Elements of Surgery

by Robert Liston

Retention takes place in females from paralysis of the bladder, and the same treatment is necessary as in the case of the male. Hysterical women often take it into their heads that they are unable to empty the bladder, and will not attempt it; and though it may be difficult to convince them of their mistake, yet when they are left to themselves for a little, and begin to feel some of the torments which attend retention, they contrive to get rid of their burden, and that without any very great exertion. Sometimes they omit attempting to empty the bladder when they could, and then they cannot effect it when they would do so. Others are still more whimsical, and will push into the viscus needle-cases, bodkins, portions of tobacco-pipes, and such like. The surgeon should be aware of such whims and fancies.

There is, in general, no difficulty in passing the catheter. A short one is preferable, there being less chance of giving pain; and the operation must, of course, be proceeded in with the utmost regard to delicacy. The forefinger is placed in the upper part of the orifice of the vagina, and the point of the instrument, when placed a little above this mark, readily slips into the urethra. It is recommended to use the clitoris as the guide, placing the finger on this, and moving the point of the instrument thence downwards; but when this method is pursued, the catheter is apt to enter the more patent passage. The instrument is to be carried gently onwards, in a horizontal direction, till the urine flows. In some cases of enlargement and displacement of the neighbouring parts, the urethra is elongated, and its course irregular; in such, a long elastic catheter is required. If objections are made to the use of the catheter, at an early period of retention, nitrous ether may be given internally, fomentations applied to the hypogastrium, and a turpentine enema administered. Puncture of the bladder can seldom, if ever, be necessary in the female; if it should be required, the opening may be made either above the pubes or through the vagina. From the latter method there is a risk of fistula remaining; but this, as will afterwards be noticed, can in some cases be ultimately made to close. The operation above the pubes has, in some instances, been necessary during parturition, when instruments could not be passed by the urethra, nor through the coats of the vagina and bladder.

False communication betwixt the vagina and bladder, termed Vesico-vaginal fistula, is usually the result of mismanagement during parturition. The bladder has been allowed to become over-distended, and in this state to be pressed upon and bruised by the child’s head; or it may have been compressed and bruised by instruments employed in tedious delivery. The consequence is inflammation, violent, and followed by sloughing. On the separation of the sloughs, the urine escapes, perhaps six or eight days after delivery; or the anterior surface of the vagina, and the coats of the posterior and lower part of the bladder, have been lacerated by the imprudent use of the crotchet, or some such crooked and awkward tool; then the escape of urine is immediate. The unnatural flow continues, diminishing after a time, and if the opening be at first not large, and have gradually contracted, ultimately it may escape in but small quantities, at least during the recumbent posture. Of course, the size and site of the opening are very various. I have been consulted in some dreadful cases, incurable and loathsome—the consequence of most culpable neglect and ignorant rudeness on the part of the accoucheur;—the bladder, without any part of its posterior fundus, has been rent so as to admit the fingers; the rectum also torn extensively—in some, merely a shred of the sphincter remaining; feces and urine constantly mixing in one vast offensive cavity. But in general the opening is in the neck of the bladder immediately behind the commencement of the urethra, and nearly in the mesial line; sometimes it is considerably further back. It can be felt by the finger, and is readily brought into view by means of a proper speculum, a copper spatula being at the same time used to prevent the folds of the vagina from interrupting the view; the speculum opened by handles attached to the blades, and prevented from shutting by a serrated semicircular plate interposed, is the most convenient and suitable.

Attempts have been made to close the aperture, by paring the edges, and then inserting sutures; but this is a proceeding both difficult in execution and not likely to prove successful; the thinness of the parts, the presence of a secreting surface on each side, and the oozing of acrid urine betwixt the edges, all militate strongly against adhesion. No benefit can be expected from any treatment, unless the opening be of no great size, and in such cases the cautery will be found most effectual. The speculum is introduced into the vagina, so as to expose the aperture, and guard the neighbouring parts from the cautery; and should the opening not appear distinct, a flexible wire is passed by the urethra, and insinuated through it. A small heated cautery is then slid cautiously along the speculum, and applied lightly to the margins, with the view of producing a superficial slough; this separates, and during the consequent cicatrisation the opening contracts. When the edges have again become smooth, the cautery is applied as before, and by several repetitions complete closure may ultimately be obtained. The interval between the applications is necessarily considerable; each must be allowed to have its full effect. Once I attempted to combine the cautery with the suture; first applying the heated wire, and after separation of the slough, and when the margins were tumefied, excited, and apparently prone to adhere by the formation of new matter, then approximating them by a species of twisted suture. At first, matters proceeded favourably, but the ultimate result was not very successful—it was such, however, as to render the plan worthy of being again tried; if fortunate it would very much abridge the cure. By the cautery I have succeeded in relieving many, and in curing a few perfectly. I cannot quit the subject without expressing regret at the frequent occurrence of such cases. I have had three or four cases in the hospital at one time, and they are constantly being presented for relief.

