I advise,
will I think, generally provide against hemorrhage from it, care
being taken to leave the end of the pedicle out of the wound.
Hemorrhage may kill either by the exhaustion immediately in-
duced, or by the peritonitis it kindles.

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c. Acute peritonitis in a more or less severe form is a most
frequent occurrence after extirpation. Its origin we may trace
to the natural effort of the system to close the wounds made in
the tissues in the operation, by effusion of plastic lymph. Every
precaution is to be taken against the advance of this inflamma-
tion, and its treatment must be based on the ordinary principles.
Some of the following cases exhibit this casualty, its course,
and the treatment adopted.

d. Peritonitis of a low or typhoid type appears later than the
preceding conditions; and is seen when any of the cut tissues.
put on an unhealthy appearance, and when probably some
morbid excretions get into the blood.

Here, again, no special directions are necessary, since the
ordinary principles of treatment are those to be pursued.

It will sometimes happen that unlooked-for conditions pre-
sent themselves after the abdomen is laid open, and complicate,
or even render impossible, the operation. Among such is an
unusual vascularity of the cyst and consequent danger of fatal
hemorrhage. Examples of this condition have occurred suffi-
ciently aggravated to deter from completing the operation: in
such the surgeon must rely on his own judgment; no precise
rules can be laid down, but I imagine the vascularity of the
sac need rarely arrest the operation. Unexpected attachments
of the cyst posteriorly, to the intestines, or to other viscera, of
such a nature that it would be dangerous to destroy them, will
operate more frequently in discountenancing extirpation. Cancer,
indeed, may not be discovered until after the operation is com-
menced, and be so situated as at once to stop it.

Now, im all these cases, excepting cancer, where the steps
previous to the drawing forth of the cyst have been proceeded
with, and we are compelled to cease from the attempt at extir-
pation, the excision of a portion of the cyst is a mode of treat-
ment still available.

Case LIV.—of fourteen years’ duration: Tapping and pressure em-
ployed with much benefit; Ovariotomy; Death.—Miss E., a single lady,
zt. 27. This case was first treated by pressure, reported in the Lancet of
April 5th, 1845, which proved so far successful, that there was no re-
appearance of the disease for nearly two years. She was afterwards

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tapped again, and recovered so well as to be allowed to marry. After
her pregnancy and delivery, three cysts were found, two of which were
tapped. She nursed her infant for twelve months, Two years after-
wards, the cyst having re-filled, she was again tapped, and continued
well for another two years, when the cysts began suddenly to fill
again. It was then determined to extirpate.

Operation.—A four-inch section was first made through the linea
alba, and the first cyst presenting itself was tapped. The incision was
now enlarged, in order to puncture a second cyst, existing in the left
hypochondrium, and pushing the lungs up to the third rib. Still it
was found impossible to remove the sac, as a third cyst was discovered,
occupying the pelvic cavity, having very slight recent adhesions in
one spot on the right side. The incision was consequently further
extended ; the pedicle common to the three cysts was tied by a double
ligature, and the operation completed in the usual manner. Perito-
nitis supervened, and the patient died on the third day, apparently
more from exhaustion than from the severity of the inflammation.
Probably an earlier operation might have been safe and successful.

Casr LV.—Ovarian Dropsy of two years’ duration: Ovario-
tomy: Vascular Adhesion, and Death from Hemorrhage: Autopsy.—
M. A. B., et. 23, admitted at St. Mary’s Hospital May 7th, 1852 ;—
married: no children; catamenia regular, first appeared at 11 years
of age. She has generally had good health.

Two years ago, whilst walking down a hill, she felt something give
way in the abdomen, and soon afterwards noticed, as it appeared to
her, a hard round tumour in the right inguinal region, which has
gradually increased in size up to the present time. She has a pricking
pain in it occasionally. The tumour over which the integument,
moves freely, now occupies the abdominal cavity, reaching up to
within an inch and a half of the ensiform cartilage. Distinct fluctua-
tion is perceptible at the upper part, where there are also one or two
hard nodules. The tumour is universally dull; resonance is heard
on perecussing over the stomach and the lumbar regions. She has
never suffered from difficulty of breathing or indigestion, but has
occasionally had faintness come on after taking food. Urine plenti-
ful; sp. gr. 1022, alkaline, non-albuminous. She is 383 inches in
circumference.

11th, A small trocar—as an exploring needle—having been thrust
into the tumour, a little below the umbilicus, a fluid escaped which
contained much albumen, and some scales of cholesterine.

19th. Bowels have acted freely from the aperients given; feels very
weak; has no pain or inconvenience from the tumour. On examina-
tion, a defined margin is felt in the upper and right part of the abdo-
men, like the edge of the liver, but the finger cannot be passed under
it, Above this margin there is what feels to be liver, or a hard part
of the tumour: it moves with the general mass. When she lies upon

s

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her left side the tumour retains its form; but a prominence is felt and
visible above, and considerably to the right of the navel, and is
separated from the general enlargement by a well-marked fissure.
The integuments are adherent to the tumour in front of the abdomen,
as the recti muscles start: forward when the patient tries to raise
herself.

20th. 1.30 p.m. She was placed under the influence of chloroform,
and an incision, commencing two inches below the umbilicus, and
extending downwards about three inches along the median line, was
made, opening the peritoneal cavity, and bringing into view the
ovarian cyst. This last appeared very vascular, several large vessels
coursing over its surface, intersected by numerous smaller ones. The
peritoneum covering it was firmly adherent to its surface. It was
therefore determined to remove the whole cyst, and on passing the
hand over the upper part of it, a firm adhesion was found and divided.
By the evacuation of the cyst rather more than 18 pints of a dark
yellowish-brown fluid, presenting a glistening appearance from having
scales of cholesterine floating in it, were obtained. An attempt was
now made to draw the emptied cyst out of the abdomen, but this was
prevented, although the adhesion above-mentioned was destroyed, by
another cyst about the size of two fists. This in its turn was emptied
by the trocar; its contents were similar to the former. There were
also several other slighter adhesions which gave way under the finger
when the cyst was drawn out of the abdomen, and along with it an
apparently solid mass, occupying the pelvic cavity. The common
pedicle was firmly tied by a double ligature passed through it, each
portion tying half the pedicle. The cyst was then cut off.

The edges of the wound were brought together by deep interrupted
sutures, and by fine superficial ones, to bring the margins of the
integuments in close apposition; the ligatures were twisted together
and brought out at the lower part of the wound: a pad of wet lint
was then placed over the wound, and a bandage, made for the pur-
pose, round the abdomen. She was ordered opii gr. j. statim et 3-tiis
horis. The hard portion of the cyst consisted of numerous smaller
cysts, containing a fluid of a more gelatinous consistence than that
from the tapped sacs. On inspection of the vessels, two fair-sized ones
were found in the band adhesion.

9.30. Pulse 126; felt very faint on the bandage being readjusted :
given some brandy-and-water. Respiration 39; complains of pain in
the right shoulder ; has been sick several times; is rather restless,
and very thirsty; to have some lemon-juice; to omit the opium for a
time.—12 p.m: Has been again sick: feels easier; does not complain
of any pain; countenance less pale; skin natural; respirations 42 ;
pulse 148; about half-a-pint of light-coloured urine drawn off by
the catheter.

20th. 9.30. Has had several attacks of vomiting. Pulse 160; no
pain; headache. Ordered acid. hydrocy. dil. gutt, ij. every four hours.

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The sickness, rapid pulse, and general irritability continued with
slight exacerbations until 5 a.m. on the 22nd, when she was suddenly
oe with symptoms of collapse, and died in about a quarter of an

our.

Death here resulted from hemorrhage, and that from a very un-
usual source, viz., the vessels of a band of adhesion, as is shewn by the

Post-mortem Examination.—Body well formed. Abdomen, some-
what tympanitic. Edges of incision adherent except in one or two
spots, through which a little pus escaped by pressure ; this pus found
in the track of the deep sutures. On opening the abdomen, there
were found, about 21 inches to the right of the umbilicus, the
remains of the adhesion divided in the operation, surrounded by
a dark coagulum. The cavity of the peritoneum contained about
40 oz. of dark clotted blood. Coagula adhered to the intestines at
various parts ; the peritoneum was stained, but its vessels not much in-
jected. The blood had apparently come from the adhesion, which, as
noticed above, had two moderately sized vessels penetrating it. A
little coagulum was met with on the stump of the pedicle, which,
however, did not appear to have come from it, as the ligature firmly
constricted it. Stomach distended by flatus and fluid. Kidneys pale,
but healthy. Liver the same. Spleen small, with less blood than
usual. Uterus healthy, but left ovary contained a cyst about the size
of a walnut. Chest: old but thin pleuritic adhesions. Lungs some-
what collapsed, pale and apparently healthy. Heart,—a fibrous patch,
about the size of a sixpence, near the apex. A dark clot occupied the
right auricle, and a fibrinous mass the right ventricle. Left side
of the heart empty.

Cast LVI.—Ovarian Dropsy of nine years’ standing ; Repeated
tapping ; Extirpation ; Death.—Mrs. D., et. 37, observed the abdomen
begin to swell nine years ago, and this enlargement became so great
and was a cause of so much suffering that she was tapped five years
since, and a clear, light-coloured fluid evacuated. The cyst gradually
filled again, and after an interval of two years was a second time emptied;
then another two years having elapsed, the same process was repeated.
In January (1852) paracentesis was again, for the fourth time, prac-
tised; and afterwards the collection of fluid occurred more and more
speedily, an interval of seven weeks, and at last of only three weeks,
being interposed between the tappings. Altogether she has under-
gone the operation seven times, and of late by the rapid accumulation
her health is suffering considerably. On the last occasion the fluid
had a red colour ; from one cyst 20 quarts, and from another 6 quarts
were discharged. Ata previous operation three distinct cysts were
opened, each containing a distinct fluid. The evacuation of the cysts
has prostrated her exceedingly at the time ; indeed, after the two or
three latter operations it appeared she would hardly rally ; hence sti-
mulants and general measures to support her have been required for

s2

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some days after the tappings. The abdomen is greatly distended.
Previously to my seeing her, this patient had been under the care of
Mr. Hearne, of Gloucester.

It was clear she could not long survive the exhausting effects of the
repeated and oft-recurring tappings, and I thought the chance of cure
by ovariotomy ought to be given her, although from her feeble state
the prospect of success was not very encouraging.

