Imatges de pÓgina
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Montpellier. Even very lately Professor Osiander performed the operation in Switzerland, in the presence of three skilful physicians and surgeons. What may be its ultimate success is not yet (1808) known, but hitherto the accounts are very favourable.

Professor Osiander has two methods of operating for cancer of the womb :

First, in the manner already described. The patient must be placed on a high labour-stool, or on a table, in the position for the operation for the stone, or for delivery, and held fast. The private parts are cleaned out by injections, and softened with an ointment. The fungus is taken away with the finger, or with an instrument. If the bleeding is great, it will be stopped by applying a sponge dipped in vinegar with astringent powder; if not, the operation is immediately continued. For piercing the uterus, Professor Osiander uses small crooked needles made of soft steel, so that their points can be easily bent. Hard tempered needles are in danger of being broken, and if the broken points be not found, they might do the greatest harm. The greatest difficulty is, to bring the needles through the uterus, till by practice the necessary dexterity is acquired; but the length to which this can be carried, the following circumstance will shew. Last year, in the lying-in-hospital here, it happened, in a public operation, that the threads were drawn out of the needles, after they had been pushed through the uterus. Professor Osiander left the needles in the uterus, and thread. ed them again within the vagina, without requiring the assistance of a contrivance for throwing in light. The operator can, and must, in such a case, acquire by practice the same precision and dexterity which many blind people have, as he must act as a blind man. A needle-holder is used merely to introduce the needles ; the pushing of them through, as well as all the rest of the operation, must be performed by the fingers alone. The direction of the stitches is from behind forwards, also from before backwards, and from the sides to the centre. The greatest caution is necessary, that the needles do not go too far, and catch upon the vagina, or puncture one of the arteries, or the great veins behind the coat of the vagina. To prevent this, the operator must sacrifice his fingers; and the pointof the needle, when through, must be bent immediately with the point of the finger, and seized, and drawn through with a pair of forceps. This cannot be done without pricking the fingers; and it might have been thought that the fingers could not escape being dangerously infected, having to work so long afterwards in the morbid ichor. Professor Osiander, however, was never infected; tor, immediately after the operation, he always washes his hands

repeatedly with soap, and then washes out the pricked wounds with diluted sal volatile, and last of all sucks them out, without applying any suppurants to the wounds. After five or six days, the wounds healed without any inconvenience.

A waxed thread four times doubled must be drawn through each needle; very often two of these will suffice to draw down the uterus into the vagina ; at other times, four are required.

Many physicians have an erroneous idea of this operation ; they believe that the uterus must be drawn out before the body, that is to say, must be brought out entirely. It is equally erroneous to suppose that it is intended that the whole uterus should be cut out, and for this reason the operation for cancer of the womb is by some deniecl or rejected as impossible.

By the threads the whole womb is only fixed in the bottom of the vagina to be cut off, but the drawing of it down is sometimes rendered difficult, from an adhesion of the external mouth of the womb to the omentum. Upon a late occasion, from this cause, the uterus could not be drawn down by the threads, and the threads were accidentally cut in introducing the bistoury. Professor Osiander took a pair of lithotomy forceps, laid hold of the orifice of the womb with them, and cut the cervix off.

The cancerous and scirrhous portion is to be cut off only as far as the healthy substance, which is known by feeling the smooth surface, and elastic firinness of the latter, which are very different from the rough and woody-like scirrhus.

The crooked bistoury must be small, strong, and sharp, and rounded at the point. It is to be carried up close to the cervix, as high as possible, while an assistant keeps the labia separated. The incision must be made in curve lines, first boldly, and then cautiously, for fear of hurting the vagina. This is Professor Osiander's first and oldest method of operating.

The second is as follows: When the cervix is already for the most part destroyed by the cancerous fungus, much enlarged, and the cavity full of knotty carcinomatous fungus, and it is neither possible to lay hold of the uterus with the needles, nor draw it down, then he places the patient almost into a horizontal position; makes an assistant lay his hand on the region of the

fundus uteri, to press down the womb; fixes the bottom of the womb in the hollow of the os sacrum with the fore-finger of the left hand; introduces the middle and ring-finger into the womb, and, with the help of these fingers to guide the cuts of the scissars, he extirpates, in small pieces, all the fungous, rough, and scirrhous parts, with a pair of bent bladed scissars, and an instrument of his own invention. As soon as this is done, he fills up the cavity with a sponge dipped in wine, and in the astringent

powder spoken of before, and treats the wound in the manner already mentioned.

According to the testimony of all those who have submitted to it, this operation is not nearly so painful as one might imagine, and it heals much sooner than could be expected. Nature seems in no part of the human body to be more active in reproducing what is lost, and in healing what is wounded, than in the parts of generation in both sexes. It is surprising to see (for example) a scrotum lost by a mortification, restored again in four weeks. It is no less surprising, for a kind of mouth of the womb to be regenerated in a few weeks after the cervix uteri has been totally cut off; or regular menstruation to be re-established cqually soon from the half womb left after the operation.

