r\ W4/f :ffEjy (jl K,J CASES OCCLUSION OF THE VAGINA, RETENTION OF THE CATAMENIA, RELIEVED BY AN OPERATION. J. MASON WARREN, SPRGEON AT MASSACHUSETTS GENERAL HOSPITAL. FROM t{hE A'^'lCfN^TJjnpAlAOE- jTOT MEDICA*' '■$CFBNCES. 7 : >~ i j / BOSTON: PRINTED BY"JOHN WlLSON~& SON, 22, School Street. 1853. LIBRARY | SltRC.tCN <«N€R£l.T, orncc JUL-2-1905 • • ' * • * CASES OCCLUSION OF THE VAGINA, RETENTION OF THE CATAMENIA, RELIEVED BY AN OPERATION. J. MASON WARREN, SURGEON AT MASSACHUSETTS GENERAL HOSPITAL. AMERICAN JOURNAL OJF THe"Jm^|icJ^ J^^8|^\ JUL-3---90D ! BOSTOlN: PRINTED BY JOHN WILSON & SON, 22, School Street. 1853. CASE S OP OCCLUSION OF THE VAGINA. The cases of occlusion of the vagina, successfully relieved by an operation, are rare, and the mode to be pursued under the different circumstances in which this occurrence pre- sents itself has not been very fully pointed out by writers on the subject. In the first of the following cases, some embarrassment was therefore felt as to the proper course to be adopted. The principal authorities for reference were Boyer, Boivin, Amussat, and the case of Professor Mussey. The former of these details two or three very interesting cases, as showing the anatomical peculiarities which are likely to exist, but advises against the operation in nearly these words: " An opening into the bladder and rectum is not the only accident to be dreaded in this operation. Inflam- mation of the womb and of the neighboring parts has, to my certain knowledge, caused the death of two females, on whom it had been performed." Madame Boivin, after observing that in these cases of atresia the prognosis is worse, the diagnosis more difficult, the treatment more un- certain, and the operations more doubtful and delicate, than 4 in cases of simple closure, recounts the three instances re- corded by Boyer, in one of which the celebrated Dubois was called in consultation. The result of these cases, how- ever, was fatal, as also that of another, in which an eminent surgeon unfolded, as it were, the urethro-rectal septum, punctured the tumor, and thus gave issue to the retained fluid, for the first few days with the prospect of success. The case of Amussat is very instructive, and detailed at considerable length in the number of this Journal for Feb- ruary, 1837. In many respects it corresponds with one of our own cases hereafter given, and was operated upon with perfect success. The case of Professor Mussey is also detailed in vol. xxi. of the same Journal; and in the num- ber for July, 1850, another, with the appearances upon a post-mortem examination, is described by Dr. J. B. S. Jack- son. " In regard to an operation," he says, " which seemed to have been so imperatively required, a consultation was held with two or three professed surgeons, when the occlu- sion was discovered, but the opinions were against it." Some writers on surgery, Chelius for instance, have given general directions for the management of closure of the vagina, whether from accident or congenital malformation. But sufficient detail is wanting as to the diagnosis in reten- tion of the menstrual secretion, and the mode of giving an external outlet when the anatomical relations of the parts have been altered by inflammation or extensive gangrene. These considerations have led me to offer the following cases, with the hope that they may be of service to any surgeon who should meet with similar instances in the course of his practice. In three, it will be seen that the occlusion was the result of parturition; two were congeni- tal ; the last, accidental. 0 Case I. — This patient was a married woman, twenty years of age. A year before, she had been delivered, by means of instruments, of a dead child, after a labor of four days; very severe inflammation followed, attended with sloughing of a portion of the vesico-vaginal septum, so that the remains of the bladder, falling down, became ad- herent to the posterior wall of the vagina, and obliterated the passage. The urethra also in part sloughed, the water escaping at a valvular opening between the remains of the neck of the bladder and the os pubis. The menstrual secretion had been retained from the period of her confinement; at first she suffered at the regu- lar periodical returns of the catamenia from pain and dis- tension of the abdomen, with a sense of bearing down in the rectum. Latterly, the pain has become almost con- stant, at times amounting to a feeling as if the abdomen would give way, and so acute as only to be relieved by the persistence in large doses of narcotic substances. From these causes she was almost bedridden, and reduced to the lowest degree of emaciation. The constant dribbling of urine had rendered the orifice of the vagina so extremely sensitive that it was found quite impracticable to make any examination until the patient had been placed under the influence of ether. The cul-de- sac left at the commencement of the vagina was just suf- ficient to admit the end of the forefinger. From its upper part the urine escaped through a valvular opening, so dis- posed that a probe could not be made to enter the bladder. On passing the forefinger into the rectum, a hard and slightly elastic tumor could be felt about two inches from the external orifice, pressing backwards and partially ob- structing the bowel. The other hand being placed on the 6 abdomen distinguished a large globular mass rising above the brim of the pelvis, pressure on which communicated a distinct impulse to the finger in the rectum. The above examination led to the conclusion that the