July 1st, 1852. I proceeded to operate tor the extirpation of the
diseased ovary. Dr. Handfield Jones, and Messrs. Smith, J. Lane,
Trotter and Umphelby were present and assisted me. Beginning with
a small incision, I ultimately extended it to eight inches in length, on
account of the mass of disease, and its relations and extended adhe-
sions. Some of the last were of the breadth of the palm of the hand,
and one was long and cylindrical, and required a ligature before dis-
secting it away.

Numerous cysts were found in connexion with the larger, easily
breaking down under the slightest pressure or handling, and render-
ing their removal difficult. An immense mass of disease was removed,
weighing, with the fluid contained in the cysts, 70 lbs.

The pedicle was tied, the wound brought together by sutures, a
bandage applied, and the patient placed in bed.

Two grains of opium were given immediately after the operation,
and one grain repeated twice in the after-part of the day. She got
some sleep at night.

July 2nd. Vomiting occurred after taking some gruel; and at noon,
some nausea being present, I gave a dose of hydrocyanic acid in cam-
phor julep. A grain of opium was taken this morning. This afternoon,
pulse 90, weak ; skin warm ; mouth dry. Dozedalittle. The opium was
repeated at half-past five, and the urine drawn off. The latter had
a strong odour, was high-coloured, of feeble acid reaction, and loaded
with lithates.

3rd, 6 am: Some sickness persists; hydrocyanic acid again
given. Pulse 87, not hard; complains of pain in the right iliac fossa.
At 7.30, was ordered a suppository of three grains of opium.—6 P.u.:
Pulse increasing in rapidity, 111; tongue moist, slightly coated; skin
warm ; sickness still present. Complains but little of pain. Abdo-
men, in the epigastric region, becoming more distended, but not
tender, except in left flank; edges of wound in nice apposition.
Later in the day the pulse became weaker and indistinct: the opium
was repeated and the catheter used. Some brandy-and-water gave
benefit. .

4th, 10.30 a.m. Some sickness on three occasions; distension
of stomach less; respiration easy, but pulse fluttering and feeble; no
pain or tenderness complained of. Ordered 3j. spt. ether sulph. co.
After this she became restless; the symptoms of sinking manifested
themselves yet more, in spite of every attempt to rally her by stimu-
lants, and at 4 a.m. ofthe 5th July she died.

The constant nausea and vomiting in this case rendered nugatory

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the endeavours to support her against the shock and exhaustion at-
oe bi ae ; otherwise the degree of inflammation evi-
es oms i
i io ae iec and displayed by the autopsy, would probably
Examination, twelve hours after death.—Body not much emaciated.
Some hypostatic congestion ; a large quantity of dark fluid gushed
from the mouth ; the edges of the wound were very nicely adherent
by a gelatinous lymph ; the adhesion of tolerable firmness 3 the edges
of the wound also adhered to the intestines. The great omentum
adhered by recent exudation and blood to the peritoneum of
the anterior wall of the abdomen, at the part where some large
adhesions of the cyst had been dissected off. The pelvic cavity con-
tained a large quantity of sero-purulent discharge. The surface of
the parietal peritoneum, on the left side especially, was coated with
lymph and injected. The surface of the stomach, and of the small
Intestines generally, was covered with an extremely thin, lymphy
exudation, without much vascular injection. The surface of the
uterus was especially injected, and coated with lymph, as well as the
broad ligament, and the pedicle which had been ligatured. Right
kidney, the seat of reticular venous congestion ; a cyst on the
surface; the texture coarse; some part of the surface slightly
granular. Left kidney, in same state, but capsule more adherent ;
surface more granular. There was a quantity of blood-stained gela-
tinous mucus hanging out from the os uteri. It was continued
through the cervix, which, however, was not congested, but appeared
healthy. Texture of liver natural ; capsule thickened generally, and
anterior edge rounded. Other viscera not examined.

Case LVIL—<Attempted Excision of a Portion of the Cyst ; Subse-
quent Extirpation and Recovery.—Miss B., aged 30. In the year
1843 this lady was tapped for ovarian dropsy, and pressure applied,
and no return of the fluid took place for seven years. In 1850 she
complained of being stouter. On examination of the abdomen, I
found a solid, slightly elastic, but not fluctuating tumour in the left
iliac fossa. In 1851 I again examined her, and found the tumour,
but still could not detect fluctuation. In March, 1852, there was a con-
siderable increase of the tumour, and fluctuation was distinct. Shortly
afterwards, I introduced a very small trocar, and drew off an ounce.
of clear, transparent, and very slightly albuminous fluid. After a few
days, had a consultation with Dr. Tyler Smith and Mr. Lane, and we
agreed that it was a favourable case for excising a portion of the cyst,
as there were probably no adhesions, and the patient was in excellent
health and spirits, most confident, indeed, of a successful issue of the
proposed operation. I advised her to live on milk, farinaceous and
vegetable diet ; to take no beer, wine, or spirits, and to keep her
bowels.well open daily. This was steadily attended to, and the size
of the abdomen was very much decreased from these means.

Operation.—March 29th, 1852. 1.30: Present, Mr. Lane, Mr.

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J. Lane, Dr. H. Jones, Mr. Wellings, Mr. Bullock, and my brother,
Mr. George Brown. ©

Chloroform having been administered, and a towel placed round
the lower ribs and made tight, the patient was brought low down to
the foot of the bed, and the abdomen being held by the Messrs. Lane,
I made an incision of four inches between the umbilicus and pubes,
dissected down to the peritoneum, and divided it on a director ; seized
the cyst with forceps, and then introduced the trocar, and drew off
about nine pints of clear fluid. The external covering of the cyst
was very vascular, some large vessels ramifying on it. Avoiding all
the larger ones, I dissected out a piece of the cyst, of the size of the
palm of my hand, and found the whole cut edge of the remaining
portion of cyst, which was thick (one-eighth of an inch), bled freely,
and no torsion of the vessels seemed to stop it. Under these circum-
stances, finding there were no adhesions, we determined to remove the
entire cyst. On drawing out the cyst, I came upon the thick, round
pedicle of the tumour on the left side ; its base was an inch and a half
broad, and one large blood-vessel passed through the centre. I
passed a double ligature through the base, and tied both sides
tightly, then brought the edges of the wound in the abdominal wall
together by four deep sutures and by three superficial ones. I left
the ligature out, and secured it by strapping to the right side ;
applied a water compress, and over the whole abdomen one of my
many-tailed bandages. The operation occupied more than half an
hour. She was some time in reviving from the chloroform, and was
sick after taking some brandy-and-water. Pulse 108.

At 8 o'clock p.m, took some beef-tea, and 2 grains of opium. At
10 p.m, Dr. H. Jones and Mr. Bullock saw her with me. Pulse
108 ; skin soft and moist; countenance cheerful and hopeful; ap-
plied fresh water dressing, and reapplied the bandage; passed the
catheter, gave some milk gruel, and 1 gr. of opium. At 12 she was
sick, and vomited freely.

30th. At 4 a.m, the vomiting recurred, but she slept afterwards
quietly ; skin moist ; pulse 100, and compressible—7.30 a.m.: Feel-
ing sick, gave some ice to suck, which gave relief; took some bread-
and-butter, and tea.—2.30 p.m.: Pulse 96 ; countenance cheerful ; has
had some beef-tea ; wound looking healthy ; no swelling of abdomen.
—10.30 p.m.: Rather faint ; placed a plaster over the entire abdomen,
having first applied lint and napkins. Has passed urine freely.

31st. 8.30 a.m. Has passed a good night, and slept for several hours,
merely waking for a time: took some arrow-root. Urine passes
freely, but there is no power over the sphincter vesice. Pulse 100;
skin moist; countenance cheerful—10 p.m.: Pulse 96; soft and com-
pressible; skin moist; complains of feeling faint: this is evidently
nervous depression, not vascular. Ordered some more beef-tea for sup-
port, and an opium pill if at all wakeful. No tenderness nor swelling
of the abdomen.

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April Ist. 8.30, aw. Has passed a good night from one dose o
opium ; enjoyed her breakfast 3 pulse 56; ame eae
moved the interrupted sutures, —9,30 : Very comfortable; pulse ‘96,

2nd. 8.15. Has passed a very restless night, not free “from pain ;
had two grs. of opium, one at 12, and another at 3; is now very
drowsy. To have beef-tea,—8.30, p.w.: Has passed a very comfortable
day; pulse 96; removed the two lower sutures; the wound is united
by the first intention.

3rd. Has passed a good night.

9.30, p.m. Very low and faint, and the sutures have given pain;
removed the upper three sutures; gave some wine; to have arrow-
root, with one ounce of wine in it.

oth. Gave an injection of warm water, which emptied the bowels.

From this time she gradually progressed without any single un-
favourable symptom, and on the 27th the ligature came away.

30th, Down in the drawing-room, convalescent.

This case exhibits an important feature in the operation, as it offered
@ serlous practical difficulty in completing the excision, viz., the
hemorrhage from the numerous blood-vessels ramifying in the exter-
nal tunic, and unless I had decided to extirpate the entire cyst, I
must have applied ligatures to all the blood-vessels before closing the
wound in the abdomen; but I believe that the chief danger of ovario-
tomy arises from the presence of the ligatures within the peritoneum ;
I consider, therefore, the excision simply of a portion of the cyst the
safest and best plan.

This lady married in Oct. 1853, and now, June, 1854, is in the 8th
month of pregnancy.

Casz LVIII.—Ovarian Dropsy, fifteen months’ duration; Ovario-
tomy; Death; Autopsy.—Hlizabeth D., set. 29, married, was admitted
into Boynton’s ward, St. Mary’s Hospital, labouring under ovarian
dropsy.

The abdomen began to rapidly enlarge on the right side about
fifteen months since. Health pretty good; catamenia regular until
recently. Has one child six years old. By careful manipulation the
hand can be passed under the tumour, so as to negative the proba-
bility of adhesions; the cyst can also be moved a little from side to
side; fluctuation obscure.

