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CONTRIBUTIONS so THE SCIENCE OF OBSTETRIC SURGERY.
614
chiefly in this, that they may commence at exists a greater or less prolapsus of the posterior wall of the any age. Five years ago I operated on a woman, aged forty-five, vagina. By denuding also merely the prolapsed part of this, for strangulated femoral hernia. 1 he case did well, and as she the impossibility of what so often happens-a sinus between was leaving my care, she pointed out to me a black spot, the the new perineum and vagina permeable by urine or diseharge, size of a shilling, level with the skin, on the inner surface of in fact a recto-vaginal opening-is secured ; and the parts the thigh of the same side, resembling a vein mark. She was the new rectum cicatrize so rapidly that I have been. admitted into the hospital, November, 1861, with a tumour, obliged to employ repeated dilatation to keep the rectum suffis originating in that spot, about the size of a small pear. I re- ciently open. W next proceed to denude the fissure; and what possible. moved it by operation, and on examination it proved to consist entirely of vascular tissue. It was quite subcutaneous, and was objections can be offered to " its sides being held by an asnourished by a few small arteries. sistant, so to insure sufficient tension," &c. ? But these vein growths may pass into the usual transformaFirst, we may dispense also with this assistant. Secondly, tion of vascular tissue, and then, instead of disappearing by if employed, he has a slippery affair to hold, which he possibly lets go during the incision, and if he hold it firmly, he is at absorption, acquire in their new characters an vitality. They may grow as erectile tumours, the charac- least somewhat in the way of the operator; and, further, the teristics of the tissue being more and more marked, and the hold which he must take for tension. when the incisions are vascular supply from natural arteries becoming the more abund- completed on each side, renders them, if possibly "clear," at ant. Such are probably the cases recorded of naevi appearing least not straight and equable-thus requiring retouching of the mucous membrane-but leaving most probably a biconcave at mature age. That these vascular tumours, however, do really undergo a intersuace not the best for ar)l)ositioi). To obviate all this, I substitute for this assistant a tricusped transformation into cysts, was shown by the examination of a tumour removed in 1849 by Mr. Lawrence from the neck of vulsellum, sufficiently wide to command the sides of the fissure a girl, aged three years and a half. Part consisted of blood- and any extent desired of mucous membrane. This will not vessels, and part of cysts containing a yellow, coagulating slip, and permits me further, I trust with some advantage, to violate the second injunction of Mr. Brown in reference to fluid, like blood deprived of its colouring matter. these two there was no abrupt line of demarcation ; the vessels "incision." To this I simply object as being painful and slow. seemed slowly undergoing the cyst-like transformation. In I am aware that chloroform will overrule the first part of the another case, also examined by me, I traced a vein as large as objection, but certainly not the second. I simply transfix with the radial, opening into the cavity of the cyst, which formed a sharp pointed bistoury, and thus almost instantaneously one of a large cluster, removed by Mr. Lawrence from a boy’s obtain evenly-cut surfaces fit for apposition. I pass over the division of the sphincter ani as a splendid side. Some of these cysts contained a serous fluid, others a more bloody fluid. In another case the cysts communicated part of Mr. Brown’s operation, and one on which I can suggest either with the femoral vein or with the saphena at its junction no improvement, and now I arrive at the insertion of the quill sutures. At p. 36 op. cit., Mr. Brown directs at this point of with the femoral. Respecting the treatment, the works on Surgery teem with the operation, that " the tlaighs are to be approximated, and a multitude of applications, both caustic and irritant. In the then the quill sutures introduced." Now unless the denuded selection of remedies we must be guided by the size and situa- margins are put in apposition, it is quite impossible with Mr. tion of the tumour, the age of the patient, and the character of Brown’s needle to traverse by one continuous arc-sweep both the growth. But the result of my own experience, and that of margins of the wound ; and yet, if placed in apposition, the many of my colleagues also, has been that where extirpation, operator is quite in the dark as to what he may, or may not, whether by the knife, the écraseur, or the ligature, is prac- transfix, with the exception of the mere margins of the fissure. ticable, it yields by far the most satisfactory issue. U nfortu- Nosecure provision can thus be made by the first, or rectal suture, for a new recto-vaginal septum; and a recto-vaginal nately it is a proceeding not always applicable to the case. opening results. In trying to secure sufficient view by partial Bridge-street, Blackfriars, Dec. 1861. apposition, I have bent one of Mr. Brown’s needles-obtained from a first-class maker-at its junction with the handle, and was thus compelled to transfix again with another needle. To CONTRIBUTIONS prevent all these difficulties, 1 advise simply a precisely similar so needle, but not fixed in the handle, and like a crochet-needle. The whole wound being exposed, the first transfixion is made THE SCIENCE OF OBSTETRIC SURGERY. in the usual way; the handle is then removed. Any intermediate BY CHARLES EDWARDS, A.B., M.D., F.R.C.S., parts which it may be necessary to include, are now clearly Cheltenham. visible; and finally, the needle is replaced in the handle, and with minute exactness and no difficulty, is passed through the right denuded surface. The second, and if necessary, the third, III.