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ioners liave (says Dr Hamilton) universally agreed that the safe node of operating is by ligature."1 "1 shall (observes Dr Rams)otham) consider tins as a point settled, at least in our Island."'
The removal, however, of large uterine polypi by excision, has long ippeared to me to be in many respects a simpler and a safer operation ban their removal by ligature. It is, on the whole, more easily iccomplished; the cure of the disease by it is infinitely quicker; it s accomplished with far less restraint and annoyance to the patient; vith less risk of local irritation; and, as I believe, with less ultimate :hance of actual peril to health and life.
Two objections have usually been urged by accoucheurs against he removal of large uterine polypi by excision. The first of theso objections, viz., the danger of haemorrhage, has been particularly nsisted on by those practitioners who have written in favour of deli*ation. But the fact is, that excess of haemorrhage is not common ifter division of the peduncle of the polypus; and however great that or any other traumatic haemorrhage from the impregnated jterus may be, it can always be arrested by properly rilling the k'aj^ina for a few hours with pieces of sponge or other appropriate plug. Dupuytren, though using no plug or other means to prevent jleeding, only met with two cases of severe haemorrhage out of somte 200 instances in which he removed uterine polypi by excision; and Lisfranc only observed it twice out of 165 similar operations practised by himself.3 1 believe, however, from what I have myself seen, that the practitioner, in employing excision, must expect considerable haemorrhage in a proportion of cases much greater than this; but at the same time lie can, I repeat, always readily arrest it, when it does occur, with proper plugging; and it is perhaps best— as a general rule—to prevent and forestall its occurrence by introducing, for ten or twelve hours after every case of resection, a proper tampon of fine sponge into the vagina. Let me add, that it is well to have each piece of sponge which is used previously transfixed by a strong thread, the end of which should be left out of the vagina, in order to permit of the more easy withdrawal of the plug.
The second objection usually urged against excision is of greater weight, viz., that more or less injury is always liable to occur to the pelvic attachments of the uterus, if it and the polypus are forcibly dragged down by Museux's forceps, or by hooked vulsella, so as to bring the peduncle of the tumour into view before dividing it,4 a plan followed by most operators;5 or, on the other hand, if the
1 Practical Observations on Midwifery, p. 40.
2 Medical Gazette for 1835, p. 433.
5 Lisfranc's (/Unique Chirurgicale, vol. iii., p. 210.
* Dr Heming's Translation of Mad. Boivin's Treatise on Diseases of the Uterus, pp. 210, 211.
5 When the texture of the polypus is too soft to allow, without tearing, of the mass being drawn downwards by vulsella, Lisfranc even advises the hooks of the forceps to be fixed in the cervix uteri itself, to get a sufocient peduncle is divided while the polypus and uterus are in situ, thai scissors or knife employed, are, it is averred, apt to injure and cut the vaginal -walls and neighbouring tissues, while worked within the vaginal cavity.1
Of late vears, I have used a means of excising large uterine polvpi, that seems to me to obviate entirely this last class of objections, and by which, as I have been led to believe, the whole operation is much simplified, and rendered both greatly more easy to the practitioner, and more safe to the patient. By the means or instrument in question, the peduncle of the polypus is divided in siln, and without any chance of its cutting portion injuring the structures of the vagina or vulva.
The instrument, or polypus-knife, to which I refer, is sketched in Plate I., fig. 1. It is of the form of the usual midwifery hook; with the concavity, however, of the hook not blunt, but turned into a cutting surface by the insertion of a small piece of well tempered steel blade into it. A transverse section of the curved or cutting portion of the instrument, and of its included knife-blade, is shown in the small figure, No. 2. The entire length of the instrument which I have hitherto employed in my own practice is ten inches— the length of the wooden handle being four inches, and that of the metallic shaft six inches. A shorter instrument might, perhaps, suffice equally well. The plate represents the curved portion, or hook at the extremity, as somewhat wider and larger than in the polyp tome made for me in the first instance, and which 1 have generallv employed in practice. Perhaps an increased or a diminished size and width, in the curved hook at the extremity of the instrument, would render the operation of division by it more easy, accordim as the stalk of the polypus was very thick, or comparatively slender The extreme point of the instrument is blunt and rounded; anil the cutting portion or blade is so protected and concealed by it, and by the back wall of the curve, that it can be introduced into and withdrawn from the vagina, without any chance of its edge injuring or dividing the vaginal structures themselves. To be always able to discover the direction to which its hooked extremity
Eoints after it is introduced into the vagina, the front aspect of the andle is distinguished by having a slight knob or other mark upon it.