June 16th, 1852. Operation.—She was placed under the influence
of chloroform, and an incision about four inches long made in the
median line below the umbilicus. A large irregular tumour was then
exposed, only adherent at one small point to the omentum. It was
punctured in several places, and small quantities of somewhat gela-
tinous fluid let out, but not sufficient to materially lessen the sac.
The incision of the external parietes was therefore extended upwards
above the umbilicus for about three inches, and downwards to within
two inches of the pubes; the omentum was then carefully dissected off

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the cyst, a piece of the peritoneal covering being taken with it, and a
small vessel tied with ligature cut off close. A large vessel running
up from the pedicle on the cyst was also divided. The pedicle was
then tied with three ligatures passed through it, and the whole tumour
removed; it weighed 111b. 30z. The edges of the wound were then
brought together with fourteen deep sutures, and three or four super-
ficial ones, the ligatures being brought out at the bottom, with the
exception of that on the omentum, which was left in the abdomen.
Wet lint and a bandage were applied.
_ 3.45. Pulse 80; she feels cold; respiration tranquil.

6 p.m. Is complaining of a good deal of pain in her abdomen, and
that the bandage is tight. This was loosened. Ordered opii gr. ij. stat. et
post horas 2.—9.45. Is complaining of increased pain ; has had no sleep ;
abdomen a little increased in size; complains again of the bandage ;
tongue and skin moist, the latter quite warm, the former rather white ;
pulse 100, soft; respirations 36; very slight abdominal movement; a
little tenderness; has her knees drawn up. Hydrarg. chlorid. gr. v.
4-tis horis. Opii grs. ij. 2ndis horis.

June 17th. 1.15 a.m. Pulse 100, fuller; has been easier, but is now
complaining much of pain. V. 8. ad 3xxiv. The blood was buffed.
She became faint ; pulse afterwards was 120, small and rather feeble ;
said she was easier, and could take a deep breath much easier; her
skin became cold, and with clammy perspiration ; was sick at the
termination of the bleeding; vomit of the same character as before.—
9 a.M. Pulse 110, small and rather feeble; respirations 24; tongue
furred at centre, rather red at edges; no distinct tenderness; has been
sick several times; skin moist; countenance rather darker. Ordered
 Opii, m xl; decoct. amyli, 3ij. ft. enema statim, et post horas iv.
utend., si opus sit. Movement of upper ribs 20, lower 10; abdomen
nil. A leather plaster was placed with relief over diaphragmatic ribs
and abdomen.

lpm. Slept for about twenty minutes after enema, and has not
been sick within the last half hour, but the sickness has just come on.

9.30 p.m. Pain removed by leeches; pulse 150, small: inclined to
be running; tongue moist; bore pressure on abdomen fairly well.
Pil. opii, gr. ij. statim et 3-tiis horis si opus sit; beef-tea.

June 18th. 8 a.m. Has passed a tolerable night, sleeping quietly at
least five hours; has taken this morning some tea and toast; she was
sick after the opium pills given last night, but not at other times;
some hiccup; tongue moist, somewhat coated in middle; pulse 135,
small, vibrating, weak; skin warm, not burning; forehead cool;
urine drawn off this morning of natural appearance; abdomen not
more distended; bears gentle pressure without pain; aspect quiet,
not anxious; about one tea-cupful of beef-tea taken and retained last
night. Ordered beef-tea, milk, and lemon ice to-day.

2.30. Frequent sickness; greenish mucous and watery matter

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OR ENCYSTED DROPSY OF THE OVARY. 265

vomited; feels comfortable : i : Sas,
feeble OL ee ae pain or distension; pulse 145, small,

Acid. hydrocyan. M xvi.
Sod sesquicarb. 3iss.
Aq. piment. 3j.
Aque 3v.

Capiat 3j. statim et omni hor.

9 p.m. Has had a little brandy-and-water. Aspect improved;
feels tolerably comfortable ; less sickness; pulse 150, not sharp; respi-
rations 20. Quine disulphi gr. ij.; acid. sulph. dil. mv.; spt. seth.
sulph. co. M xv.; aque 3ss., frequently.

19th. Slept for two hours (12 to 2, a.m.), and dozed at intervals
afterwards. Feels this morning quite comfortable, and her aspect is
decidedly improved. Tongue moist, slightly coated; small, feeble
respirations, 18. Has had:two more doses of quinine without spt.
eth. sulph. co., and taken at various times arrowroot, beef-tea jelly,
with a little brandy-and-water, without being sick; wound healing by
first intention —73 p.m. Pulse 135; skin cool; complaining much of
thirst; rather inclined to be restless, otherwise comfortable ; has com-
plained of some headache, which has been relieved by cold wash.

- 20th. 10 am. Pulse 126; small, somewhat less feeble; tongue
coated rather thickly, with red edges; had some quiet sleep in the
night, waking at short intervals; countenance not anxious; some
ligatures removed ; size of abdomen rather increased ; no tenderness ;
a fresh layer of plaster girding the abdomen. Applied—pil. sapon.
co. gr. x., a8 a suppository, last night. Port wine, lean of mutton
chop, at 1 p.m. Enema, with some castor oil.

9 p.m, Sickness again this evening, apparently from ether given by
mistake. Pulse 114; more distinct and less feeble; bowels freely
opened by enema; tongue less coated; she complaining much of
flatulence ; enjoyed her meat. THaustus acid. hydrocyan. repeated
occasionally, Pil. sapon. co. gr. x. at bed time.

21st. 9 a.m. Much flatus discharged per anum with relief, also
from the stomach after aq. menthe. pip.; slept about one hour.
Tongue coated in centre, clean at edge ; abdomen softer and smaller ;
complains of pain in left side of chest, evidently from distension of
stomach. Pulse 114; skin warm. Chop to-day ; porter, half a pint ;
brandy 3v.

9 pM. Six sutures removed; enjoyed her chop and porter ; flatu-
lence troublesome ; bowels did not act.

Tr. hyoscyam. 3j. -
Mist. camph. 3ij.
Sod sesquicarb. 3j. 3j. hdc nocte.
Repeat pil. saponis co. gr. x, h. n. pro suppositorio.
22nd. Has not had more than a half-hour’s sleep during the night ;

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soon after 1 p.m. was sick, and continued to be so at intervals until
5am. Has taken some breakfast this morning with relish. Bowels
acted twice in the night ; motions natural. One ligature removed at
upper extremity of wound ; no union had taken place there. Pulse
144; same character.—2 p.m.: Several sutures removed; straps of
plaster applied.

10 p.m. During a fit of vomiting i in the afternoon the plaster gave
way, and the lips of the wound separated, completely exposing the
intestines, which were seen covered with lymph. The edges of the
wound were pared and brought together by four sutures ; since then
she has been pretty comfortable ; ” complains of hunger. There has
not been much sickness or faintness. Bowels have acted once,
motion healthy ; the pain in left side has disappeared. Pulse 140,
small, vibrating.

Acidi nit. dil. 3ij.
Dec. cinchone, 3iv.
Aq. pimente, 3),
Tr. card. co. 3ss.
Aq. ad 3viij.

3j- 4-tis horis.

23rd. 9 am. She took last night some cold meat, bread, and
porter, and enjoyed it very much ; slept well at intervals; medicine
agrees well, and seems to quiet the stomach. Pulse 135, small; skin
not hot; tongue quite clean.

10 pm. Bowels open; thrice open to-day. Has been sick very
slightly ; has eaten half of two mutton chops at different times, and
drank half a pint of porter with much relish; has slept a good deal,
and soundly, during the day. Pulse 144, soft, weak; skin cool and moist.

24th. 84 a.m. Slept little last night. Bowels open several times.
Pulse pretty good; wound open for about two inches, at the upper
part, a suture having given way. Has slept a good deal during
the day ; has taken two mutton chops and a boiled sole, and 3xvj. of
port wine and Ziv. of brandy; no sickness. Bowels have not acted
since last night. Wound dressed to-day.

25th. 9 a.m. Passed a better night than she had yet had; aspect
this morning very favourable ; cheerful. Pulse 120, of more strength.
Bowels acted three times during night ; much flatus escaping. The
quantity of acid. nit. dil. diminished one half yesterday, and Tr.
cinchone 3j. added to the mixture. Tongue clean, rather dry. Some
sanious discharge from the whole extent of the wound escaped on
dressing it ; some feeble granulations at its lower part; abdomen
decidedly smaller.

26th. Quite comfortable, taking her food well. Bowels open twice
with healthy motions. Urine passed naturally.

27th. Tongue moist, clean. Slept nearly all night well. Bowels
not open all night. Pulse 120, more distinct ; countenance improved ;

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wound looking healthy, suppurating and forming granulations. Diet,
wine, one pint ; porter, half a pint ; sole, rice and milk.

29th. Wound looking more healthy ; feels comfortable ; has passed
two tolerable nights; skin warm. Pulse weak, 129.

30th. Bowels disturbed during the night, acted three times, motion
dark, offensive, and watery. Pulse 135,weak and small; aspect rather
depressed ; is tired of port wine ; prefers stout, which she had to-day.
Much flatulence ; appetite not so good; discharge from lower part
of wound very offensive, as from sloughing tissue. 3ij. of wine added
to mixture.

July Ist. Slept quite quietly all night; the bowels were rather
inclined to be relaxed, but were quieted by an opium suppository. Has
taken her food well. Pulse 117, more distinct ; wound gaping at upper
part, but granulating well at base and edges ; aspect better.

2nd. Good night; bowels quieted by opium suppository ; takes
her food well.

3rd. Tongue rather dry, especially at apex ; slept well with opium
suppository ; bowels disturbed much last evening, quiet since then ;
wound healing rather languidly. Pulse 126 ; skin somewhat hot.

6th. Tongue rather dry. Pulse 120, very weak ; skin rather burn-
ing, dry; much depressed yesterday by great heat ; appetite failed ;
bowels act involuntarily, require to be quieted by suppositories ;
aspect less favourable ; says she feels comfortable, having been shifted
to another part of the ward; takes her food better to-day; throat
said to be a little sore, (it seems rather that the jaws are stiff;)
wound looks languid, but not otherwise unhealthy ; ligature of pedicle
came away with a portion of the slough. Add quine disulph. gr. x.
to the mixture.

8th. Condition much the same ; bowels tend to be relaxed, but are
quieted by the opium suppository; catamenia present last night ;
wound in about the same state ; dressed with black wash ; takes beer
and wine well, but not much food ; much less of discharge. Pulse 117,
of rather more volume; skin tolerably cool; jaws continue stiff;
glands under right side of the lower jaw enlarged, so that she cannot
open her mouth well.

Ferri et quine citratis, gr. xv.
Tinct. cinchon. co. 3ij.
Aq. pimente, 3j. three times a day.