-COMPLETE LACERATION OF THE PERINEUM; THE suture can be passed in the same way, apposition once for all OPERATION. instituted, and the quill suturing completed. To favour adhesion the latter process should be as simple and HAVING concluded my last paper with the preparation and Too great conas is computible with perfect apposition. gentle position of the patient, I now proceed simply to describe the striction may be immediately recognised by the expanded sur. salient points of the operation itself. My practice may be, face margins of the wound, and the difficulty of bringing them perhaps, best illustrated by quoting from the distinguished into a line by the superficial stitches, and remotely by the puffy work of Mr. Brown, and giving practical reasons where I ven- and livid appearance of the parts between the superficial and ture to differ. deep sutures. With respect to the " quills" of elastic catheter, it sometimes At page 35, on " the mode of operating," Mr. Brown says-that the parts recede in the interspaces of the sutures, lst, " the sides of the fissure should be held by an assistant, so happens and thus there results a strain upon the stitches. This can be as to insure sufficient tension," &c.; 2ndly, "aclean incision effectually prevented by covering the catheter in the first place is now to be made," &c.; "the denudation of the oppo- with line7i or caznbric, and well soaking this with collodion. 3rdly, site side of the fissure;" and lastly, "the mucous membrane This uniform support will frequently permit the dispensing from any intermediate portion of the recto-vaginal septum to with a third stitch. The sutures, if of twine, I would by no means wax, but simply moisten with a little blood, and allow them to be pared away." for a few minutes. I respectfully beg to reversa all this, and take the last step dryThe operation is now brought to an end by well cleansing first. Why ? I have thus a more perfect view for accurate denu- the part over the superficial stitches, and superimposing a dation of the most difficult part, which, if taken in Mr. Brown’s narrow slip of lint, well moistened with collodion. This will order, will be deluged with blood from the previously incised afford uniform superficial support, and prevent the contact of irritating fluids. edges of the fissure; and thus much difficulty-an assistant allCorollary : It is evident that I have dispensed with all assis. his -much denudawith delay-and possibly imperfect sponge tant-surgeons, except the gentleman who administers chloro. tion will here result. form. I shall conclude this vitally important subject w;th a very I attend, then, first to the recto-vaginal septum, and at this practical observations on the after-treatment. stage of the operation another matter seems vitally important. It sometimes, if not most commonly, happens that there Havelock House, Dec. 1E61. differ from them
about
independent
Between
few
chiefly in this, that they may commence at exists a greater or less prolapsus of the posterior wall of the any age. Five years ago I operated on a woman, aged forty-five, vagina. By denuding also merely the prolapsed part of this, for strangulated femoral hernia. 1 he case did well, and as she the impossibility of what so often happens-a sinus between was leaving my care, she pointed out to me a black spot, the the new perineum and vagina permeable by urine or diseharge, size of a shilling, level with the skin, on the inner surface of in fact a recto-vaginal opening-is secured ; and the parts the thigh of the same side, resembling a vein mark. She was the new rectum cicatrize so rapidly that I have been. admitted into the hospital, November, 1861, with a tumour, obliged to employ repeated dilatation to keep the rectum suffis originating in that spot, about the size of a small pear. I re- ciently open. W next proceed to denude the fissure; and what possible. moved it by operation, and on examination it proved to consist entirely of vascular tissue. It was quite subcutaneous, and was objections can be offered to " its sides being held by an asnourished by a few small arteries. sistant, so to insure sufficient tension," &c. ? But these vein growths may pass into the usual transformaFirst, we may dispense also with this assistant. Secondly, tion of vascular tissue, and then, instead of disappearing by if employed, he has a slippery affair to hold, which he possibly lets go during the incision, and if he hold it firmly, he is at absorption, acquire in their new characters an vitality. They may grow as erectile tumours, the charac- least somewhat in the way of the operator; and, further, the teristics of the tissue being more and more marked, and the hold which he must take for tension. when the incisions are vascular supply from natural arteries becoming the more abund- completed on each side, renders them, if possibly "clear," at ant. Such are probably the cases recorded of naevi appearing least not straight and equable-thus requiring retouching of the mucous membrane-but leaving most probably a biconcave at mature age. That these vascular tumours, however, do really undergo a intersuace not the best for ar)l)ositioi). To obviate all this, I substitute for this assistant a tricusped transformation into cysts, was shown by the examination of a tumour removed in 1849 by Mr. Lawrence from the neck of vulsellum, sufficiently wide to command the sides of the fissure a girl, aged three years and a half. Part consisted of blood- and any extent desired of mucous membrane. This will not vessels, and part of cysts containing a yellow, coagulating slip, and permits me further, I trust with some advantage, to violate the second injunction of Mr. Brown in reference to fluid, like blood deprived of its colouring matter. these two there was no abrupt line of demarcation ; the