Paring and Suture Clamp Forceps. BY EDMOND V. JOYE, M. D., ATLANTA, SA. ttKPKlNTJtD FROM ffitie 'Meto STorft JtteDicat ®oucnal for July IS, 1889. Reprinted from the New TorJc Medical Journal for July 13, 1889. PARING AND SUTURE CLAMP FORCEPS By EDMOND V. JOYE, M. D., ATLANTA, GA. When operating for vesico-vaginal fistula I have often been annoyed and delayed by the difficulty of keeping the tissue tense while paring and suturing. To overcome this difficulty I have devised, and caused to be made by George Tiemann & Co., New York, the following instrument, which seems to meet all indications for operation for simple vesico-vaginal fistula and other operations upon the female genitals, and renders the operations comparatively simple and easy, reducing the time of their performance more than two thirds. The instrument consists of two blades, each nine inches and a half long, which are crossed and locked similarly to the Hodge forceps. One inch of the extremity of each blade is made round, into which are in- serted two hooks, three eighths of an inch apart. The hooks are sharp and small at the free end, and thick where they enter the blade, so made to avoid tearing out easily. The shanks, four inches long, bear the screw lock of the Hodge forceps. The handles are five inches and a half long, slightly curved downward, in order to be out of the way of the operator, with a ratchet to hold the blades together, the rotation of the tissue hooked up having a constant 2 PARING AND SUTURE CLAMP FORCEPS. tendency to extend the blades. The right-hand blade is marked with an R on the handle, and the left-hand blade with an L. In the end of each blade is a female screw. Each blade is provided with two extra blocks, one an inch long, made round, into which are inserted three hooks equidistant, and has a male screw on one end and a female screw on the other end. The other block is an inch and three fourths long, is also round, has inserted five hooks equidistant, and has a male screw on one end. The hooks of the extra blocks are exactly like those on the main blade. The blocks are marked with the letters R and L to indicate to which blade they belong. These extra blocks are to be screwed on to the main blades whenever the opera- tor desires to increase the capacity of the instrument, making the instrument to have, at the option of the operator, either two, five, seven, or ten hooks on each blade, respectively, thus giving it a capacity of meeting many and varied indications. When performing any of the operations hereinafter mentioned the operator should notice the amount Fig. 1. PARING AND SUTURE CLAMP FORCEPS. 3 of tissue necessary to be pared, and should arrange tlie instru- ment to meet the needs of each individual case by screwing on to the main blades the blocks that will furnish hooks suffi- cient for him to hold, pare, and suture the extent of tissue necessary to overcome the existing difficulty. The whole in- strument is made as light as is consistent with strength and durability. Fig. 1 represents the instrument with two per- manent hooks on the main blades, and the extra blocks, of three and five hooks, respectively, which can be screwed on to the main blades as desired. Fig. 2 represents the appli- cation of the instrument. A shows the manner of hooking the blades into the tissue. B shows the manner of rotating the blades after being hooked into the tissue. The operation for simple vesico-vaginal fistula is thus performed : The patient is placed in the position recom- mended by Dr. J. Marion Sims for such an operation. Chloroform is administered, Dr. Sims’s duck-bill speculum introduced, and an assistant holds up the right buttock. The instrument being unlocked, the left-hand blade is passed into the vagina and hooked into the mucous tissue on the right side * of the fistula, not too near the edge, and rotated from left to right, thus bringing the lock up with the points of the hooks looking toward the right side ; and, as the screw of the lock is upon the top of the blade, the handle is held down and the right-hand blade is then passed in over the other, and the hooks are hooked into the left side of the fistula; it is then rotated from right to left, and brought above and across the left- hand blade. The blades are now locked and the han- * Right and left as mentioned in this article have reference to the operator’s right and left—viz., the right side of the fistula, the right side of the median line, and the right side of the lacerated perinaeum mean on the operator’s right as he faces the parts; so with the left; not the patient’s right and left. 4 PARING AND SUTURE CLAMP FORCEPS. dies brought together and fixed by the ratchet. The fistula is thus firmly held, with its edges everted. The next step is to pare the edges, which is best done with Fia. 2. Fig. 3. Dr. Emmet’s straight and curved scissors. This accom- plished, pass the needles, armed with silver wire, one in front of the first hook, then one between each two ad- PARING AND SUTURE CLAMP FORCEPS. 