11th. The catamenia having been present for about four days,—this
being the natural period, have to-day advanced to the extent of
menorrhagia, which has brought her very low. She had stimulants.
administered freely this and the next day, but continued to sink, and
died on the 12th, about 94 p.m. The menorrhagia was checked by
application of ice to the vagina. The discharge from the abdominal
wound had been unhealthy during the last four days. The stiffness
of the jaws continued to the last.

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. Examination, seventeen hours after death—Body emaciated, wound
in abdomen 72 inches long, its margin separated, its base and sides of a
semi-sloughy appearance. The base was formed by the omentum for
the greater part of its extent, covered on its surface with feeble gra-
nulations, almost lapsed into a state of slough, The peritonzum of
the edges of the wound was adherent to the visceral layer; on the
left side these adhesions did not extend far; on the right, they were
much more extensive, and spread over the whole of the right iliac and
lumbar regions. The stomach and duodenum were tolerably healthy,
and free from traces of inflammation ; the whole of the small intestines
were covered with granular lymph of some standing, and of a rather
dark and sloughy aspect. The inflammation had been most conside-
rable on the right side of the abdomen, where it had united together
the intestinal convolutions extensively by effused lymph, and had
also passed on in several places to the production of pus. In some
parts ulceration of the intestinal canal had commenced, extending in
the direction towards the cavity of the bowel; one such patch in the
cecum was very remarkable, having caused thickening and congestion
of the mucous lining. The interior of the ilium was much congested.
The peritoneum covering the uterus and bladder was inflamed and
covered with lymph, as also that covering the liver, which was united
by some rather long adhesions to the diaphragm. There was a small
excavated ulcer on the vaginal surface of the cervix uteri ; the mucous
lining membrane of the womb was much congested, especially towards
the right Fallopian tube ; in the direction of the other it was pale, and
a probe could be passed from the uterine cavity through the remains of
the tube, which had been divided in separating the pedicle of the cyst.

Case LIX.—Ovarian Dropsy of one year’s duration; Treatment at
first by Tapping and Pressure ; Excision of Portion of Cyst impracti-
cable ; Ovariotomy ; Cure.—Oct. 29th, 1853, Mrs. B., aged 57, a lady
from the country, consulted me, and stated that she first noticed en-
largement of the abdomen on the right side eight months ago; at
first the increase was gradual, but of late had been much more rapid;
ten years since, the catamenia disappeared, but reappeared last April;
has had seven children, the youngest being 14 years old. I recom-
mended that tapping should first be had recourse to, followed by
steady pressure. Accordingly, on November 3rd, I removed by tap-
ping thirteen quarts of fluid, which contained a considerable quantity
of albumen, and then applied one of my “ovarian bandages,” and gave
her bichloride of mercury in tincture of bark. Her health and spirits”
rapidly improved, and she returned home to the country.

On December 3rd, she wrote me word that she was still much im-
proved in health; that she had as requested by me, taken an accurate
account of the fluids taken and the urine voided; and had found the
former from the 10th of November to the 3rd of December, twenty-
four pints, and the latter twenty-nine pints; showing that the
kidneys had excreted an excess of fluid of five pints.

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After this the cyst gradually refilled; and, on February 27th,
1854, she came up to town again, and wished the operation for extir-
pating the tumour to be performed. I very fully explained the
danger to be apprehended, and requested that she would take a few
days to consider the subject. This she did, and again requested that
the whole or a part of the cyst might be removed. Accordingly, on
March 2nd, just four months after tapping, having kept her a short
time previously on farinaceous diet, I undertook the operation. Being
brought under the influence of chloroform, administered by Mr.Moullin,
I placed her diagonally across the bed, and, assisted by Messrs. Nunn,
Winchester, Wilkin, and my son, proceeded to operate. Making an
incision in the median line, midway between umbilicus and pubes,
about three inches in length externally, I came down upon the peri-
toneum, which gave some little trouble in dividing, with the aid of a
director, because there was so large a quantity of fluid between the
peritoneum and cyst. This was, however, shortly all evacuated, and
-the ovarian tumour well seen. I had at first intended to have taken
out a piece of the cyst only, but I found the coats so thick that it
was quite impracticable. I passed my hand round the tumour and
found no adhesions. An assistant then seizing the tumour with a
pair of vulsellum forceps, I introduced a trocar to evacuate the fluid.
While the liquid was escaping the patient retched a little, and expelled
the tumour entirely through the orifice, the internal incision being
not more than two and a half inches in length. I then tied the
pedicle, which was four inches broad at the junction with the tumour,
and two inches long, in two portions, with double ligatures of well-
waxed twine, and removed the tumour. During the expulsion of the
tumour, a very small portion of the omentum and of the bowel pro-
truded, which were held back by flannels first wrung in hot water.
The pedicle was tied to a director placed transversely across the abdo-
men, in order to keep it external, and the opening closed by four deep
sutures above the pedicle, and one beneath, and by four or five inter-
rupted sutures. A pad of lint soaked in cold water was applied, and
one of my flannel many-tailed bandages steadily tied.

Two grains of opium were given as soon as she recovered from the
effects of the chloroform, and one grain ordered to be given every two
hours, and ice to be sucked constantly. ; ;

11 pu. Has had six grains of opium. Pulse 98; wiry; complains
of flatulence, with nausea and retching; slight uneasiness and evident
symptoms of approaching peritonitis. Bled her from the arm to six-
teen ounces. After bleeding, pulse fell to 84. Gave ten grains of
calomel and two of opium. : :

12 p.m. Pulse 88; sickness continued. One grain of opium every
hour; to have barley-water and iced water ad libitum.

March 3rd, 1 a.m. No sleep; sickness continues; pulse 90.—2.30 :
Has slept an hour and a half; feels very comfortable : sickness
quite gone—4 am. Slept nearly two hours; slight return of sick-
ness; pulse 86.—5.30. An hour's sound sleep; pulse 84.

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6.30. Has been very quiet; countenance perfectly calm. No in-
dications of peritonitis; pulse 86, and good. Has taken in all twelve
grains of opium. She now mentioned that whenever she took opium
she had dryness of the throat and great thirst; and although she
had taken twelve grains of solid opium, there were no signs of nar-
cotism. During the whole of the day she was very calm and composed.
Bowels were acted upon three times by the calomel, and she passed a
great quantity of flatus—11 p.m. Ordered a quarter of a grain of
muriate of morphia every two hours till sleep is induced. During the
night she took four doses, was perfectly calm, but had very little
sleep.

‘th. 7 am. Pulse 72; skin moist; bowels quiet; no tenderness
on pressure; no facial indication of peritonitis. Since operation the
urine has been drawn off by catheter every four hours. Beef-tea and
barley-water allowed, and the morphine ordered to be repeated at
night.

bth. Has had a comfortable night, and slept well. Pulse 72;
capital spirits; the upper part of the wound healed by first intention,
and the pedicle of the tumour begins to slough. On the 10th, re-
moved superficial sutures; on the 12th, removed two upper deep su-
tures, union perfect; on the 15th, ligatures came away; and on the
16th, she was able to be removed to the sofa.

25th. Is quite well, and has gone a little way out of town.

May. This patient continues in the enjoyment of good health.

This case is sufficiently interesting in itself to make it unnecessary
for me to offer many remarks. I would merely, however, draw atten-
tion to the fact of the tied end of the pedicle and the ligatures being
kept external, as recommended by Mr. Duffin, and also lately practised
by Mr. Erichsen, as it may be found hereafter a decided improvement
to the usual method of leaving the end of the pedicle to slough off in
the pelvic cavity.

7. Other Modes of Treatment.—Besides the preceding, which
are the chief modes of treatment put into practice, there are
others recommended and employed by individual practitioners.
Of these I cannot speak from my own experience, and shall
therefore only refer generally to what those who have devised
them set forth as their advantages, and what have been the
results of experience with them, so far as I have been able to
ascertain.

a. Dr. Tilt has recommended* opening ovarian’ cysts by
Vienna paste, applied to the integuments in the median an inch

* Lancet.

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OR ENCYSTED DROPSY OF THE OVARY. 271

or two below the umbilicus, or otherwise where the parietes are
thinnest, and allowed to ulcerate through into the sac. The
objects in view are thus stated :—1. To establish solid adhesions
between the peritoneum covering the cyst, and that lining the
abdomen. 2. To effect the smallest possible ulcerative opening
of the cyst through the centre of these adhesions. 3. To keep
the cyst always full, and only relieve it of the overplus of fluid
by which it is distended. Abdominal pressure, gradually aug-
mented, is indispensably necessary; and injections of tepid water,
to meet the third object of the treatment.

Mr. Grant Wilson was induced to try this plan of Dr. Tilt
in a favourable case,* in which the health was remarkably good.
The eschar was made about two inches below the umbilicus;
one application of caustic was sufficient, but it was eight weeks
before the eschar separated sufficiently to discharge the water.
“At first no injection of any kind was used, but in three or
four weeks from the evacuation of the water the discharge be-
came purulent and fcetid, and my patient’s health declined so
rapidly that I feared I should lose her. Under a generous diet,
with quinine internally, and the repeated injection of the cyst
with warm water, she rallied, after having lain a month or six
weeks longer, in a very precarious state. At that time a weak
solution of iodine (one drachm of the compound tincture to six
ounces of water,) was occasionally used, without producing any
ill effect, and a portion of gutta percha tubing was fitted to the
opening of the wound. ‘This was fitted with a wooden plug, so
that the discharge could be drawn off at stated times. Before
this the wound showed a disposition to close permanently, and
required to be opened by a probe, to evacuate the fluid that
accumulated, the patient always suffering until this was done.
From the time the gutta percha tube was introduced, and the
iodine injection used, the cyst began to contract, and the patient
to improve steadily, and this continued until she has now got
quite well. The tube remained in four or five months, and was
then removed. I have recently seen her, and there is still a
small fistulous opening, not quite closed... . but a probe will

* Provincial Medical and Surgical Journal, Jan. 22nd, 1851.

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272 ON OVARIAN DROPSY, ETC.

pass in no direction beyond half an inch, and she has gained
flesh and strength, and has been enabled to resume her usual
habits. I think I am justified in calling it a cure, though I
should scarcely be disposed, except under peculiar circumstances,
to recommend a repetition of the treatment.”