tumor felt in the abdomen and rectum was the uterus and upper part of the vagina distended by the menstrual fluid. The question next arose how was this tumor to be attacked : the most feasible plan seemed to be to puncture it by the rectum. The impossibility of keeping a passage open in this direction was an objection to this course, as affording only a temporary relief. An attempt to dissect the bladder from the vagina, supposing its posterior wall destroyed, and the relation of these organs to be as in the accompany- ing illustration by Dr. Dalton, would almost inevitably create an opening into its cavity. Note. —The large rounded tumor, in the upper part of this plate, is the distended uterus ; immediately below and connected with it, so as to form one cavity, is seen a section of the upper part of the vagina, in front of which lies the bladder ; posterior to both of these is the rectum. 7 In consultation with Dr. Morrill Wyman, the physician of the patient, the plan which was afterwards put in execu- tion was agreed upon ; and in the operation, which was performed April 11, 1850, I was assisted by Dr. "Wyman, Dr. S. D. Townsend, and Dr. C G. Adams. The patient being brought as completely as possible un- der the anaesthetic influence of sulphuric ether, was placed on the edge of the bed, with the limbs supported, as in the operation for lithotomy, and the labia held apart by silver hooks. The forefinger being now placed in the rectum to serve as a guide, a transverse incision was made across the lower part of the vagina through its parietes, so as to ex- pose the cellular membrane lying between it and the rectum. This dissection, passing under that portion of the vagina which served as a fundus to the bladder, was continued upwards beween these organs for two or three inches, until the distended cul-de-sac could be distinctly felt. A very large trocar and canula was now plunged into the tumor, and, when withdrawn, a quantity of thick tarry- looking fluid began very slowly to flow through the tube; about a pint was allowed to escape, when the canula was withdrawn, being too short to be left with safety, and a female catheter introduced in its place. In the afternoon of the day of the operation, the patient was comfortable, and greatly relieved from the previous distressing sense of distension. At intervals, however, there were severe contractile pains in the uterus like those attending the first stages of parturition, and by them the catamenial fluid was forcibly expelled. Spirituous applica- tions were made to the back, and an opiate administered, by which her sufferings were temporarily relieved. On the following day I learned that she had passed an uneasy night, the pains continuing at intervals, causing a 8 free evacuation of fluid. Her mother estimated that at least two quarts had passed through the instrument, with the effect of greatly diminishing the tension of the abdo- men. Towards evening she had an access of pain and fever, with some obstruction to the discharge; the bowels being constipated, she was ordered a cathartic of castor oil. On the thirteenth, the report was that the medicine had operated with much relief, and the uterus had again re- sumed its action. This organ could now be felt above the pubes, somewhat tender on pressure, and contracted into a small, well-defined tumor. For about a week she improved steadily, the discharge continuing at intervals. It was with the utmost difficulty that any instrument could be retained in the opening; and when displaced, as it was once or twice by her restlessness, the aperture was found to have so contracted as to render its replacement almost impracticable; especially as her complaints were very great from the excessive sensibility of the external organs. After the lapse of this period, she was attacked with a catarrhal affection, during which, from some exposure or error in diet, she was suddenly seized with violent pains in the abdomen, meteorism, great sensibility on pressure, with other symptoms denoting peritoneal inflammation. These were gradually relieved by treatment, the patient barely escaping with her life. During this attack the canula had necessarily been removed, and every measure for maintain- ing the opening abandoned. It was therefore a subject of interesting speculation, whether, at the next catamenial period, the aperture would be pervious, and also if the uterus, after so great distension, would resume its normal functions. To the great satisfaction both of the patient and myself, the menstrual secretion came on naturally about 9 four weeks from the date of the operation, and gained an exit without difficulty. The subsequent improvement was gradual, and only interrupted in the course of the summer by an attack of varioloid, which disease prevailed in the house. I have recently heard from this lady through her mother, who informs me that from a mere skeleton her daughter has become quite fleshy; that she has regained her health and strength so as to be able to use exercise on horseback; and that the menstrual secretion is natural at the regular periods. Case II.