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 obstructing the vaginal orifice, extremely unyielding. At last, seeing some more leucorrhoeal 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 instrument 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 lithotomy 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 discovered, 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 hæmorrhage of any consequence 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 unfavourable symptoms, and on the 18th returned home, having previously 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 vagina. This objection 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. CHAPTER XI ENCYSTED TUMOUR OF THE LABIA. THESE tumours are met with of various sizes, but are generally 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, aggravated by locomotion, by defæcation, 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. 1. Simple incision, and evacuation of the contents. 2. Insertion 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 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 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. CHAPTER XII. DISEASES OF THE RECTUM RESULTING FROM THE 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, displacement, 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 bowel as the primary seat of the disease, and yet the patient shall derive no benefit from any of them; for the uterine and intestinal affections are related to each other as . |