Imperfections of the female genital organs are sometimes met with. The external parts may be well formed, while the vagina is short, and the uterus and its appendages are wanting; or these may be perfect, and the vagina closed at its external orifice, either by a thin and dense membrane, or by a thick and fleshy substance. Young children are not unfrequently presented with the latter kind of imperfection, but in them there is no need for interference; the urine is not obstructed, and it is only towards puberty that a necessity arises for removal of the deficiency. At this period, the menstrual discharges are retained, if the vagina continue closed, and accumulate in great quantity, producing much distention of the canal, pain in the hypogastrium, general uneasiness in the parts, and sometimes swelling of them to a great extent. On division of the membrane, there is sometimes an escape of many pounds of dark, thick, putrid fluid, and all the symptoms quickly subside. A cautious incision is made in the mesial line, until the obstruction be completely divided; if an opening be found, a probe, or director, is introduced, and by this the knife is guided. There is seldom any risk of the parts again coalescing; when the obstruction, however, is unusually thick, the insertion of dressing between the edges during granulation may be necessary to prevent contraction.

Unnatural adhesions of the external labia occasionally take place, occurring in early life from the healing of excoriation and ulceration caused by neglect of cleanliness. Perhaps the closure is not to such an extent as to prevent escape of the discharges, but still it is inconvenient and requires attention. The parts must be divided in the proper direction and to the necessary extent, and, by the interposition of dressing, reclosure is prevented.

Contraction of the vagina at a distance from the orifice sometimes occurs. On one occasion I was requested by an accoucheur to examine and divide a very tight, firm stricture, scarcely admitting the finger. Labour had commenced, and the expulsion of the fœtus was prevented by the stricture; it was attributed to injury inflicted in a former delivery. By a probe-pointed bistoury, guided on the finger, it was notched pretty deeply at many points—a proceeding which I have frequently followed with advantage in simple stricture of the rectum. Everything proceeded happily.

Occasionally the contraction of the vagina is to a great extent; the uterine discharges are not permitted to escape at all, and great uneasiness is thereby occasioned. In one case, in which the canal may be said to have been wholly obliterated, from what cause or at what period it did not distinctly appear, I ascertained the position of the uterus by the finger passed into the bowel, pushed a curved trocar on to it through a considerable thickness of parts, and afterwards dilated this artificial passage by bougies gradually increased in size. The vagina was thus reëstablished, and menstruation again occurred, and without interruption. A case, in which the vagina was obliterated to the extent of from two to three inches, occurred some months ago at the North London Hospital. It took place, it appears, after an accouchement, the genital organs being raw and sore, with considerable loss of substance from phagedænic ulceration. A large tumour could be felt betwixt the hand placed on the hypogastric region and the finger in the rectum. The patient was exceedingly urgent in her entreaties to have the canal restored, and the attempt was made. The contiguous viscera being emptied, a trocar, guided by the finger in the bowel, was pushed in the course of the vagina as far as was thought safe; the canula was retained, and, some days after its withdrawal, the part was farther dilated by gentian root. It was intended to have carried the pointed instrument farther, but symptoms of peritoneal inflammation supervened about the tenth day, and in spite of active treatment proved fatal. The uterus, os uteri, and from an inch and a half to two inches of the upper part of the vagina, were enormously distended with dark, putrid, grumous, and bloody fluid, of the consistence of tar; the trocar had reached the parietes of the cavity, and, if pushed forward another line, must have entered the vagina, and allowed the fluid to escape. There was a quantity of putrid and dark-coloured serosity in the cellular tissue of the pelvis and behind the peritoneum. It is to be regretted that I did not feel warranted in the first instance in pushing the instrument forward more boldly. Had the fluid been allowed to drain off, the probability is, that the future infiltration and peritonitis would not have occurred. The intention was, being foiled in the first attempt, to dilate the canal sufficiently to admit the finger, and by the direct guidance of that to carry the perforation farther.

Violent and deep inflammation of the external parts of generation is not uncommon,—the result of bruise or wound. It is generally met with in the lower class of prostitutes. The inflammation often attacks the vagina and neighbouring parts, followed by great swelling; and, if not allayed, extensive abscess forms, with much fever and pain; pointing takes place betwixt the external and internal labia. The parts must be copiously leeched, and afterwards fomented; strict rest and antiphlogistic regimen must be observed, and when matter has formed, a free opening should be made early, to prevent deep and extensive mischief. A sinus sometimes, though rarely, results; generally the cavity fills up, and the discharge ceases in a very few days. These parts are much more vascular than the lower part of the bowel, and when in a diseased condition, are not of necessity so frequently put in action; hence extensive incision and division of the sphincter is here very seldom necessary.

Tumours of various kinds are met with about the external female organs; more rarely, internally. Encysted tumours of the labia are not uncommon, and sometimes solid swellings, varying in size and structure, grow from these parts. I had occasion to remove one of the latter description, which weighed many pounds, and had been productive of great and long inconvenience. The general rules for the extirpation of tumours apply to them. Considerable hemorrhage may be expected. The operation must be done so as to deform and impair the functions of the parts as little as possible.