— On February 4th, 1850, I was applied to by Mrs. B., aged thirty, in consequence of the suffering pro- duced by the retention of the menstrual fluid from an occlusion of the vagina subsequent to parturition. In the August previous, she had been delivered of her first child after a labor of four days, during a portion of which the head of the infant remained in the pelvis. In- struments were used, but ineffectually, and the delivery was ultimately accomplished without them ; very severe inflam- matory symptoms, attended with a purulent discharge, fol- lowed ; and finally it was discovered that the vagina had become entirely obliterated. From that time the return of every catamenial period has been marked by the most dis- tressing pains in the back and abdomen, lasting three or four days, and progressively increasing in violence: this was accompanied with some constitutional disturbance, and these repeated attacks have gradually impaired her health. An examination showed that the vagina was entirely closed, and hardly a perceptible cicatrix could be detected to indicate the line of union. At the lower part .of the 2 10 vulva, an orifice was discovered large enough to admit a probe, which, on being introduced, could be passed up a distance of three inches in the direction of the uterus, and was distinctly perceived through the recto-vaginal parietes by the finger introduced into the rectum. At this period, no abdominal or rectal tumor was ascertained to exist. It was determined to etherize her, and attempt to restore the vaginal passage. After having brought the patient fully under the influence of the anaesthetic agent, a bougie was passed into the fistu- lous opening. This was followed by the finger; and, by proceeding carefully in this way, by distending and separat- ing the adherent parts, a free opening was made of about three inches and a half or four inches. At this point a reg- ular organized septum precluded any advance, unless by the assistance of cutting instruments. A bit of sponge was therefore introduced and directed to be kept in situ during the night. On the day following, the sponge was removed and re- placed by another. This course was continued for a week, when, no tumor being discovered in the rectum to indi- cate the situation of the distended uterus, and there being no trace of the os uteri in the vagina, it wTas determined to suspend any further proceedings, resting contented with what had been gained, and enjoining upon her to use all m necessary means for keeping the passage open until the distension caused by the menstrual secretion should be suf- ficient to serve as a guide to the knife. A few months after, having rigorously followed up the above directions, she visited me a second time, suffering in the same way as before, and urgently demanding relief. An examination elicited no change in the situation of the 11 parts. As the pain was very distressing, however, I con- sented to make an incision at the upper part of the vagina, with the hope of throwing some light upon the direction in which the enlargement of the uterus was taking place. This was done, and the dissection carried as far as was thought safe, but with no good result. On the 3d of May, I again saw her. She had for four days been in extreme pain. The vagina, so far as it had been dilated, I found to be of its natural dimensions. The finger introduced into the rectum at once detected, about two inches from the anus, a hard tumor, such as might be presented by the enlarged prostate in the male, and with as little sensation of fluctuation. She informed me that for the previous twenty-four hours there had been a bloody discharge from the vagina; and traces of this secretion were perceived when that passage was examined, apparently coming from the mucous membrane. Not the slightest indication of any tumor could be found in this direction, even when the abdomen was strongly pressed upon. Although the rectal tumor was free from fluctuation, I had no question, from my previous experience, but that it proceeded from an enlargement by distension with fluid of the upper part of the vagina or uterus, and therefore pro- posed an operation, which was readily acceded to. On the 3d of July, the operation was performed, with the assistance of Dr. Channing, the patient being first etherized. The upper and back part of the vagina was cut freely through with a round-bladed bistoury, and very soon with a slight dissection the tumor which had been felt by the rectum presented itself, but much softer and more elastic than when examined through the intestinal wall. A large trocar was now plunged into it in a direction obliquely 12 backward, in order to avoid wounding the os uteri, in case that organ projected into the vagina. A free discharge of the black tarry substance described in the last case at once took place. About half a pint of fluid having escaped, the canula was withdrawn, and the finger introduced into the opening, which was enlarged in either direction with the probe- pointed bistoury. On exploring the cavity, no distinct projection answer- ing to the os uteri could be discovered. The whole inte- rior both of the uterus and vagina seemed to form but a single receptacle, a little contracted at one point, like the hour-glass contraction of the uterus, and this apparently 'answering to the situation of the os tineas. The mucous membrane appeared much swollen and traversed by large vessels, which stood out in bold relief. A long narrow bit of sponge was passed into the vagina, half of it being al- lowed to remain within and half without the opening just made. The patient declared herself at once relieved from all her distressing symptoms. From the difficulty of maintaining the new opening, it was found necessary, a few days after the operation, to introduce a sponge tent, which was removed daily and gra- dually increased in size. At the end of a week, the patient having exposed herself by going out of doors and washing her person with cold water, immediately after the sponge had been