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In the suminer of 1859, I was asked to see Miss of this city, aged 23, who, I was informed, had never menstruated, and who suffered greatly in consequence. Miss was a stout, red-faced girl with bloated swollen face, and presenting an appearance of general plethora. She told me her sufferings were almost incessant, but were more severe for a few days in each month; and this condition of things had continued from the age of fourteen, with gradually increasing severity. Her days were passed in pain and her nights in troubled and disordered sleep, in feverish dreams, or wakefulness. Several years before, she had, by the advice of her physician, commenced taking morphia, which she had rapidly increased in quantity, without being rendered oblivious to her sufferings; and the sleep into which she would sometimes fall, was so laboured, and her breathing so stertorous, as frequently to oblige her parents to arouse her. Several physicians had been consulted during the long course of her sufferings, and as my patient had retained a list of the medicines employed by each, it presented a most formidable array of emmenagogues, cathartics, sudorifics, and special derivatives and stimulants. As the potent armaments of the materia medica had already been pretty fairly exhausted, I proposed a tactual examination. To this, however, there were objections, until the very intelligent midwife who had been instrumental in having ne consulted, (and who, at my request, made an examination,) had informed the patient she was unlike the rest of womankind. On inspection, the wons veneris was very scantily supplied with its usual covering, and the cashion of adipose tissue over the symphisis pubis was neither thick nor firm. The meatus urinarius existed at its normal site, and a little below, was a slight depression marking the place of the vagina. But there was no preputium clitoridis-no clitoris-no labiæ or nymphæ--no vestibule. An examination, per rectum, established the existence of an uterus, but, with the catheter at the same time in the urethra, no interposed vagina could be felt. I at once proposed to remedy, surgically, this anomalous state of things, hoping a division of the skin—which seemed to be thinwould lead to something like a vagina. Consent having been obtained, I made the first incision on the 23rd June, 1859, from within three lines of the meatus, to within the same distance of the rectum.
Here and there, in the line of the incision, I met with condensed areolar tissue, but no vestige of a vagina. I now made up my mind that there existed no natural passage, and that it was necessary to hew one out of the soft tissues. A day was named for the purpose, and in the meantime a large fine Turkey sponge was immersed in a thick solution of gum acacia, and submitted to enormous pressure for a few days, by which it was reduced to the thickness and hardness of sole leather.
On 27th June, the patient was placed under the influence of chloroform,
and an incision, the length of the first, was made in the mesian line ; a three-valved speculum was introduced, and through it, several narrow strips of hardened sponge. The hemorrhage during the operation was somewhat alarming; but, after my departure, the quantity of blood lost was so great as to soak through the bed, run in a stream upon the floor, and induce frequent syncope. When hastily summoned to the bedside, I removed the thickly swollen slices of sponge by strings, which had, previous to their introduction, been attached to each piece; and employed astringent injections. The hemorrhage gradually ceased; not, however, till I had time to reflect that Simpson's fate-under somewhat similar circumstances-was to be mine, with a renommée, however, less able to bear a shock which had almost unseated the advocate of hysterotomy. Two days after the removal of the sponge, I reintroduced fresh pieces through the speculum — the patient being under the influence of chloroform-and repeated this proceeding, without chloroform, every second day for a fortnight, when, by coaxing and urging, I induced the patient to submit to the knife again--assuring her friends and herself that the hemorrhage on this occasion would be inconsiderable, as I could feel the uterus at a short distance from the wound already made. On 15th July, another and a deeper incision was directed upwards and backwards, and still in the mesian line, when the os uteri was reachedfull, thick-lipped, and pouting. No discharge or secretion of any kind escaped, though an elastic bougie was made to enter the interior cavity to the usual depth. I had now a vagina formed, suited to any purpose, and the compressed sponge still increased its capacity. The sponge was removed, and fresh pieces introduced every second day for several weeks, when the speculum, covered with lint, was substitutedintroduced in the ordinary way, and the handles secured together. A fortnight after the last operation a very moderate secretion took place, which increased at the succeeding menstrual periods, with complete relief to all those distressing symptoms for the relief of which she had consulted me. The morphia was laid aside, and sleep, without it, was sound and refreshing; and the patient, from a bloated, swollen and apoplectic looking object, became as slender and as genteel as she could ha.e desired. The dilating process was continued several months. Some time ago, I was asked my opinion concerning her marriage (then on the tapis), and, after an examination, unhesitatingly counselled it. (The smooth walls of the artificial vagina were now lubricated with a secretion, and the organ was of the ordinary capacity.) The marriage took place, and the lucky possessor of the slun unweibliche fraulein is still-so far as I am aware, ignorant of the circumstance that the knife had carved for him a path to enjoyment. And now I have to mention what to me appears the most remarkable
circumstance in the case. Previous to the operation there was no sexual desire, but when menstruation had been fairly established there was a difference in that respect; and after marriage, gratification had increased with sexual indulgence. The patient has not become pregnant. These, gentlemen, are, briefly, a few of the more salient points of a case which had much interested me. I have consulted every work within my reach for details of a similar one, but could find none, till the report of that of Dr. Collins, above mentioned, attracted my notice.
Cuse of Aneurism of the Aorta. By John Duff, M.D., Surgeon Royal
Artillery, Quebec. Sapper Samuel Pemberton, R. Engineers, æt, 30, service six years; of which five on present station, B. N. A.-admitted into Hospital 16th August, 1865, died 2nd January, 1866.