6. Dr. Tanner has suggested, that when an opening is made
into the abdomen, and adhesions are found preventing the re-
moval of the tumour, the cyst should be emptied by tapping,
and that, in order to prevent the fluid from being re-secreted,
a ligature should be applied round the pedicle, so that the
main supply of blood to the cyst may be cut off. Dr. T. thinks
that sufficient blood will still be supplied to the tumour through
the adhesions, to prevent gangrene of the cyst. I think this
suggestion a sound one, and well worthy of a trial, and shall
have no hesitation in putting it into practice on the first appro-
priate occasion.

Several other expedients have been at various times adopted ;
such are the introduction of a seton into the cyst; tapping and
leaving a tube within its cavity, through which the contents may
discharge ; acupuncture and electricity. The results of these plans
have not been sufficiently encouraging to induce a repetition.

Digitized by Microsoft®

 
APPENDIX.

To the illustrative cases contained in the body of the present
treatise, I am able to append the following which have recently
occurred in my practice.

Cast A.—Complete Rupture of the Perineum of three and a
half years’ duration: Operation; Cure.—Mrs. H., xt. 29, con-
sulted me at the request of my friend Mr. Wilkin, May 10th,
1854, She has been married seven years, and had four chil-
dren. At the birth of her third child no medical attendant
was present, and no assistance being rendered her, the perinzeeum
was severely torn: she was after this very ill. Two years and
a half after this accident, or thirteen months ago, she had an-
other child. She has but little control over her motions, and
none when they are relaxed. The sensations of bearing down
are constant and painful.

On examination I found complete rupture of the perineum;
the anterior half of the sphincter ani lost, and I recommended
an operation.

May 20th. Having produced anesthesia by chloroform, I
operated in the usual manner; Messrs. Nunn, Spencer Wells,
Wilkin, Moullin, and my son being present. As the patient
was young, and still apt to bear children, I did not restore the
perinzeum in its entire length, but yet made it sufficiently long
to secure complete sphincter power and a sufficient support to
related parts. There was considerable bleeding, and torsion
was used to several small arteries.

21st. Has had much pain since the operation, and taken alto-
gether twelve grains of opium.

T

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pass in no direction beyond half an inch, and she has gained
flesh and strength, and has been enabled to resume her usual
habits. I think I am justified in calling it a cure, though I
should scarcely be disposed, except under peculiar circumstances,
to recommend a repetition of the treatment.”

6. Dr. Tanner has suggested, that when an opening is made
into the abdomen, and adhesions are found preventing the re-
moval of the tumour, the cyst should be emptied by tapping,
and that, in order to prevent the fluid from being re-secreted,
a ligature should be applied round the pedicle, so that the
main supply of blood to the cyst may be cut off. Dr. T. thinks
that sufficient blood will still be supplied to the tumour through
the adhesions, to prevent gangrene of the cyst. I think this
suggestion a sound one, and well worthy of a trial, and shall
have no hesitation in putting it into practice on the first appro-
priate occasion.

Several other expedients have been at various times adopted ;
such are the introduction of a seton into the cyst; tapping and
leaving a tube within its cavity, through which the contents may
discharge ; acupuncture and electricity. The results of these plans
have not been sufficiently encouraging to induce a repetition.

Digitized by Microsoft®
APPENDIX.

To the illustrative cases contained in the body of the present
treatise, I am able to append the following which have recently
occurred in my practice.

CaszE A.—Complete Rupture of the Perineum of three and a
half years’ duration: Operation; Cure—Mrs. H., et. 29, con-
sulted me at the request of my friend Mr. Wilkin, May 10th,
1854. She has been married seven years, and had four chil-
dren. At the birth of her third child no medical attendant
was present, and no assistance being rendered her, the perineum
was severely torn: she was after this very ill. Two years and
a half after this accident, or thirteen months ago, she had an-
other child. She has but little control over her motions, and
none when they are relaxed. The sensations of bearing down
are constant and painful.

On examination I found complete rupture of the perinzeum ;
the anterior half of the sphincter ani lost, and I recommended
an operation.

May 20th. Having produced anzsthesia by chloroform, I
operated in the usual manner; Messrs. Nunn, Spencer Wells,
Wilkin, Moullin, and my son being present. As the patient
was young, and still apt to bear children, I did not restore the
perinzeum in its entire length, but yet made it sufficiently long
to secure complete sphincter power and a sufficient support to
related parts. There was considerable bleeding, and torsion
was used to several small arteries.

21st. Has had much pain since the operation, and taken alto-

gether twelve grains of opium.
T

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274 APPENDIX.

22nd. The pain continues severe, although opiates are largely
taken.

23rd. The pain was so great from the sutures that I removed
one of the quills, leaving the threads. In the evening the other
quill came away.

25th. Is doing very well. Removed the other sutures. No
suppuration going on.

29th. A careful examination per vaginam et rectum showed
union to be perfect. This day she was allowed to pass her
urine, resting on her hands and knees.

June Ist. The bowels have been freely relieved by several
injections of warm water, and although several large and hard
masses of feeces escaped, the new structures were uninjured.

8th. Now has control over the bowels, and is up and feels
well.

Case B.—Ruptured Perineum of fifteen years’ standing :
Procidentia Uteri: Operation; Erysipelas; Cure-——Maria M.,
zt. 38, married. Admitted May 4th, 1854 into Boynton ward,
St. Mary’s Hospital. She was sent to place herself under my
care by Dr. Riding. Her appearance is healthy. She states
that in her first and only confinement, fifteen years ago, the
perineum was ruptured into the anus during the passage of the
head of the child. The labour was very lingering, lasting five days.
On the last day she had very few pains, and the child, though
large, was, she states, expelled without much effort on her part,
but no instruments were used. Nothing was done at the time to
close the rupture; and ever since she has had little or no power
over the bowels. About three years ago, prolapsus uteri occurred,
and she became an out-patient of St. Thomas’s Hospital, but
obtained no relief. Belts to support the parts have been tried,
but could not be worn in consequence of the pain they occasioned.
There is much bearing down, and pain in the lower part of the
back.

The parts return when lying down, but are always protruded
when in the erect posture. From the great difficulty in retain-
ing her feces she has allowed her bowels to be very irregular
in action. The catamenia have always been regular. On exami-

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APPENDIX. 995

nation, a rupture of the perineum into the anus, procidentia
uteri, and protrusion of posterior surface of the bladder, were
found. There is great thickening of the mucous membrane
between the vagina and rectum, and the lips of the uterus, espe-
cially the posterior, are much enlarged. She has had great
difficulty in making water, and states, that on evacuating the
bladder, “the womb seems to be drawn up.”*

May 10th. Mr. Brown operated to-day in the usual way. Some
slight arterial hemorrhage occurred, which demanded the ligature.
After recovering from the chloroform, 2 grs. of opium were
given, and 1 gr. to be continued every four hours. The
catheter to be kept in the bladder.

11th. Comparatively free from pain; no hemorrhage has
occurred. Feels very comfortable. To continne the opium
every six hours.

12th. About the same.

(18th. On examination, there was a little sloughing about the
quilled sutures, with very offensive discharge; the quilled sutures
were removed and the collected matter pressed out, and lint
with chloride of lime applied.

14th. Still much discharge; the parts have to be pressed and
cleaned four or five times a day. Some bloody thin discharge
proceeds from the anterior part of the wound through the
vagina. Continue the opium as before.

16th. Still the foetid discharge, which is nearly as great in
quantity, persists.

B Acid. nit. dil. m xv.
Tinct. cinchonz, 5ij.
Aque ad 3j—Ter die.

Lotio nigra, p. a. a.

16th. She has pain at the precordial region, which she
attributes to the medicine ; to be therefore discontinued. The
discharge is not so great and is thicker. To use water dressing,

and take the opium pill every night.

* The notes of this and the two following cases are taken from the
‘Case-book, as kept by Mr. Talbot, house surgeon of St. Mary's

Hospital.
Tt 2

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276 APPENDIX.

17th. Doing well.

19th. There is some erysipelatous redness on the left side of
the wound, which is proceeding up over the left buttock.
Lotio plumbi, p. a. a.

20th. The redness has advanced, and occupies half of the left
buttock. The swelling near the cleft of the nates is rather
hard, and the surface in many parts is covered with vesicles.
The interrupted sutures removed, and the edges of the wound
found to be in an ununited state, though at the deep part of
the wound adhesion had taken place. Flour to be dusted on
the erysipelatous part in place of the lotion.

22nd. Erysipelas extending over both buttocks. Has a sen-
sation of tightness in the abdomen, and a slight cough. Feels
very uneasy and weak. Is feverish, and has a nervous way of
drawing her breath. OI. ricini 3j. statim, which in consequence
of nausea is to be preceded by a powder composed of Hyd.
chlorid., gr. iij. sacchar. alb. gr. iij.; and four hours after an
enema to be given.

28rd. Erysipelas still extending. Bowels freely open. Feels
very low and weak. Decoct. cinchon. 3j. Ammon. sq. carb.
gr. iij., ter die. Two hours after, becoming worse, she had
to omit the bark and take Tr. Ferri mur. m xv. every four
hours, with Liq. opii. sed. m viii. Local application the same.

24th. Much the same. Erysipelas extending; is very weak ;
can scarcely turn in bed. Wine 3viij daily. To have arrow-
root and oysters. i

25th. Rather weaker; pulse frequent and very compressible.
Pint of beef jelly. Wine 12 oz.

26th. Redness not quite so great, but it covers a greater
surface. Has very little power. There is a little slough over
the left buttock. Bread poultice to be applied. Sleep broken
and unrefreshing. Ammon. sq. carb. gr. x., Tr. cinchone, 3ij.,
Sacchar. q.s. Decoct. cinchons 3j. ter die.

27th. Erysipelas has advanced nearly to the waist; the
slough has also increased in size. Her pulse is rather stronger,
and not quite so frequent. She slept last night, and was
refreshed thereby. Her looks are better.

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APPENDIX. . 277

28th. Better in every respect.

29th, 80th, 31st. Has daily progressed ; erysipelas disappear-
ing fast; the perineum sound, and there is no prolapse of
uterus or bearing down.

Case C.—Vaginal Cystocele: Operation; Cure.—Mary H.,
zt. 55, laundress. Admitted April 4th, 1854, into Boynton
ward, St. Mary’s Hospital. She is the mother of seven children,
the youngest twelve years of age. All her labours she describes
as quick and favourable. About eighteen months ago she
experienced pain in the back, of a dragging nature, which three
months ago became much worse, and there was prolapse beyond
the vulva of about the size of an egg. She had no advice, and
the prolapsus has been gradually increasing for the last three
months: it is now as large as the fist. She attributes her
present condition to her having lifted a very heavy weight
(eighteen months ago), and fancies she heard something snap at
that time.