removed, was seized with severe pains in the ab- domen and in the lower part of the back, tympanites and all the symptoms denoting inflammation. The treatment consisted in the application of leeches, and the other mea- sures usually adopted. In three or four days the pain and tenderness gradually concentrated at the lower and left 13 side of the abdomen, where a large hard tumor could be perceived through the parietes. These symptoms were sud- denly relieved by the discharge of a quantity of pus from the vagina. The tumor in the abdomen now gradually subsided. The intestinal canal remained for a length of time quite irritable, diarrhoea being produced whenever she took solid food. She left town on July 31, quite weak, but recovered. She was advised to have a small rectum bougie passed into the opening in the vagina daily, as the disposition to contraction was still great; and it was thought unsafe, through fear of exciting a fresh attack of inflammation, to maintain any substance constantly in the aperture. Case III. — Congenital Occlusion. — Miss S., seventeen years old, has been suffering for two years with a sense of distension and weight in the lower part of the abdomen and back, attended by a forcible pressure in the vagina, as if for the purpose of expelling some foreign substance. She has also been greatly annoyed with a frequent desire to micturate, and of late has passed water as often as every twenty minutes through the day, but with diminished fre- quency at night. She suffers much severe pain at the ex- tremity of the urethra, which is aggravated by the passage of the water. She has never menstruated. Her physician, a person of much intelligence, when ap- plied to, at once suspected the cause, and on making an examination discovered that the vagina was completely imperforate. I saw her on the next day, and found the fol- lowing appearances: — On separating the external labia, no traces of the vagina were visible. At the central part of the fossa, usually occupied by this outlet, the meatus urina- 14 rius was perceived surrounded by small vegetations, which, on the slightest touch, elicited the most violent resistance and cries from the patient. A probe being passed into the urethra, its farther progress was resisted at the distance of an inch from the orifice; but finally, by turning it up- wards in almost a vertical direction, it entered the bladder, which was contracted to the smallest dimensions. The finger was now introduced into the rectum, and at once detected a hard tumor two inches from the anus, press- ing backwards against the spine. It seemed quite solid, .and without the slightest indications of elasticity. On passing the hand over the abdomen at its lower part, a hard projection was felt in the centre just above the pubis, having a prolongation about four inches in length, extending into the right iliac region. Pressure on this swelling caused a movement of the tumor in the rectum, and was attended with much suffering. No doubt remained in my mind that these tumors were caused by a retention of the menstrual fluid in the uterus and upper part of the vagina, and also the Fallopian tubes, as in the case already referred to, recorded by Dr. J. B. S. Jackson, in the American Journal of the Medical Sciences, July, 1850. An operation was therefore at once advised, which was performed on the following day, with the assist- ance of her physician, Dr. Tyler, Dr. Channing, and Dr. Storer. The patient being fully etherized with chloric ether, an incision was made transversely across the mucous mem- brane of the lower part of the vagina. This disclosed muscular fibres, which being carefully divided through the aperture thus made, a delicate membrance of a dark color protruded. It was suggested by one of the gentlemen 15 present, that this might possibly be the peritoneum, which, in a case of malformation and non-existence of the vagina, had taken an abnormal direction. For the purpose of testing this, I attempted to separate it from the surround- ing textures, knowing the loose character of the cellular tissue which attaches the peritoneum to the neighboring organs and the pelvis. This was at once found to be im- practicable ; and, on a renewal of the effort, the resisting part yielded, and the finger passed through into what appeared at first to be the abdominal cavity, so well defined was the anatomy of the walls of the pelvis. The absence of intes- tines, and the appearance of a small quantity of dark- colored fluid by the side of the finger, soon made it evident that the vagina had been opened. The size of the cavity occupying the entire pelvis, and the complete absence of os uteri or other boundary between the uterus and vagina, was on examination sufficiently evident to all present. By the aid of slight pressure on the abdomen, about half a pint of thick, tenacious fluid escaped. As the uterus did not at once take on contractions, no further efforts were made to evacuate the fluid; but a bit of sponge was intro- duced into the opening to prevent the parietes from adher- ing. The vegetations at the orifice of the urethra were now removed by the scissors, and the base of the tumors cauterized with nitrate of silver. To show the extreme sensibility of these tumors, it may be observed that, as soon as they were interfered with, the patient, although well etherized and perfectly passive through all the previous operation, immediately drew back as if in extreme pain. At 7, p.m,., she was in good spirits, and expressed herself entirely relieved by the operation. The effects of the ether