5 jacent hooks, and, lastly, one on the outside of the last hook. Twist up the sutures and cut tlnm off, unlock the blades, rotate them in the opposite direction from that in which they were passed in and hooked, thus relieving the hooks, withdraw the blades, and the operation is complete. Fig. 3 represents the instrument after having been hooked near the edges of the fistula, rotated and locked, holding the fistula open, to show the sutures. To complete the operation, draw the handles together, constricting the fistula, twist up and cut off the sutures, unlock, rotate in the opposite direction from that in which they were applied, and withdraw the blades. The advantages gained are these: First, by fixing the fistula with the instrument, the operator is enabled to pare the edges at one stroke of the scissors. Second, the blades constricting the pared edges of the fistula furnish considera- ble support for the passage of the needle, which can be pushed through both sides at once, taking good hold at the same time, and also from this fact the sutures can be better twisted and adjusted. Lastly, the operator has entire con- trol of the parts, for by depressing the handles he elevates the fistula, and during the paring and suturing can bring it clearly into view. This simple instrument can be used in all operations wherein eversion, elevation, and continuous and perfect ad- justment of the tissue are necessary, as in laceration of the perinyeum, colporrhaphy (anterior and posterior), etc. When performing the operation of elytrorrhaphy, the patient is placed in Sims’s position and his duck-bill speculum intro- duced. The operator, determining his line of operation, passes in the left-hand blade of the “ paring and suture clamp forceps,” hooks it into the anterior wall of the vagina on the right side of the median line, and rotates the blade from left to right. He then passes in the right-hand blade, over the 6 PARING AND SUTURE CLAMP FORCEPS. one already in position, hooks it into the anterior wall of the vagina on the left side, at the same distance from the median line, and rotates the blade from right to left. The right-hand blade is then brought down upon and across the left-hand blade and locked. The operator can now put the tissue be- tween the blades upon the stretch by separating the handles. He can then bring the mucous membrane so stretched clear- ly into view by depressing the handles, and is thus enabled to readily cut away or freshen the mucous membrane in any given direction, as in Sims’s V-shaped operation for pro- cidentia, apex to vulva, base to os uteri, or Emmet’s opera- tion for procidentia. The three points, one in front of the os uteri and the two lateral ones, are easily located and fresh- ened while the tissue is firmly held by the forceps ; or, as is suggested by Munde, all the intervening tissue between the blades can be freshened or denuded and the sutures passed and twisted up. The operator having entire control of the parts, by elevating or depressing the handles of the forceps the blades giving support to the tissue allows him to pass in the needles, armed with sutures, more accurately. The operation is completed by drawing the handles of the forceps together, thus bringing the freshened surfaces into accurate and perfect contact, without any traction upon the sutures whatsoever. The sutures are then drawn up, twisted and cut off, the blades are unlocked and each is rotated in the opposite direction from that in which it was applied, unhooked, and withdrawn. Emmet’s, Munde’s, and Stoltz’s operations for cystocele can be greatly facilitated by the use of this instrument; also like operations on the posterior vaginal wall. Emmet’s opera- tion for urethrocele is thus performed with the “ paring and suture clamp forceps” : Sims’s speculum is introduced ; the left-hand blade is passed into the vagina and hooked into the /interior wall on the right side, parallel to and an inch and PARING AND SUTURE CLAMP FORCEPS. 7 a half from the point where the slit in the urethra is to be made, and rotated from left to right and held in this position. The right-hand blade is then passed in and hooked into the anterior vaginal wall on the left side, at a point immediately opposite to the other blade and at the same distance from the median line, and rotated from right to left, bringing it down to and across the left-hand blade ; the blades are locked and the handles separated until the tissue between the blades is placed upon the stretch ; the handles arc then fixed by the ratchet, a grooved sound is passed into the urethra, and the slit is made just in front of the neck of the bladder. “The hyperplastic mucous urethral membrane is drawn through this slit with a tenaculum, trimmed down until the urethral canal appears free, and its border is sewed by fine silk or catgut sutures to the mucous membrane of the vagina.” Should the operator desire to constrict the edges of the slit, he can unlock the blades and unhook them, and rehook them on either side of and near the slit, rotating them as before, and hold the edges firmly everted while stitching the urethral mucous membrane to the mu- cous membrane of the vagina. He then unlocks the blades and, rotating them in the opposite direction from that in which they were applied, withdraws them. Cystocele in many cases can be overcome by paring the tissue and making two longitudinal wounds in the anterior wall of the vagina, parallel to and on either side of the