On admission this man complained simply of a dull pain in his loins, which being looked upon as nothing of consequence was treated accordingly. Three days afterwards, however, the pain not yielding, I made an examination, and the following was the state of parts detected, as entered in the Medical Register—“ Marks of cupping are seen on the loins, also a blister, which he says had been practised some time ago, for the same complaint, namely, lumbar pains-states that the pain is increased in the lumbar region, when he lies on his face -- but when turning on his back, this pain is most felt in the abdomen. This latter region examined, and a well defined pulsating tumour detected, immediately above the umbilicustumour feeling about the size of a small orange-stethoscope discovers an obscure bruit, but whether this is an aneurismal bruit, or the result of a tumour pressing on the aorta is not at all so very clear. I am inclined to think the latter on account of the peculiarity of the pain shifting with different positions of the body, as if from the traction of a moveable tumour, the traction varying according to position.”
This was the first entry in register. Matters went on pretty much unchanged up to the 1st Sept, when following is a copy of that date—" Bruit heard to day very distinctly in the epigastric region, to the right of the mesial line.—Site of bruit well defined, and confined to a space not larger than a crown piece. This bruit is sometimes absent, which makes it doubtful as to whether or not it is caused by aneurism, or is the result of pressure upon a vessel, by a tumour, the pressure varying in different positions. No impulse or bruit detected when the man is in the erect position. Is now markedly jaundiced, probably from pressure on gall duct. States that some times when he lies on his back, he sees a lump
rise slowly in the epigastrium till it attains the size of an egg, when it gradnally subsides again.” On 17th September, the tumour is noted as increasing ; pain becoming more severe, and of a dragging character and the bruit heard over a much larger extent of surface. On 6th October report states:-" Complains of constant pain in back, and neighbourhood of tumour generally ; bruit now audible over the whole tumour, and its aneurismal character is more apparent.” Nov. 16th, report states : “ Tumor very perceptibly increased, its aneurismal character well defined.” After this date the man rapidly got worse, and pain increased depriving him of sleep, till on the 4th December he was reported “as unable to get up, or even sit up;" says, that when he attempts to do so, he feels “ pain dragging down from shoulders and chest,” and this time the tumour was easily felt of a conical form and about twice the size of a closed fist. On the 2nd January, 1866, just after finishing breakfast, which consisted of tea and toast, he suddenly died, and with his death the tumour in the abdomen at once disappeared. Throughout, the treatment was purely palliative. The mau, naturally of a weak habit of body and relaxed appearance, could not sustain any depressing treatment, even should this line of action have been considered as likely to give a chance of recovery, as it is reported to have done in some rare instances. Local applications and opiates to relieve pain, were therefore chiefly had recourse to, with general rest. The man's history does not furnish any clue to the origin of the disease. History sheet shows him as having been under treatment several times, for venereal affections, and once with secondary syphilis. Never strained or injured himself in any way to his knowledge. His general appearance may be mentioned as having been weakly. Post-mortem appearances, twenty six hours after death.
Body emaciated but not to any great extent. No tumour can be felt in abdomen. Chest-on opening the cavity an enormous mass of clotted blood is found filling its right side, the pleural cavity completely occupied by it; the lung being pressed backward toward the spine. Both lungs healthy; slight pleural adhesions ; old ones left side. Heart healthy
; -abdomen-stomach, liver, and other viscera healthy. Close to the lower border of stomach, and towards its pyloric extremity, a tumour about the size of an orange presented itself, at first looking like diseased pancreas, but closer examination detected the latter, in a state of almost complete absorption, lying along the surface of, but not in any way incorporated with this tumour. Dissecting backwards, this tumour was found to be connected with the aorta. This vessel was dissected out, by cutting it across immediately below its arch and working downwards. During this operation the following state of matters was discovered—
a large aneurism of aorta, involving about one half inch of the thoracic and the same if not two inches of the abdominal aorta; the main trunk of the superior mesenteric was also involved. The aortic portion of the aneurism was firmly attached to spinal column, but the mesenteric aneurism formed a large conical and very moveable tumour, apex of cone pointing to abdominal wall, below the lower border of stomach, which as before noted had removed a great portion of the pancreas from pres
The lesion took place in the thoracic portion of the aneurism close to the crus of diaphragm, just as the thoracic was about to become the abdominal aorta. The aortal aneurism had some layers of fibrine formed round its wall, but the mesenteric was almost filled with thick layers of tough organized looking coagula—that portion of the aortic wall which rested on the vertebræ, was entirely absorbed, the vertebrae in reality forming the back wall of the aneurism, they also were extensively absorbed and broke down under finger ; cartilages prominent and not altered.
REMARKS.—There are some points of considerable interest connected with this case.
It will be remembered that at one time the bruit was noted as being peculiar, in occasionally being obscure, and at times nerer heard, when the man was in the erect position ; and in this position na impulse felt. Now the examination having always taken place after breakfast, can it be that the stomach in a state of distention, occasionally so crowded over the mesenteric tumour as to prevent impulse being selt or heard. The peculiarity of pain noted on admission to Hospital, as shifting with different positions of body, as if from traction of a moveable tumour, and which at one time gave rise to doubt as to whether or not an aneurism really existed, is I think fully accounted for when we consider that the mesenteric aneurism formed in reality a large moveable tumour, which no doubt did alter its position, according to whether the man lay on his back, side,
Note by Dr. Anderson.-Having seen the above case during life, and having been also present at the post-mortein examination, I thought it of such interest that I requested Dr. Duff to permit it to be published in the Canada Medical Journal ; he consented, and permitted me to take a copy of the abstract for that purpose. It has occurred to me, that when the man stood erect the tumour being pendulous, by graritation, brought the sides of the mesenteric artery together and thus produced occlusion, which I think may fairly account for no bruit or impulse being detected.
25 St. Geneiveve Street, Quebec, 1st. Feb., 1866.