had passed off, notwithstanding she had been kept for three- 16 quarters of an hour fully under its influence. I warned her of the great danger she incurred from any irregularity in diet or exposure to cold, as I found her disposed to leave her bed, and she was demanding food. On the 14th September, the day following the operation, she was reported to have passed a good night. The sponge was removed from the vagina, and a free discharge of the peculiar fluid took place; after a few hours it was again introduced. No urine had been passed since the operation ; during the succeeding night, however, a copious evacuation of the bladder took place. On the 17th, she still continued to improve, and the tu- mor of the abdomen to diminish. The finger passed into the vagina could distinguish the os uteri, as it were, gra- dually forming itself. It was about the size of a tumbler, with thick edges, and covered with dilated blood-vessels. The sponge tent, when withdrawn, was very offensive. As she was urgent to go among her friends, I agreed to- day, the 20th, that she should do so; being conveyed to the railroad in a carriage with care, and kept in a recumbent position until she arrived at the point of her destination. She was then to remain a few weeks longer in bed, or on a sofa, without attempting to use any exercise. At the pe- riod of leaving town, she was quite well; the urine was passed naturally and without pain, the sensitive tumors of the urethra having been destroyed by the operation; the discharge from the vagina had partially ceased, or had been replaced by a serous exudation ; her appetite and the state of her digestive organs were natural. On the 4th of October, the physician of this patient wrote to me as follows: " A case could not proceed more more satisfactorily or more rapidly than that of Miss S. 17 She has not had a bad or even a troublesome symptom. I could not conveniently use the dilater which you sent, but substituted a glass female syringe, which she was able to wear during the whole day, the discharge passing off through the calibre. She was able to use without pain one of seven- eighths of an inch in diameter. The discharge has ceased, and she yesterday went to her home." The following cases have occurred since the first were published, and are extracted from the same journal. Case IV. Occlusion after Labor. — Mrs. M., thirty-five years old, applied to me about a year since, with the following statement from her physician: " Mrs. M., some years since, immediately after giving birth to her first infant, was attacked with pleuritic inflammation, which resulted in hydrothorax. Her strength became greatly impaired, and oedema of the cellular membrane was quite general. While laboring under this low state of her general health, it was discovered that the mucous membrane of the vagina had begun to slough. Summoned to see her, I found this so much the case that the separation of the slough was easily effected with the forceps, and I was able to remove it readily by the scissors. The process of casting off the slough having been completed, a copious discharge of thin ill-conditioned pus flowed away, acrid enough to excoriate the labia and surrounding parts. Suitable bougies were provided and introduced, to prevent the contraction and adhesion of the surfaces of the vagina; but so great was the sensitiveness of the parts, that, though warned of the consequences in neglecting their use, they were imperfectly used, or altogether dropped, so that the occlusion became almost complete. A devious and extremely small canal 3 18 was found to exist, by which the catamenia have flowed away. In the efforts made to explore it, a very small probe was made to pass a short distance along the canal. No prolonged effort at dilatation has ever been attempted in her case, nor has she for years been subjected to medical examination. " I should have remarked, that the labor in giving birth to her infant was a very rapid one, and that the child was so small and delicate that it lived but a short time. The labor was conducted by a careful midwife, no physician being near; and no ground existed for believing that any injury whatever was sustained by the vagina in the pas- sage of the child. Nothing unusual transpired to call the attention of her husband or attendants to the organs of generation. In the bad state of her constitution, under the dropsical tendency of her system, the irritation of the vagina, consequent on delivery, passed rapidly into a gangrenous state of the lining membrane." On examination, I found the vagina, as above stated, almost completely occluded. On one side was a small, tortuous passage, into which a probe penetrated for a short distance, and could be felt for the space of an inch or more through the parietes of the vagina, by means of a finger introduced into the rectum. With this guide, and with a finger kept constantly in the intestine, a careful dissection was made in the direction of the uterus. Very shortly, all assistance from the fistulous passage was lost, and it was necessary to proceed without any guide. This was done with great caution, from fear of penetrating at the side of the uterus into the peritoneal cavity. In the course of two weeks, after a number of dissections, and the constant ap- plication of the prepared sponge, cut into a conical shape, 19 and introduced so as to assist in dilatation, what appeared to be the os uteri was finally reached. At this period the patient had occasion to leave town. I saw her again at the end of a month. The use of the sponge tent had been