urethra, extending from either side of the os uteri to the edges of the vulva. These, when sutured and healed, will form two longitudinal cica- trices, which will give support to the relaxed anterior wall. The posterior wall can be so treated for proctocele, the wounds to extend from either side of the posterior vaginal pouch to the edges of the vulva, parallel to and on either side of the median line. In procidentia, the paring and 8 PARING AND SUTURE CLAMP FORCEPS. suturing of both the anterior and posterior walls of the vagina in the directions mentioned, will form, when healed, four longitudinal cicatrices which will act as four splints, prevent- ing the sinking down of the uterus or the shortening of the antero-posterior diameter of the vagina. The width of the denuded surfaces in any of the operations must be deter- mined by the condition of the case. The paring and sutur- ing can be done very readily with the “paring and suture clamp forceps” manipulated as before described. In perineorrhaphy, Munde says: “ While denudation is under process, the index and middle finger of the left hand of the assistant who holds the left leg, and the right hand of the other assistant, separate the labia by traction on the sound skin, and enable the operator to see the vaginal canal as he proceeds inward; this traction must be uniform, and is regulated by the operator at will during the whole opera- tion, so as to secure the best possible symmetry of the two halves of the wound, and exactly corresponding points of entrance and exit of the sutures.” This traction can be made with this instrument with more uniformity than with the hands of an assistant, and the instrument gives the opera- tor complete control of the parts, both when denuding and when suturing. The instrument is applied in this manner: The left-hand blade is hooked into the sound skin on the right side of the lacerated perinaeum, and rotated from left to right; then the right-hand blade is hooked into the sound skin on the left side of the wound and rotated from right to left. The blades are then locked. The elasticity of the rotated edges causes the handles to be fully extended, and the op- erator can, by depressing them, draw the sides of the wound tense, and, thus causing the wound to gape at its outer edges, readily bring the tissue at the bottom of the rent to view. The tense condition of the sides allows the operator to pare them with Emmet’s fiat scissors, kept level with the sur- PARING AND SUTURE CLAMP FORCEPS. 9 face, without any danger to the structures below the mucous membrane. The paring done, the sutures are passed. After this the wound and vagina are thoroughly cleansed. The handles of the in- strument are brought together and fixed by the ratchet, which causes the blades to bring the two halves of the freshened wound into close contact and firmly hold them in this position. The opera- tor draws up the sutures one by one and twists them, unlocks the blades, and removes the instru- ment. There is no traction upon the sutures to bring the edges of the wound together. They are held together by the blades of the instrument, and by so supporting them the operator is enabled to twist up and tighten the sutures with more uniformity than he can possibly do by drawing the wound together by the sutures. Again, when the blades are re- moved, the strain comes alike upon all the sutures at one and the same time, and greatly di- minishes the danger of their tear- ing out. Fig. 4 represents the instru- ment applied as directed to a lacerated perinseum, and shows the rent gaping by the action of Fig. 4. 10 PARING AND SUTURE CLAMP FORCEPS. the instrument, the tissue pared, the sutures passed. To complete the operation, draw the handles of the instru- ment together, thus bringing the pared edges accurately into position. When operating for lacerated perinaeum, the operator must adapt the instrument to the length of the rent, using the number of hooks which will thoroughly evert and ac- curately adjust the tissue after it has been pared and the sutures have been passed. lie must be careful to see that the instrument, after being applied as before described, will thoroughly and accurately bring the edges together before he commences the paring. In other words, the operator, after hooking the blades on either side of the rent and everting the edges, locks the blades and draws the handles together. lie then readily sees if the edges of the rent are brought into proper and exact apposition through- out its entire length; if they are not, he should notice what the difficulty is and overcome it by unhooking the instru- ment and reapplying it in such direction as will enable him, by drawing the handles together, to make the edges meet at all points. This done, he extends the blades and proceeds with the operation as before described. REASONS WHY Physicians Should Subscribe FOR The New York Medical Journal, EDITED BY FRANK P. FOSTER, M. D.,J Published by D. APPLETON & CO., 1, 3, & 5 Bond St. 1. BECAUSE : It is the LEADING JOURNAL of America, and contains more reading-matter than any other journal of its class. 2. BECAUSE : It is the exponent of the most advanced scientific medical thought. 3. 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