Elements of Surgery

by Robert Liston

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

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

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

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

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

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

The inflammatory stage must be subdued by antiphlogistic measures, proportioned to the intensity of the action and the state of the constitution; they seldom, if ever, require to be at all severe. Turpentines, and other internal remedies, which may prove beneficial in the gonorrhœa of males, are of little use. The external means are to be chiefly trusted to, consisting of astringent and stimulating washes; when the vagina is affected, the solutions must be thrown up by means of a syringe. In leucorrhœa, the same external treatment is required, and the use of a syringe is always necessary. The washes most commonly employed are—solution of the sulphate of zinc, of alum, and of the nitrate of silver, or a decoction of oak bark or galls. In leucorrhœa the internal exhibition of preparations of iron and of tinct. lyttæ in pretty large doses may be considered as almost a specific, stimulating the whole system, and correcting that state of morbid debility, both general and local, on which the vitiated secretion depends; and the injection for the vagina, which is perhaps most efficacious, is the solution of the nitrate of silver. The solid caustic may often be rubbed over the surface of the vagina affected by bad leucorrhœa or gonorrhœa, when exposed and brought into view by the speculum, with the best effects. When the menstruation is irregular, blisters and sinapisms may be applied to the loins, with cold bathing, general and local. In gonorrhœa, when only the external parts are inflamed and furnish discharge, the application of a solution of the sulphate or of the acetate of zinc to the parts, by means of lint, effects a cure in a few days—along with strict attention to cleanliness, the observance of rest, regulation of diet, and occasional doses of gentle physic.

Gonorrhœal Lichen not unfrequently follows suppression of the discharge both in males and females. It is preceded by smart fever, headache, and violent pains in the limbs. Inflammation of the fauces is generally present, with superficial ulceration or excoriation; and sometimes the abraded portions of the mucous lining are covered with a whitish exudation. The symptoms subside on the appearance of the eruption, which is papular. It generally appears first on the breast and arms, and then extends over the whole body, accompanied with slight itching. If the case proceeds favourably, the red papulæ disappear in a few days, leaving blains in their stead. Desquamation of the cuticle generally follows. This affection must not be confounded with a cutaneous eruption which sometimes follows the use of copaiba, and which is a species of urticaria.

When the fever is violent, bleeding must be had recourse to, but not to a great extent, and only when it cannot with safety be avoided. Gentle laxatives are to be given. Diaphoretics are very beneficial, and the patient should not be exposed to cold or wet, but kept rather warm, otherwise the eruption may be repelled, the affection thereby prolonged, and the constitutional disturbance augmented. The fauces soon recover under the use of simple gargles. Mercury is hurtful.

Retention of Urine in females arises from tumours, natural or morbid, of the uterus, or of the vagina and appendages, from displacement of these parts, or from foreign bodies lodged in them. But the consideration of such affections belongs to the accoucheur.