In employing this polvptome, the stalk of the polypus is first to be reached by the apex of the first finger of the right hand, introduced along the short anterior or pubic surface of the vagina; the instrument is then pushed by the left hand along this finger as a guide, and passed over or above the peduncle of the tumour, in such a
hold for diagsing down it, and the polypus witli it, to the vulva.—Gazetu Medicate, ]834, p. 149.
1 Quia secantia instruments acgre in vnginam iminitti possunt, ne pamvicinas laedent, et facile lethales hremorrhagias gignant.''—JVissen De Polypii _^teii. 1789, p. 34.
direction that the concavity of the hook will come down upon and embrace this peduncle, as the instrument is pulled again downwards. The next step is to make the blade of the polypus-knife cut through the stalk of the tumour. For this purpose, a little simple traction, with a slight rolling or sawing motion, is all that is generally required. If the tissue of the peduncle is dense and strong, the dividing force of the instrument may be increased by the forefinger of one hand being applied with a tractive power to the blunt extremity of the instrument, while the handle is dragged down and moved in a sawing direction, by the other hand of the operator. Sometimes when the polypus is round and loose, after the curve or hook is applied to its pedicle, the cutting portion of the polyptome will divide this stalk most readily, by merely doubling backwards with the fingers the body of the polypus upon its own stalk, and pulling the knife against the bent peduncle. In such a case, the peduncle is divided as much by pressing it against the knife, as by pulling the knife through the peduncle.
During the last few years, I have removed a very considerable number of uterine polypi of different sizes, and some of them of large dimensions, with this curved polyptome; and I can now speak from somewhat extensive experience of the perfect facility, and safety of its employment.
Sometimes soft and slender cellular and canaliculated polypi, usually of an elongated form, are met with in practice, which afford no sufficient resistance for a knife to divide them or their peduncles. In such cases, the peduncle of the polypus is, perhaps, rrtost easily severed, by the careful clip of a pair of blunt-pointed, curved scissors. In all other forms of the disease, where the tumour was large and pedunculated, I have of late employed the polyptome. In using it, the patient is placed in bed, in the common position on the loft side; and generally the whole operation is accomplished so readily and easily, that she is often not aware that more than a common digital examination has been made. I have several times seen some difficulty attend the removal of the amputated polypus itself from the vagina, after its stalk was divided, in consequence of the great size of the tumour; and in order to effect extraction, I have occasionally been obliged to transfix it with the teeth of a large vulsellum. But hitherto 1 have met with no special difficulty, in at once and easily dividing the peduncles themselves of the polypi, with this polypus-knife.
The whole operation is simple and safe, expeditious and painless, and approaches, perhaps, more than any other in practice, to the Asclepedian character of the object of the physician: "ut luto, ut celeriter, ut jucunde curet."
In conclusion, let us compare and contrast, in a few points, the operation of the excision of a common or large sized uterine polypus, by the method I have described, and its removal by the ordinary operation of deligation.
1. lielatice difficulty of the Excision and Deligation of Uterine Polypi.