April 5th. Mr. Brown operated in the usual way. After the
operation, one grain of opium was given every six hours, and
cold cloths applied to the parts—10 p.m. Is very comfortable,
experiencing very little pain or hemorrhage.

6th. Very comfortable ; passed a very good night; ordered
wine 3iv.

8th. Going on well; the quilled sutures removed. Ordered
mutton chop, beef tea Oj., porter Oss.

llth. Interrupted sutures removed, and the parts found
united.

15th. Doing very well. There is not much discharge.

18th. The bowels acted to-day after the exhibition of castor-
oil.

25th. The wound is quite healed, and she is going on well.

May 4th. Discharged cured. When standing up, there is no
protrusion, but she feels some bearing down pain; she is there-
fore directed to keep a good deal in the horizontal posture for
a fortnight before recommencing her employment.

23rd. She presented herself for examination. Wound well

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278 APPENDIX.

closed; no protrusion; no pain. She looks and feels. a per-
fectly different woman. She now follows. her employment
(though not yet to the same extent as formerly) with great
comfort.

Casz D.—Procidentia Uteri, with Complete Eversion of the
Vagina: Operation; Cure—Sarah W., et. 53, admitted into
Boynton ward, St. Mary’s Hospital, March 31, 1854; was sent
me by Dr. Barnes. Ten years ago was delivered of her first
child. The labour was natural, and of six hours’ duration.
About three weeks after her confinement she resumed her occu-
pation as maid of all work, and continued in her situation for
two months, when she suffered from leucorrhcea and bearing
down of uterus, with considerable pain at times (menstruation
being regular, though tedious). She continued to work for
about a year in spite of this affection, when, becoming worse,
she applied for medical aid, and left her situation. The pro-
lapsus beyond the external parts being great, she has worn
pessaries for the last eight years at intervals, and also a truss
for the prevention of the prolapsus ; but these only relieved her
partially, and sometimes caused so much irritation as to oblige
her to remove them. For the last eight years she has been
unable to retain her urine, passing it by drops every half-hour
with great pain.

April 5th. She was operated on in the usual manner. Portions
of mucous membrane were dissected off, and the parts drawn
together by quilled and interrupted sutures. The patient was
under the influence of chloroform during the operation, which
lasted nearly three-quarters of an hour. She was put to bed,
and one grain of opium given every six hours. Wet lint was
applied to the external parts and occasionally renewed.—
7 p.m. A great many clots have passed, and there is a continued
oozing of blood, notwithstanding the constant local application
as well as the sucking of ice. Cold applications still to be
used.—l0 v.m. The blood has apparently ceased to flow; feels
very weak, and complains of much pain; pulse frequent and
weak ; ordered wine 3ij.

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APPENDIX. 279

6th. Very little blood was lost last night ; has frequent sick-
ness. It was discovered this morning that from the constant
application of cold cloths last night, one of the quilled sutures
had got entangled and given way. Ordered, wine 3iv., lemon-
ade, brandy 3ij., lemon juice 38s.

B Potasse bicarbonatis, gr. xv.
Acidi hydrocyanici dil., m iij.
Aque 3}. 2-dis. horis sumend.
10 p.m. The sickness has abated ; there is no more hemorrhage ;
she is not in so much pain ; feels inclined for sleep.

7th. Much better.

8th. Feels weak ; complains of pain in the back; the quilled
sutures removed. To take soda water with boiling milk, equal
parts.

10th. Cannot relish the ordinary diet; feels pretty comfort-
able. The interrupted sutures were removed; union had only
taken place at the posterior parts of the wound; lint dipped in
oil applied.

12th. Pretty comfortable.

18th. Bowels acted to-day, after taking castor oil, for the
first time.

25th. The wound is healing, and she appears and expresses
herself comfortable.

May 6th. Allowed to get up.

8th. She suffers when walking about from no protrusion or
bearing-down pains.

13th. Doing well.

22nd. Discharged, but recommended not to work for a fort-
night or more, and to wear a support to the new perimzum for a
short time.

This was one of the worst cases that can be met with, so
complete was the procidentia; and yet in five weeks she is
quite cured. It will strike the reader how futile were the
pessaries, and what irritation and discomfort they created ; and
I think the case very well proves the truth of my remarks in
the chapter treating of the displacement of the uterus.

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280 APPENDIX.

Cast E.—Ovarian Disease: Ovariotomy ; Death; Autopsy.
—Mrs. R.., «xt. 37, consulted me in October, 1853. She gives
the following history of herself:—That she was married at 19,
and is the mother of two children, aged respectively 133 and
1z. She enjoyed good health till May, 1852, when, bemg on
a visit in the west of England, she retired to rest on a Sunday
night, slept well till six o’clock the following morning, but
was then suddenly seized with most violent pain on the right
side of the abdomen, reaching to the hip-joint, and downwards ;
the pain, accompanied by sickness, lasted day and night till mid-
day on the. following Wednesday, when it gradually subsided,
leaving only a pricking at the hip-joint, which continued some
days longer. In about three weeks she recovered her usual
health, but after a time observed a tenderness, accompanied
with slight swelling, at the lower part of the belly. Of this she
took little notice, her general health being unimpaired; and she
continued able to take long walks without inconvenience. As
winter advanced, the swelling continued to increase, and in
April, 1853, she consulted Dr. Locock, who pronounced the
disease ovarian dropsy, and merely recommended attention to
the general health, with the support of a belt, and when the
symptoms became more urgent, to consult me. She passed the
summer at the sea side, and endured much mental affliction at
that time. The disease also gained ground, and in October
she became greatly prostrated in health, with entire loss of
appetite and strength. At this time she saw me, and I advised
change of air, with the adoption of every means for restoring
strength, and the use of a tight bandage. She left town for
Brighton, and at the end of three weeks was greatly improved,
having gained strength and appetite, and could take long walks
with but little inconvenience. Two months afterwards, she
began to experience much restlessness at night, with a sense of
weight and oppression in walking. She had much pain in the
hip, knee and ankle. The sleeplessness continuing so distress-
ing, she determined again to consult me. Six months having
elapsed since I first saw her, I was greatly surprised at the
improvement in the general health ; and she, having heard that

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APPENDIX. 281

I had just had a successful case of ovariotomy, determined to sub-
mit to the operation, after having been fully impressed with the
danger to be apprehended, which was even greater in her case
than ordinary.

Everything having been previously prepared for the operation,
and chloroform being administered, I proceeded to operate at
2 o’clock, on Thursday, April 6th, 1854: Present, Messrs.
Lewis, Nunn, Spencer Wells, Moullin, Winchester, and my
son. It was determined to make an exploratory incision about
an inch in length, to examine the nature of the adhesions, and
to be guided by the result as to what should afterwards be
done.

An incision was accordingly made, and the finger introduced
and passed. over the tumour, and all the adhesions within reach
easily broken down; the incision was therefore enlarged to 33
inches, and the hand introduced, all the adhesions gave way:
in front of the tumour; but at the upper part and at the sides
they were found to be very strong. The trocar was then intro-
duced, and twenty-one pints of turgid, white, oily fluid, with a
fatty sort of substance floating in it, evacuated. After about
twenty minutes of difficult manipulation, all the adhesions were
broken down. On the left side there had been a layer of
plastic matter, apparently effused by peritonitis, thrown out
between the tumour and the peritoneum, glueing the two
together, and especially adherent to the cyst, to which it almost
formed an outer covering. This layer was at last, with great
difficulty and trouble, peeled off the tumour; a small portion
of the bowel and omentum, to which the cyst was adherent
above, protruded, but was held back by flannels wrung in hot
water. There was some bleeding, but none of any consequence.
The pedicle of the tumour, which was four inches broad, was
tied in four portions, and retained external by means of a
director placed transversely across the abdomen. The wound
was closed by four deep interrupted sutures and two superficial
ones. In the tumour there were three lumps of hair about
half the size of the palm of the hand, and a great many fatty
cauliflower excrescences on its inner coat, She had two grains

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282 APPENDIX.

of opium directly after the operation, which were repeated at
intervals all night, so that up to eight o’clock on the morning
of the 7th, she had taken fourteen grains of opium and four
grains of muriate of morphine, but still had only had two half-
hour’s sleep. Constant vomiting prevented her having any rest.
Pulse from 96 to 100. To take grs. 4 of opium and a mixture
of hydrocyanic acid, ammonia and soda. 11.30 p.m.: No more
sickness ; has had refreshing sleep twice for three-quarters of an
hour.

8th. 2 a.m.: Has had more sleep, and taken beef tea, lemon
ice, barley water, and tea. 5 a.m.: A little restless, with a
slight pain from flatulence, which was relieved by passing it
through the bowel; to take two grains of opium. 11 a.m.:
Still very comfortable; pulse 120; to take two grains of opium.
1.30 p.m.: Has had refreshing sleep; hands moist, two grains
‘of opium. 7.30 p.m.: Very comfortable; says she feels quite
well; skin moist. No swelling of abdomen; removed dressing
for the second time; the pedicle begins to be ee to be
washed with a solution of chloride of lime.

9th. Has had on the whole a comfortable day, but spans
evening she was distressed with eructations of wind and feeling
of sickness: gave a warm rhubarb draught.

10th. 7 a.m.: Has passed an uncomfortable night; been sick
and restless. Bowels relieved four times and much flatus es-
caped per rectum after injections. A dose of creasote relieved
the sickness for some hours. 10 p.m.: Has vomited a pint of
dark fluid: gave 20 drops of bimeconate of morphia. Sickness
recurred soon after: repeated opiate in two hours, and again in
four hours.

11th. From 4 4.m. : no sickness but occasional hiccup. 7:30 a.m.
Is quiet and sleepy: pulse 100. 1] 4.m.: Has had some very quiet
and refreshing sleep, and is better. 9 p.m.: Has passed a very
quiet day, sleeping, and has taken a cup of beef-tea. Barley-water
and chicken broth have been given alternately every hour. Re-
moved the two upper deep sutures: healthy pus came from the
wound.

12th. 8 a.m.;: Has passed an uncomfortable night, frequently

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APPENDIX. . 283

sick. Gave two grains of calomel, and in the evening the bowels
were well relieved by an injection: omitted the opiate at night.