persisted in, and, by a slight cut- ting operation, the vagina was restored to nearly its natural dimensions. Previous to her leaving town, the catamenial discharge came on freely, and with less suffering than for many years. She was advised to persevere in the means which had been used to prevent the contraction of the vagina. Case V. Congenital Occlusion of the Vagina. — Miss P., fourteen years old, began to suffer, two years since, with pains in the lower part of the back and abdomen. These pains gradually assumed a periodical character, coming on at an interval of four weeks, and were so intense as to re- quire alleviation by means of medicine. A physician, being consulted, suspected an obstruction of the vagina; and an examination confirmed his suspicions, showing this passage to be completely occluded. An inci- sion was made through the solid obstruction which pre- sented at that part, with the hopes of discovering a cavity containing the menstrual fluid; but the operation met with no success. From this time, the sufferings of the patient gradually increased, and, at the menstrual periods, were so severe as to produce a degree of prostration which confined her for some days to her bed, and finally even threatened life. When I first saw Miss P., the external organs of genera- tion were so sensitive as to cause her to make great com- plaint on any attempt at an examination. The external 20 labia were found to be well developed. The orifice of the urethra occupied its normal position, or was a little lower than natural. Below this, not the slightest depression in- dicated the orifice of the vagina. The finger, being intro- duced into the rectum, detected, at the distance of about two inches from the anus, a hard, globular tumor, the size of a billiard-ball. Before removing the finger from the rec- tum, a catheter was passed into the bladder; and this was at once felt by the finger in the rectum, in the median line; the coats of the bladder and rectum only intervening, for a distance of one or two inches, — that is, as far as the above- mentioned tumor. At this point, the catheter could be made to pass on each side of the tumor, but was with difficulty detected in the rectum. I had no doubt, from the result of the examination, that the tumor felt in the rectum was the upper part of the vagina and uterus dis- tended by fluid, and the cause of the serious symptoms under which the patient labored. An operation was there- fore proposed, and at once, with the assistance of her phy- sician, performed. Anaesthesia being induced, a transverse incision was made directly below the orifice of the urethra. With much caution, a dissection was now made between the rectum and the bladder, until, by cutting and separating the tissues by the fingers, the tumor described as felt in the rectum was reached, lying very deep, and affording but little opportunity for a fair examination. The depth at which it lay, and its apparent solidity, for a moment caused some embarrassment as to the proper course to be pursued, espe- cially as one of the gentlemen present seemed convinced, from its hardness, that it could not contain a fluid. But, finally, being satisfied in my own mind that the tumor could be nothing else but what had been suspected, I 21 determined on puncturing it. The escape of the thick tarry fluid, which has been observed in one or two other cases before related to the Society, at once confirmed the truth of the diagnosis. The aperture was now enlarged so as to allow two fingers to pass freely up into the cavity containing the fluid, which was apparently the uterus and upper part of the vagina distended so as% to form a single sac. The patient, on recovering from the effects of etheriza- tion, declared herself entirely relieved from her previous state of suffering. The use of the prepared sponge, to pre- vent the closure of the passage, was advised, as also the occasional introduction of bougies, to maintain, if possible, the normal size of the canal. Case VI. Occlusion of the Vagina occurring soon after Marriage. — The patient was a widow, forty-five years of age. The account she gave was, that she was married at an early age; that les premieres approches du mari were so violent as to cause a severe inflammation of the vagina, which eventually terminated in the almost complete closure of the upper part of the canal. At the catamenial periods, much difficulty and suffering were experienced in the egress of menstrual fluid, which was discharged slowly, and appa- rently by a circuitous route. She suffered from this cause until within three years, when that function ceased to be performed, but was replaced by a mucous secretion. Her health latterly has been poor, and she has been more or less troubled with pains in the back and loins, all of which she has attributed to the retention of fluids in the uterus. On examination, I at once detected an obstruction two inches from the orifice of the vagina, caused apparently 22 by an adhesion of its parietes. With the aid of the specu- lum, a small aperture was observed on one side, into which a probe penetrated a short distance. As the patient insisted on having an operation, I con- sented to do it, although, at the same time, I informed her that it was very doubtful whether the obstruction was the cause of the symptoms, considering the present state of the functions of the uterus. A director was forced into the passage, which had at first only admitted a probe. This was followed by a larger instrument; and, by proceeding gradually, it was shortly found possible to use