The duration of the cure is very different, as it is in every operation for cancer. One circunstance, and the result of experience, is of great importance, namely, that neither during the operation, which is conducted with so great difficulty, nor during the subsequent treatment, has one patient hitherto died. Some of them died more than a year afterwards from other causes, as from apoplexia nervosa, dropsy, and the like, or the disease returned suddenly again from new causes, and became incurable ; others continued three years and more in good health.

The sooner a patient resolves to submit to the operation, the longer will she enjoy her recovery; and the better she observes the diet that is prescribed afterwards, the better chance will she have of being freed from the evil for ever.

It is consolatory to observe, that, in a disease which has been thought incurable, more has been done than was formerly thought possible, and that thus a new path is opened for the art of surgery, by which suffering humanity may derive help and comfort. Let, then, practitioners labour to acquire the courage and dexterity which is required to undertake such an operation, and conduct it to a fortunate termination.

On a Newly Constructed Sound, for the purpose of discovering the

Stone in the Bladder, accompanied with a Plate. By JAMES BARLOW, Surgeon, Blackburne, Lancashire.

WHOEVER views with attention the delicate and complex

structure of the urinary organs, will readily admit, that their consequent exposure to discase and pain, demands from the surgeon the most prompt and attentive consideration to impart relief. On these grounds, I trust the experienced reader will give me credit for attempting to obviate certain difficulties in the ordinary niode of sounding the bladder, which I have occasionally experienced in practice; and which I presume others must have also shared with me; hence, I have been led to make the following observations on the construction and superiority of the sound, as represented in the annexed plate, which I have lately been in the frequent habit of using, and can with confidence assert, that it possesses many advantages over those in common use, being moved with greater facility in the canal of the urethra and cavity of the bladder, when searching for the stone in that viscus.

Cases frequently occur where the prostrate gland is morbidly enlarged, and where inflammation has spread over the internal membrane of the bladder, and along the posterior portion of the urethra, * producing spasm and irritation, and, when complicated with stone in the bladder, it exhibits an additional aggravated cause of the frequent desire to expel the urine. This reiterated excitability of the functions of the urinary organs, whether dependent on voluntary or involuntary action, manifests a degree of sympathizing agency over these parts, which presents a frequenť and obvious barrier to the introduction of either the sound or catheter:

To accomplish the introduction of the sound with safety to the patient, and facility to the surgeon, he should be furnished with a variety of instruments of different degrees of curvature, length, and diameter, proportioned to the age and size of the patient.

The membrane of the urethra sometimes becomes inflamed and dry, which likewise prevents the free motion of the sound.

As no two cases are in every respect exactly similar, and almost every writer on surgery has described the anatomy of the parts subservient to lithotomy, it appears superfluous in this place to enter minutely on the subject; presuming the reader to be fully acquainted therewith. It will be granted, that the nianagement of the catheter requires nearly the same maneuvre to conduct it into the bladder as the sound ; let me then entreat the attention of the young surgeon to the concluding paragraph, so elegantly expressed by an author of distinguished celebrity, when closing his directions on the mode of introducing the instrument into the bladder. “ The catheter," says he, “in the hands of a surgeon, like the pencil in the hand of a painter, requires frequent use, and much practice, to be managed with facility and success. Rules may be laid down for the forming a rough outline; but those more delicate movements, which, in many instances, are necessary to insure success, can no more be described, than a painter can describe those finer touches of bis peneil, which are necessary in the perfecting of some finished performance.”

When having introduced a common formed sound into the bladder, for the purpose of exploring the different parts of that viscus to find the stone, I have frequently perceived the instrument so firmly embraced by the urethra, that it was scarcely moveable without the whole of that canal, and body of the penis co-operating with the motion exercised by the hand in attempt ing to complete this stage of the operation ; hence will appear the difficulty and obscurity of such blind research, and the uncertainty of identifying the tremors communicated from the stone, along the sound; these perverse circumstances first suggested the idea of the necessity of adopting an instrument differently constructed from those in common use.

I am disposed to believe, that the failure attendant on detecting the stone may not unfrequently be attributed to an irritable and spasmodic affection of the * muscles of the perinæum and bladder, opposing the motion of the instrument, independent on organic disease ; for when its point is conducted to the membranous part of the urethra, ejaculator seminis, and prostrate gland, it excites the contiguous muscles of the lower part of the pelvis and bladder into action, which impedes the motion of the instrument. In this uncertain and embarrassed posture of af.

* Is it not the two muscles surrounding this portion of the urethra, as de. scribed by Mr Wilson, which chiefly tends to impede the introduction of any instrument into the bladder? See Medico-Chirurgical Transactions, Vol. I.

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