13th. 8 a.m.: Has passed a comfortable night, and is better.
This evening, 7, p.m., is considerably better, and feels cheerful ;
removed the last suture.

14th. Has had a restless night, and is not so well this
morning, but has had no return of sickness for forty-eight
hours, and considerably less hiccup. Bowels have been opened.
three or four times. 11 .m.: Very restless, with oppression on
the chest ; small quick pulse ; clammy cold perspiration on the
skin and hands. Gave her some hot brandy and water, and
half-an-hour afterwards some port wine, with twenty drops of
bimeconate of morphia, which in half-an-hour produced sleep and
quieted the restlessness.

15th. 8 a.m.: Has been very sick all night after taking any-
thing, but has less oppression, and is not so low as last night.
Ordered her a drop of prussic acid every hour, and wine and
nourishment to be continued. She had a relapse, rapidly got
worse, and sunk at 11.30 p.m.

An autopsy was made at 4 o’clock p.m. on April 16th. An
immense quantity of sanio-purulent matter was found in the
pelvic cavity ; the bowels had a slight blush upon them in some
parts ; the lower part of the omentum was very much enlarged
and indurated; that which remained of what at the operation

- seemed to be a second covering of the cyst, was found to be very
adherent to the peritoneum and nodulated in some parts, and
there were evident symptoms of severe inflammation of old
standing. A portion of the thickened omentum, and a piece of
the layer, together with the vermiform appendix, the kidney, and
the uterus, were removed for subsequent examination. In the
thorax the lungs were found to be very extensively congested ;
the muscular coats of the heart flabby with fatty degenera-
tion in some parts, and there was some fluid in the pericardium.
The stomach was enormously distended. On examination, the
uterus was enlarged, and the walls of pale aspect, but nothing
abnormal could be seen; the thickened portion of omentum was
of simple inflammatory origin, and contained some spots of fatty

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284: , APPENDIX.

degeneration ; the vermiform appendix empty and natural; on
one side of the layer which covered the ovarian cyst was a dense
layer of thickened fibrous membrane, beneath which was a quan-
tity of less indurated areolar tissue and fat containing a good
deal of black pigmentary substance. The kidney, though much
enlarged, was tolerably healthy; a little interstitial fibroid
formation existed among the tubes; capsules shrunk.

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INDEX,

Abscess, Pelvic and Psoas, 204
Acetum Cantharidis, 109

Lytte, 49, 55
Actual Cautery, 50, 57, 102, 124, 145
ae ees of, in the intestines,
Artificial Oviduct, 218
Ascites, 197

Bandage, perinzal, 87

Barnes, Dr., 12

Bird, Dr. F., 175

Bladder, distended urinary, 202

pi Dr., 10, 85, 185, 189, 179,

Brigham, Mr., 137

Case of delivery, after operation for Rup-
tured Perineum, 50

Catheterism, frequent, 36, 73

“Celsus, 12

Chailly-Honoré, M., 10

Childs, Mr. G. Borlase, 242

Churchill, Dr. Fleetwood, 4, 87, 90, 172,
183, 199

Cooper, Sir Astley, 131

Constipation, case of, 154

Copeland, Mr., 151

Copland, Dr., 170

Coulson, Mr., 135

Crouch, Mr., 247

Cystocele, vaginal, 70
Cases of, 74-79

Davidson, Mr., a case of Ruptured Pe-
rinezeum cured by operation, 18

Denman, Dr., 119 ;

Dessault’s method for curing Vesico-

Vaginal Fistula, 91

Cases cured by, 91

Dieffenbach on Ruptured Perineum, 13
His rules of practice in, 13

Diet, generous, after operation, 41
Advocacy of, by Dr. Skey, 42

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Dropsy, Ovarian, 159
Of Fallopian tubes, 171

Encysted tumours of the Labia, 144-6

Erichsen, Mr., 249

Ergot of Rye, 8

Excision of a portion of the cyst in
Ovarian Dropsy, 234

Extirpation, &., 241

a accumulation of, in the Rectum,
Fissure of the Rectum, 153
Fistula
Vesico-Vaginal, 89
Causes of, 89
Situation of, 89
Symptoms of, 90
Treatment of, 91
Cauterization, 91
Cases recorded as cured by, 91
Suture, 92
By whom advocated, 92
That advocated by Dr. Marion
Sims, 93
Position for operating for, 95
Instruments, 96-9
After-treatment, 100
Cases of, 100-111
Recto-Vaginal, 112
Causes of, 112
Treatment of, 112
Operation for, 113
After-treatment, 113
Cases of, 113-115
In Ano, case of, 155

Gooch, Dr., 119, 120
Graafian Vesicles, 160

Haighton, Dr., 183
Hamilton, 120

Hawkins, Mr., 131
Hayward, Dr., 95

 
282 APPENDIX.

of opium directly after the operation, which were repeated at
intervals all night, so that up to eight o’clock on the morning
of the 7th, she had taken fourteen grains of opium and four
grains of muriate of morphine, but still had only had two half-
hour’s sleep. Constant vomiting prevented her having any rest.
Pulse from 96 to 100. To take grs. 4 of opium and a mixture
of hydrocyanic acid, ammonia and soda. 11.30 p.m.: No more
sickness ; has had refreshing sleep twice for three-quarters of an
hour.

8th. 2 a.m.: Has had more sleep, and taken beef tea, lemon
ice, barley water, and tea. 5 a.m.: A little restless, with a
slight pain from flatulence, which was relieved by passing it
through the bowel; to take two grains of opium. 11 a.m.:
Still very comfortable; pulse 120; to take two grains of opium.
1.380 p.m.: Has had refreshing sleep; hands moist, two grains
‘of opium. 7.80 p.m.: Very comfortable; says she feels quite
well; skin moist. No swelling of abdomen; removed dressing
for the second time; the pedicle begins to be offensive, to be
washed with a solution of chloride of lime.

9th. Has had on the whole a comfortable day, but ‘owe
evening she was distressed with eructations of wind and feeling
of sickness: gave a warm rhubarb draught.

10th. 7 a.m.: Has passed an uncomfortable night; been sick
and restless. Bowels relieved four times and much flatus es- .
caped per rectum after injections. A dose of creasote relieved
the sickness for some hours. 10 p.m.: Has vomited a pint of
dark fluid: gave 20 drops of bimeconate of morphia. Sickness
recurred soon after: repeated opiate in two hours, and again in
four hours.

11th. From 4 a.m. : no sickness but occasional hiccup. 7°30 a.m.
Is quiet and sleepy: pulse 100. 11 a.m.: Has had some very quiet
and refreshing sleep, and is better. 9 p.m.: Has passed a very
quiet day, sleeping, and has taken a cup of beef-tea. Barley-water
and chicken broth have been given alternately every hour. Re-
moved the two upper deep sutures: healthy pus came from the
wound.
. 12th. 8 a.m.: Has passed an uncomfortable night, frequently

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APPENDIX. . 283

sick. Gave two grains of calomel, and in the evening the bowels
were well relieved by an injection: omitted the opiate at night.

13th. 8 a.m.: Has passed a comfortable night, and is better.
This evening, 7, p.m., is considerably better, and feels cheerful :
removed the last suture.

14th. Has had a restless night, and is not so well this
morning, but has had no return of sickness for forty-eight
hours, and considerably less hiccup. Bowels have been opened
three or four times. 11 p.m.: Very restless, with oppression on
the chest ; small quick pulse; clammy cold perspiration on the
skin and hands. Gave her some hot brandy and water, and
half-an-hour afterwards some port wine, with twenty drops of
bimeconate of morphia, which in half-an-hour produced sleep and
quieted the restlessness.

15th. 8 a.m.: Has been very sick all night after taking any-
thing, but has less oppression, and is not so low as last: night.
Ordered her a drop of prussic acid every hour, and wine and
nourishment to be continued. She had a relapse, rapidly got
worse, and sunk at 11.30 p.m.

An autopsy was made at 4 o’clock p.m. on April 16th. An
immense quantity of sanio-purulent matter was found in the
pelvic cavity ; the bowels had a slight blush upon them in some
parts ; the lower part of the omentum was very much enlarged
and indurated ; that which remained of what at the operation
- seemed to be a second covering of the cyst, was found to be very
adherent to the peritonzum and nodulated in some parts, and
there were evident symptoms of severe inflammation of old
standing. <A portion of the thickened omentum, and a piece of
the layer, together with the vermiform appendix, the kidney, and
the uterus, were removed for subsequent examination. In the
thorax the lungs were found to be very extensively congested ;
the muscular coats of the heart flabby with fatty degenera-
tion in some parts, and there was some fluid in the pericardium.
The stomach was enormously distended. On examination, the
uterus was enlarged, and the walls of pale aspect, but nothing
abnormal could be seen; the thickened portion of omentum was
of simple inflammatory origin, and contained some spots of fatty

Digitized by Microsoft®
284 _ APPENDIX.

degeneration ; the vermiform appendix empty and natural; on
one side of the layer which covered the ovarian cyst was a dense
layer of thickened fibrous membrane, beneath which was a quan-
tity of less indurated areolar tissue and fat containing a good
deal of black pigmentary substance. The kidney, though much
enlarged, was tolerably healthy; a little interstitial fibroid
formation existed among the tubes; capsules shrunk.