vessels "incision." To this I simply object as being painful and slow. seemed slowly undergoing the cyst-like transformation. In I am aware that chloroform will overrule the first part of the another case, also examined by me, I traced a vein as large as objection, but certainly not the second. I simply transfix with the radial, opening into the cavity of the cyst, which formed a sharp pointed bistoury, and thus almost instantaneously one of a large cluster, removed by Mr. Lawrence from a boy’s obtain evenly-cut surfaces fit for apposition. I pass over the division of the sphincter ani as a splendid side. Some of these cysts contained a serous fluid, others a more bloody fluid. In another case the cysts communicated part of Mr. Brown’s operation, and one on which I can suggest either with the femoral vein or with the saphena at its junction no improvement, and now I arrive at the insertion of the quill sutures. At p. 36 op. cit., Mr. Brown directs at this point of with the femoral. Respecting the treatment, the works on Surgery teem with the operation, that " the tlaighs are to be approximated, and a multitude of applications, both caustic and irritant. In the then the quill sutures introduced." Now unless the denuded selection of remedies we must be guided by the size and situa- margins are put in apposition, it is quite impossible with Mr. tion of the tumour, the age of the patient, and the character of Brown’s needle to traverse by one continuous arc-sweep both the growth. But the result of my own experience, and that of margins of the wound ; and yet, if placed in apposition, the many of my colleagues also, has been that where extirpation, operator is quite in the dark as to what he may, or may not, whether by the knife, the écraseur, or the ligature, is prac- transfix, with the exception of the mere margins of the fissure. ticable, it yields by far the most satisfactory issue. U nfortu- Nosecure provision can thus be made by the first, or rectal suture, for a new recto-vaginal septum; and a recto-vaginal nately it is a proceeding not always applicable to the case. opening results. In trying to secure sufficient view by partial Bridge-street, Blackfriars, Dec. 1861. apposition, I have bent one of Mr. Brown’s needles-obtained from a first-class maker-at its junction with the handle, and was thus compelled to transfix again with another needle. To CONTRIBUTIONS prevent all these difficulties, 1 advise simply a precisely similar so needle, but not fixed in the handle, and like a crochet-needle. The whole wound being exposed, the first transfixion is made THE SCIENCE OF OBSTETRIC SURGERY. in the usual way; the handle is then removed. Any intermediate BY CHARLES EDWARDS, A.B., M.D., F.R.C.S., parts which it may be necessary to include, are now clearly Cheltenham. visible; and finally, the needle is replaced in the handle, and with minute exactness and no difficulty, is passed through the right denuded surface. The second, and if necessary, the third, III.-COMPLETE LACERATION OF THE PERINEUM; THE suture can be passed in the same way, apposition once for all OPERATION. instituted, and the quill suturing completed. To favour adhesion the latter process should be as simple and HAVING concluded my last paper with the preparation and Too great conas is computible with perfect apposition. gentle position of the patient, I now proceed simply to describe the striction may be immediately recognised by the expanded sur. salient points of the operation itself. My practice may be, face margins of the wound, and the difficulty of bringing them perhaps, best illustrated by quoting from the distinguished into a line by the superficial stitches, and remotely by the puffy work of Mr. Brown, and giving practical reasons where I ven- and livid appearance of the parts between the superficial and ture to differ. deep sutures. With respect to the " quills" of elastic catheter, it sometimes At page 35, on " the mode of operating," Mr. Brown says-that the parts recede in the interspaces of the sutures, lst, " the sides of the fissure should be held by an assistant, so happens and thus there results a strain upon the stitches. This can be as to insure sufficient tension," &c.; 2ndly, "aclean incision effectually prevented by covering the catheter in the first place is now to be made," &c.; "the denudation of the oppo- with line7i or caznbric, and well soaking this with collodion. 3rdly, site side of the fissure;" and lastly, "the mucous membrane This uniform support will frequently permit the dispensing from any intermediate portion of the recto-vaginal septum to with a third stitch. The sutures, if of twine, I would by no means wax, but simply moisten with a little blood, and allow them to be pared away." for a few minutes. I respectfully beg to reversa all this, and take the last step dryThe operation is now brought to an end by well cleansing first. Why ? I have thus a more perfect view for accurate denu- the part over the superficial stitches, and superimposing a dation of the most difficult part, which, if taken in Mr. Brown’s narrow slip of lint, well moistened with collodion. This will order, will be deluged with blood from the previously incised afford uniform superficial support, and prevent the contact of irritating fluids. edges of the fissure; and thus much difficulty-an assistant allCorollary : It is evident that I have dispensed with all assis. his -much denudawith delay-and possibly imperfect sponge tant-surgeons, except the gentleman who administers chloro. tion will here result. form. I shall conclude this vitally important subject w;th a very I attend, then, first to the recto-vaginal septum, and at this practical observations on the after-treatment. stage of the operation another matter seems vitally important. It sometimes, if not most commonly, happens that there Havelock House, Dec. 1E61. differ from them
about
independent
Between
few