No practitioner can ever be perfectly certain that any large growth detected in the vagina, is a uterine polypus, until his finger touches and traces the peduncle itself of the tumour. And wherever the finger can thus be made to pass and detect the stalk of the polypus, the polyptome may certainly be guided to, and applied so as to divide that stalk. I refer here to cases of considerable difficulty, from the unusual shape or size of the polypus. In such instances, one cannot but conceive it easier to pass upwards a solid curved instrument directly around the mere stalk of the tumour, than to pass a piece of whipcord or other ligature behind and over the whole body and mass of the polypus itself, till, in being retracted, it comes indirectly and ultimately to embrace the stalk. For example; in Plate I. fig. 3, there is a sketch of a large uterine polypus, which I sometime ago amputated with the polyptome. The plate represents the polypus of the natural size—A marking the upper, and B the inferior extremity of the polypus, while C denotes the site and thickness of the peduncle of the tumour, as divided by the polyptome. In this instance, the polypus is of an elongated form, its peduncle being attached to its middle, and not to its upper extremity. The tumour had evidently grown into this form after being expelled from the uterus into the vagina. It had developed upwards towards the roof of the vagina, as much, or more than downwards. In this case, the peduncle of the tumour was readily caught and divided by the polyptome: but it would evidently have been a matter of great difficulty to have passed a ligature over the back and top of such a polypus, so as to embrace with it the peduncle from above.
When, however, a polypus is smaller, round or oblong, and its peduncle is attached to its upper part, there is not more difficulty in applying the ligature, than in applying the knife to the stalk of it. Some, however, of the practitioners who have had most experience with the ligature, confess to the occasional difficulty of its application, with even the best kind of canula. "By practice and dexterity," says Dr Burns, "this instrument (the double fixed canula) may doubtloss be adequate to the object in view, but without these requisites, the operator will be foiled—the ligature twisting, or going past the tumour; every attempt giving much uneasiness to the patient, and not unfrequently, after many trials and much irritation, the patient is left exhausted with fatigue, vexation, and loss of blood. This is very likely to happen if the polypus be so large as to fill the vagina. Dr Hunter," adds Dr Burns, "after repeated trials failed in a case, where the polypus filled the vagina; the pedicle in the preparation is long, and as thick as the finger.1" The application of a ligature
1 Bunib' Principles of Midwifery, p. 130.
to a large uterine polypus is, "in many cases (Dr Hamilton1 testifies) one of the most difficult and dangerous operations in surgery:" and he tells us that " lie has seen some of the most eminent practical surgeons of this part of the kingdom foiled in their endeavours to ipply the ligature."
I quote, in preference, such opinions from the writings of Professors Burns and Hamilton, because both of these gentlemen were strongly in favour of the operation of deligation.
II.—Relative Duration of the Operation of Deligation and Excision.
The process of excision is generally accomplished in the course of two or three minutes at most; sometimes in a shorter period. On the contrary, the deligation of a uterine polypus consists of a succession of operations rather than of one; and is usually protracted through a period, varying from two or three days to two or three weeks. The application itself of the ligature andcanula, in the first instance, requires as much, or indeed more, time and pains than the act of excision. But, after its first application, the ligature requires to be tightened and adjusted from time to time. "Twice a day (as Dr Gooch directs), the ligature is to be untwisted from the shoulder of the canula, drawn tighter, and then fixed again round the projecting part; and this is to be done morning and night." "Every day," (observes Sir Charles Clarke, another advocate, like Dr Gooch, for this mode of treatment)—u Every day the practitioner is to examine the state of the ligature, and as often as it is found to be at all slack, it is to be tightened. The mode of tightening it," he continues, "requires particular attention. If the canula should happen to be long, the practitioner should not hold the end of it whilst he tightens the ligature, lest with the force used the ligature should cut through the neck of the tumour, and the other extremity of the canula should be suddenly and forcibly pushed against the internal parts of the ■woman. The time," he adds, "at which the ligature will come away will depend upon the thickness and firmness of the neck of the tumour, and the tightness with which the ligature is at first applied. The neck of the tumour sometimes is cut through in four days, sometimes ten or twelve days will elapse between the application of the ligature and the removal of the tumour, and occasionally the separation of the tumour will take up three weeks; but this is an uncommon occurrence."2 "After an interval," observes Dr Churchill, "varying from six days to three weeks, the canula will be found loose in the vagina, and the stalk of the polypus severed."3
ILL—Relative Care and Management after the two Operations.
After the operation of excision, the only special treatment in
1 Hamilton's Practical Observations, p. 40.
s Observations on the Diseases of Females, page 263.
s On the Diseases of Females, p. 220.