the dressing forceps. By this means, the passage was finally enlarged so as to admit the little finger, when, by tearing and distending the parts, almost the full size of the original passage was restored, and the extremity of the os uteri exposed, buried in the adjacent structures. The caliber of the canal was maintained by the same means as had been resorted to in the preceding cases. The patient expressed herself much relieved by the operation; and, when seen a month afterwards, there had been no re- currence of the previous bad symptoms under which she had suffered. The next case, one of great interest, is introduced by permission of Dr. Storer, taken from the records of the Boston Society for Medical Improve- ment. Collection of Pus in the cavity of the Uterus; operation for opening Os Uteri, closed by a firm Septum; progressing recovery from uterine disease; subsequent death, after gastric disorder, induced by excess in eating. Dr. Hyndman first visited the patient on 3d of August last ; nine days previously, on the second day of a regular men- 23 strual period, patient wet her feet; catamenial discharge ceased suddenly. Patient reported having had a rigor the day before Dr. H. first saw her; acute pain in left side fol- lowed, « extending from the crest of the ilium, upwards, as far as the edge of the floating ribs, and as far forwards, towards the mesial line, as the umbilicus." Calomel and opium were given, and " turpentine stupes" applied over the abdomen. The above-mentioned pain extended, after three days' interval, across mesial line, towards the right side; but little pain was complained of, at any time during the attack, over the pubic region : nothing would have excited suspicion of metritis. The patient improved under the above treatment, and, in a fortnight from the time when she had the rigor, was able to be about. Three weeks later (six weeks from time of sudden suppression of menses), patient called to say " that she had not been unwell for six weeks;" she was pale and "chlorotic" in appearance. Dr. Hyndman prescribed tonics; a week afterwards1, on seeing his patient, Dr. H. was told by her that she had noticed " something of a swelling," just above pubis; on examination, Dr. H. observed " an unusual ful- ness in that region;" he supposed it might be retained menstrual fluid; swelling, however, was not very marked: , savine, in conjunction with the other medicines, was ordered. Shortly after, imprudence in eating induced an attack of gastric irritation, accompanied by pain and vomiting. Re- lief by opiates. Six weeks after this, the abdominal « swell- ing," before mentioned, had so increased that the appearance was that of a person in the seventh month of utero-gesta- tion. Dr. Storer was now called in consultation. Dr. S. saw this patient with Dr. Hyndman, on the 11th inst., and found her to be a young woman seventeen years 24 of age. Her abdomen was as large as that of a woman's far advanced in pregnancy, presenting a peculiar form, how- ever, the enlargement being anteriorly, as if something projected directly forwards — there was but slight fulness laterally. She complained of some tenderness in abdomen, upon pressure. The breasts were not enlarged, and no change in the areolae could be perceived. Upon examina- tion, per vaginam, which produced considerable uneasiness, the body of the uterus was found to be somewhat distended, and upon pressure gave to the finger the sensation of con- tained fluid. She has had no discharge of any kind from the vagina since the suppression of her catamenia. Dr. S. agreed with Dr. Hyndman in his diagnosis, that the uterus was distended by fluid; but, as the menses had been sup- pressed only about three months, he thought that they alone could not have produced the great tumefaction, but that, acting as an irritating cause, they had probably excited the uterus to pour out an abundant secretion besides. It was proposed to pass an instrument into the os uteri to empty the organ of its contents. Dr. Hyndman consent- ing, Dr. S. endeavored, the sixth day, to pass a gum-elastic catheter, supposing that there would exist only a simple agglutination of the lips together, but was surprised to find that the instrument would pass but a short distance beyond the os uteri, and that only by applying considera- ble force; and, when withdrawn, its extremity was covered with mucus and blood. Simpson's sound could be passed with no more ease. Dr. S. decided that the adhesion of the cervix was so firm as to require a trocar, or some other cutting instrument, to remove it, and suggested that the operation shonld be performed by a surgeon. Dr. J. M. Warren saw patient the following day, and, after a very 25 minute examination of the case, coincided in the above opinion; and passing a trocar into the os, and then, with considerable force, through the adhesions of the cervix, freed the uterus of seven pints of offensive pus. The girl is now (25th) doing well, although more fluid is evidently collecting in the uterus. It would appear, from the above history, that with the peritonitis, produced by the sudden suppression of the cata- menia, metritis had existed; which united the lips of the os, checked the menstrual function, and caused the lining membrane of the uterus to pour out this great quantity of purulent matter. It may not be uncommon for metritis to exist, and for any secretion to be poured, out of the uterus, which may be the result of the inflammation; but from the fact that several writers make no reference to any collection of pus in the uterus, and that