Digitized by Microsoft®
INDEX,

Abscess, Pelvic and Psoas, 204
Acetum Cantharidis, 109

Lytte, 49, 55
Actual Cautery, 50, 57, 102, 124, 145
Te cama of, in the intestines,
Artificial Oviduct, 218
Ascites, 197

Bandage, perineal, 87

Barnes, Dr., 12

Bird, Dr. F., 175

Bladder, distended urinary, 202

ge Dr., 10, 85, 185, 189, 179,
Brigham, Mr., 187

Case of delivery, after operation for Rup-
tured Perinzum, 50

Catheterism, frequent, 36, 73

“Celsus,

Chailly-Honoré, M., 10

Childs, Mr. G. Borlase, 242

Churchill, Dr. Fleetwood, 4, 87, 90, 172,
183, 199

Cooper, Sir Astley, 131

Constipation, case of, 154

Copeland, Mr., 151

Copland, Dr., 170

Coulson, Mr., 135

Crouch, Mr., 247

Cystocele, vaginal, 70
Cases of, 74-79

Davidson, Mr., a case of Ruptured Pe-
rinzum cured by operation, 18

Denman, Dr., 119 ;

Dessault’s method for curing Vesico-

Vaginal Fistula, 91

Cases cured by, 91

Dieffenbach on Ruptured Perineum, 13
His rules of practice in, 13

Diet, generous, after operation, 41
Advocacy of, by Dr. Skey, 42

 

Dropsy, Ovarian, 159
Of Fallopian tubes, 171

Encysted tumours of the Labia, 144-6

Erichsen, Mr., 249

Ergot of Rye, 8

Excision of a portion of the cyst in
Ovarian Dropsy, 234

Extirpation, &c., 241

arr accumulation of, in the Rectum,
Fissure of the Rectum, 153
Fistula
Vesico- Vaginal, 89
Causes of, 89
Situation of, 89
Symptoms of, 90
Treatment of, 91
Cauterization, 91
Cases recorded as cured by, 91
Suture, 92
By whom advocated, 92
That advocated by Dr. Marion
Sims, 93
Position for operating for, 95
Instruments, 96-9
After-treatment, 100
Cases of, 100-111
Recto-Vaginal, 112
Causes of, 112
Treatment of, 112
Operation for, 113
After-treatment, 113
Cases of, 113-115
In Ano, case of, 155

Gooch, Dr., 119, 120
Graafian Vesicles, 160

Haighton, Dr., 133
Hamilton, 120

Hawkins, Mr., 131
Hayward, Dr., 95

Digitized by Microsoft®
286

Heister, 133

Hernia, Recto-Vaginal, &c., 203

Hewett, Mr., a case by, 196

Hilton,’s Mr., operation for Ruptured
Perineum, 21

Hemorrhoids, 149

Hooper’s water-cushion, 57

Hunter, Dr. W. H., 210

Hydrometra, 205

Hymen, Imperforate, 1389-143

Imperforate Hymen, 139
Treatment of, 140
Cases of, 141

Jobert, M., 73
Jordan, Mr., 138

Knaggs, Mr., 60

Laceration of Perineum, 5
Frequency of the accident, 5
Causes of, 7
Prevention of, 9
Consequences of, 10
Difficulties of treatment, 11
History of, 12
German writers on, 14
French ,, 5, 15
English ,,  ,, 17
Cases on record of, 19
Dr. Lever’s and Mr. Hilton’s operation

for, 21
Contraindications to operation, 33
Time of operating,
Instruments for, 34
Use of chloroform in, 34
Mode of operation for, 35
Position, 35
Denudation of the surfaces, 35
Incision of the sphincter, 35
Insertion of quill sutures, 35
Interrupted do., 35
Operation in recent cases, 36
After-treatment, 36
Time for removal of sutures, 37
On immediate operation, 38
Objections to, 38
Suggestions on incision of sphincter,
sutures, diet, &c. in, 40-41
Cases of, 45-70
Acetum Lytte, use of, in, Ps
Actual cautery, 2g

Lacerated Vagina, 116-117

Langenbeck, Mr., 26

Le Dran, artificial oviduct, cases of, 218

 

INDEX.

Lee, Dr., 119, 159, 248

Lever’s operation for ruptured perineum,
21

Liston, Mr., 145

Middleton, 133
Molineux, Dr., 132
Montgomery, Dr., 121
Moullin, Mr., 51, 77

Noel, case of Procidentia Uteri, by, 87

Norman, Mr., 179
Nunn, Mr., 187, 198
Obré, Mr., 66
Oldham, 120
Opium, on use of, notes by Dr. Handfield
Jones, 42
Ovarian Dropsy
Paper in ‘‘ Lancet’ on, in 1844, 3
Four papers in do. in 1848-9, 3
On diagnosis of, 3
On artificial oviduct, 3
On excision of a portion of cyst, 3
Chapter on, 159
Origin and structure of ovarian cysts
159
Formation of multilocular cysts, 162
Growth of cysts, 164
Direction of growth, 165
Intercommunication of cysts, 166
Communication of, with Fallopian
tubes,. 167
Contents of ovarian cysts, 167
Dropsy of Fallopian tubes, 171
Causes of Ovarian Dropsy, 171
Symptoms and course of, 173
Case of ruptured cyst, by Dr. Simp-
son, 180
Diagnosis of Ovarian Dropsy, 181
Signs of, 181
General signs, 181
Special and local signs, 182
Local signs in early age, 182
Special signs of- cyst when in abdo-
men, 184
Inspection, 184
Percussion, 185
Recapitulation, 186
Microscopical diagnosis, 187
Mr. Nunn on do., 187
Exploring needles, 189
eee value of uterine sound,
90
Diagnosis of adhesions, 191
Malignant disease of the ovaria, 192

Digitized by Microsoft®
INDEX.

Ovarian Dropsy.
Chapter on—continued,

Diseases liable to be mistaken for,
194 :

Retroversion of the Uterus, 195
Tumours of the Uterus, 195

Fibro-cystic uterine tumours, 196
Ascites, 197

Pregnancy, 198
Ditto complicated with Ovarian
Dropsy, 199

Cystic tumours of the abdomen,-

201
Distended urinary bladder, 202
Enlargement of the viscera of the
abdomen, 203
Accumulation of faces in the in-
testines, 208
Recto-Vaginal hernia and displace-
ment of the ovary into the recto-
vaginal space, 203
Accumulation of air in the intes-
tines, 208
Pelvic and Psoas abscess, 204
Retention of the menstrual fluid
from imperforate hymen, 204
Hydrometra, 204
Treatment of, 205
General observations, 205
The principal modes of surgical treat-
ment, 206
Tapping, 207
Mode of, 207
Tapping with pressure, 211
Cases of, 211
And injection of iodine, 215
Artificial oviduct, 218
a. External
6. Per vaginam
ec. Per rectum
Cases of, 226
Excision of a portion of the cyst,
234
a. By a small incision
b. By a large do.
Cases of, 236
Extirpation, 241
Advocates and opponents of, 241
Average mortality, 243
Conditions rendering extirpation jus-
tifiable, 247
Preparations for operation, 250
Mode of operating, 251
The dangers to be apprehended after
operation, 254
Cases of extirpation, 255
Other modes of treatment, 269

 

287

Paget, Mr., 159
Pedunculated bodies in rectum, 154
Perinzum, structure of, 6

SaEee rigidity of, after operation,

Perineal bandages, 87

. Polypus Uteri, 118

Various forms of, 118
Glandular, 119
Cellular, 119
Fibrous, 120

Symptoms, 120

Diagnosis, 121

Prognosis, 122

Treatment, 123
Torsion, 123
Ligature, 123
Excision, 124
Actual cautery, 124

Cases of, 125-129

Pregnancy, 198
Preliminary remarks, 1
Procidentia Uteri, 85
Prolapsus Ani, 151

Vagine, 71

Vesice, 71

Uteri, 88

Rectocele, Vaginal, 79
Causes of, 79
Symptoms, diagnosis, treatment, 80
Cases of, 81-85
Recto-Vaginal Fistula, 111-115
Rectum, diseases of the, resulting from
certain conditions of the Uterus, 147
Hemorrhoids, 149
Case of, 150
Prolapsus Ani, cases of, 151-152
Fissure of the Rectum, 153
Constipation, case of, 154
Fistula in Ano, case of, 155
Diseases resulting from other conditions
of the Uterus and its appendages,
157
Causes, 157
Richard, M., 167
Ruptured Perineum, varieties of, 6

Siebold, 118
Simpson, Dr., 165
Case of ruptured ovarian cyst by, 180
Exploring needles, 189
Hydatids, 201
Tapping, 209
ireetion of iodine, 215
Sims, Dr. Marion, 98-94
Smith, Dr. Tyler, 9

a

Digitized by Microsoft®
288

Speculum, Fergusson’s, 90
Sphincter, incision of, 35
Stewart, Mr. C., 66
Stone in female bladder, 131
Diagnosis, 131
Treatment, 132
Incision, 132
Dilatation of urethra, 133
Suture for Ruptured Perineum, 35

Tanner, Dr., 271
Tapping, &c., 206
Thomas, Mr., 130
Toogood, Dr., 130
Tumour, encysted, of the Labia, 144
Symptoms, 144
Causes, 144
Treatment, 145
Simple incision, &., 145
Insertion of a seton, &c., 145
Dissecting out the tumour, 145
Injections of iodine, 145
Actual cautery, 145
Case of, 145-146
Tumour, Vascular, of the Meatus Urina-
rius, 136
Diagnosis, 136
Treatment, 137
Tumours, Ovarian, 159
Cystic, of the abdomen, 201
Twine vice silk, 35, 151

THE

 

INDEX.

Uterus, diseases of the rectum resulting
from certain conditions of, 147
Polypus of, 118-129
Prolapse of, 85
Causes, 85
Symptoms, diagnosis, treatment, 86
Relaxation of, 88
Retroversion and retroflexion of, 194
Tumours of, a. solid, b. fibro-cystic,
195

Vagina, lacerated, 116-117
Prolapse of, 71
Anterior wall of, 71°
Symptoms, 72
Treatment, 73
Cases, 74-78
Posterior wall of, 79
Causes, 79
Symptoms, diagnosis, treatment, 80
Cases, 81-85
Vascular tumour of Meatus Urinarius,
137-138
Velpeau, M., 7
Verhaeghe, M., 7, 23
Three cases of cure of ruptured Peri-
neum by, 27-31
Vesico-Vaginal Fistula, 89-111

Wilkes, Dr., 97
Wilson, Mr. J. Grant, 235-270

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Human Family. 4th Edition, revised and enlarged, By Epwin Norris, of the Royal Asiatic
Society, London. With 62 plates, colored, engraved on steel, and 100 engravings on wood,
2 vols, royal 8vo. elegantly bound in cloth, London, 1855, $10.

.—8! THNOGRAPHICAL MAPS, as a Supplement to the Natural
woe eR ny a Researches into the Physical History of Mankind, folio, colored,
and 1 sheet of letter-press, in cloth boards. 2nd. Edition. London, 1850.

LiAMS.—ELEMENTS OF MEDICINE: Morbid Poisons, By Ropert WILLIAMS,

M.D., eee ae Thomas’s Hospital. 2 vols, Svo. London, 1836-41. $7.

Sent free on receipt of price. H. BAILLIERE, Publisher,
290 BROADWAY, N. Y.

 

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