2. Inser

1. Simple incision, and evacuation of the contents. tion of a seton through the tumour, so as to produce suppuration. 3. 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.

I shall only relate one case, in which the third kind of treatment succeeded.

CASE XL-Encysted Tumour of the Labia in an unmarried lady: Operation; Cure.-M. H., æt. 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 examination, 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 1st, proceeded to operate. The patient being placed un

in the position for lithoto 1 his fin

an assistant

2. That laceration is liable 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 anaesthetics 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 objection 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 explained. When the dilatation has been a tedious and painful process, it has at length been accomplished (physiologically) by exhausting 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 contraction, 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

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 consequences 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 constant 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.

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 cystorrhoea.

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

those of circumscribed inflammation of the vulva, it is evident that correct information can only be obtained by careful examination. Upon separating the labia and nymphæ, 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 attachment, 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 disturbance, 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 once.

My friend, Mr. Brigham, of Lymm, informs me that during the twenty years he held the appointment of surgeon