the translator of Boivin and Duges's work points to a case of this description by Dr. John Clarke, contained in the third volume of the " Transactions of the Society for the Improvement of Medical and Chirurgical Knowledge," it is inferred that cases of a similar character to that now reported must be of rare occurrence. Upon looking up Dr. Clarke's case above referred to, Dr. S. found it entitled, " Case of a Collection of Pus in the Cavity of an unimpregnated Uterus." In this case, the patient was sixty-five years of age, and had ceased to men- struate for several years. After having a discharge, for several weeks, from the vagina, which was at first sanguine- ous, but afterwards became of a brownish color, and offen- sive to the smell, "the patient was suddenly seized upon waking, during the night, with violent pain in the lower part of the abdomen, and a sensation as if something had 4 26 given way there." The next day she died. Upon an exa- mination of the body after death, the uterus was found gangrenous, and perforated at its upper part; through which opening, pressure being made, a quantity of offen- sive pus issued; seven or eight ounces of similar pus were found in the cavity of the abdomen, which had been poured out of the uterus, and about five ounces were still retained in that organ. The orifice between the cavity of the uterus and its cervix was closely contracted, so as not to have allowed the contents of the uterus to be discharged through it; and the previous discharges which had existed " must have been poured out from the cervix and os uteri, and from the vagina." Sir Charles Mansfield Clarke, in his " Observations on those Diseases of Females which are attended by Dis- charges," speaks of two cases of large collections of pus being produced in the uterus by inflammation; in one of them, " the uterus was found to be so much enlarged as to fill the cavity of the pelvis." A spontaneous discharge of the fluid finally occurred from the vagina, and the patient recovered. In the next case, " the pelvis was found com- pletely filled by an enlarged uterus, which was also percep- tible above the pubis;" a sudden discharge of offensive pus took place through the rectum, which continued to flow for a time with the feces, and then entirely ceased; the uterus returned to its normal size, menstruation took place, and the patient recovered. ****** At a subsequent meeting of the Society (Dec. 23), Dr. Storer reported as follows in regard to the patient whose case is above given. Three pints of pus, in addition to the former quantity, had been removed from her uterus, by Dr. J. M. Warren, four weeks after the first operation. About 27 a week after the second operation, having for weeks lived upon a liquid, farinaceous diet, the patient ate immoderately of potatoes and cabbage; immediately after this meal, she was attacked with bilious vomiting and purging, which resisted all remedies, and she rapidly sank and died. Dr. Hyndman, who had charge of her, says that not the slightest febrile action followed either of the operations, but that she was doing very well, until the above narrated excess in eating was committed. No post-mortem examination was obtained. In the first of the cases which have been given, the only apparently feasible way of arriving at the distended uterus was adopted, viz. that of penetrating to it by a dissection carried up between the rectum and vagina. The proceed- ing eventuated more satisfactorily than could have been expected. The greatest obstacle to a rapid recovery was the almost impossibility of maintaining the new opening, on account of the great disposition to contraction ; and this was found to be true in all the cases. What appeared to be a large free opening, with no restriction on any side but the bones of the pelvis, in the course of a few days was contracted to a firm unyielding ring, into which it was with difficulty that a small bougie could be introduced. The sponge tent, when it could be borne, at once dilated the aperture again to a size as great as could be wished; but the extreme sensitiveness of the parts prohibited, in the case under consideration, a resort to this powerful agent. In fact, it was finally found necessary, on account of the 28 great resistance made by the patient, to desist entirely from all applications, and leave the course of it to nature. The subsequent month, the catamenia appeared slightly; and there has as yet, so far as I know, been no obstruction to it. In the second case, the obliteration of the vagina, which was closed throughout nearly its whole extent from the upper part to the vulva, was also caused by laborious par- turition. It may serve as an example to show the necessity of making inquiries, after a severe* case of labor, as to the degree of local inflammation, and of taking measures for preventing, if possible, such adhesion as occurred in the present instance, a matter of difficulty and delicacy; but, as so much is at stake, these considerations must neces- sarily give way to a correct appreciation of the danger which would ensue from neglecting an examination, when the discharge from the vagina was so offensive as to suggest the possibility of gangrene and subsequent adhesive inflam- mation. It may not be useless to call attention to the great resist- ance, and, in two of the cases, entire want of fluctuation, which existed in the distended sac formed by the uterus and vagina, as felt through the rectum, and which might lead the surgeon to doubt the accuracy of his diagnosis, did not other marks assist in forming it. 1 A