CHAPTER XV

OPERATIONS UPON THE UTERUS

PASSAGE OF THE UTERINE SOUND

This is an operation which is much less frequently resorted to than formerly, owing partly to the risks of sepsis attending its performance and partly to the greater perfection of the bimanual examination. Passing the uterine sound should always be looked upon as a surgical operation. The facts learnt by the use of the sound are: (1) the length and direction of the uterine cavity; (2) the condition of the endometrium: bleeding as a rule follows withdrawal in fibro-myomata and endometrial disease; (3) whether a fibroid growth is projecting into the uterine cavity, and if so, how much.

The sound may be passed in the dorsal position (Fig. 61), the cervix being held by a volsella and exposed by means of a posterior speculum, or in the left lateral position, the method usually adopted in the consulting room. In the latter the right index-finger is passed up to the anterior lip of the cervix, the sterilized sound is taken in the left hand with its concavity backwards and its bulbous end is slid gently along the palmar surface of the finger in the vagina until the os uteri externum is reached; through this it should be passed for about a quarter of an inch (Fig. 50). The instrument should now be steadied by the thumb and the two distal joints of the second finger of the right hand, and its subsequent movements controlled by the left (Fig. 51).

If the uterus is in a state of retroversion, the bulbous end will gradually enter the uterine cavity by pressing the handle of the sound forward and at the same time giving an upward and slightly backward impulse to its tip; the rough surface of the handle will be found to be looking towards the sacrum. Should the uterus be anteverted, the handle is held in the left hand as before and passed through an arc of a circle by raising the handle and turning it forward until it lies beneath the symphysis pubis, in the median line (_tour de maître_) (Fig. 52). The rough surface of the handle now looks anteriorly and the bulbous end is pressing against the internal os uteri; now bring back the handle directly to the perineum and it will glide into the uterine cavity (Fig. 53).

_Difficulties_ to be met with will be: (1) An acutely anteflexed uterus; if traction is made on the cervix with a volsella the canal is straightened and the difficulty overcome. (2) Spasmodic contraction of the internal os uteri; this soon passes off with a little steady pressure. (3) A fibroid may project into the lumen of the canal. (4) Congenital or acquired stenosis of the external os uteri.

When there is a septic discharge from the vagina, the sound should be passed in the dorsal position and through a speculum.

REPOSITION OF A CHRONIC UTERINE INVERSION

=Indications.= Chronic inversion of the uterus, with severe hæmorrhage and bearing-down pain. The uterine fundus presents in the vagina and simulates a fibroid polypus in process of extrusion.

=Operation.= This is most likely to be successful if continuous pressure be brought to bear against the inverted fundus while an attempt is made simultaneously to dilate the contracted cervix.

The patient is placed under an anæsthetic in the dorsal position and the whole hand is passed gradually into the vagina. The tips of the fingers and thumb should be pressed into the circular space at which the flexion of the walls of the body on the cervix has occurred. With the palm of the hand upward pressure is made, counter-pressure being exerted by the other hand over the lower hypogastrium. Reduction usually begins by a slight dimpling of the inverted fundus.

A more scientific method of exerting continuous pressure is by the application of Aveling’s sigmoid repositor and elastic cords (Fig. 54). This instrument consists of a vulcanite cup into which is secured a steel S-shaped rod terminating below in a loop. The cup is made of various sizes and should always be smaller than the inverted fundus over which it fits.

After it has been applied, the instrument is carefully packed round with gauze to keep it in place. Two elastic bands in front and two behind are fastened by one end to the steel loop and by the other end to an abdominal belt. By this means constant and direct pressure is obtained on the fundus uteri in the direction of the pelvic axis.

Pain is usual and must be relieved by morphine. The cup usually elevates the fundus and corrects the inversion in about twenty-four hours, but as much as three days has been occupied in the process.

CURETTING THE UTERUS--CURETTAGE

The term ‘curetting’ is applied to the operation of scraping away the lining membrane of the uterus, either for the relief of some pathological condition or for diagnostic purposes.

The endometrium is not removed in its entirety by curetting, for the uterine glands dip down to a slight extent between the muscle fibres of the uterine wall. The endometrium is removed as far down as the muscular coat, and, consequently, those parts of the glands lying amongst the muscular fibres are left intact.

=Indications.= These may be divided into the cases in which the operation is (1) Remedial and (2) Diagnostic in nature.

The diseased states of the endometrium are many and their exact pathology is still under discussion. It is, therefore, more practical to consider _the remedial indications for curetting_ from the point of view of symptoms.

(i) _Uterine hæmorrhage_ is the chief symptom which calls for curetting. The causes of the hæmorrhage may be _certain forms of endometritis_. Thus hæmorrhage is a prominent symptom of the so-called ‘hypertrophic glandular endometritis’, a diffuse overgrowth or adenomatous condition of the endometrium, probably the after-result of a previous inflammation. There is one form which gives rise to specially profuse hæmorrhage--the ‘polypoid’ or ‘villous’ form, which arises usually in women over forty years of age.

The hæmorrhage from _fibro-myoma of the uterus_ may require removal of the endometrium in order to relieve the bleeding temporarily at any rate. When milder measures fail, curetting is of great service in arresting the profuse menorrhagia which so often accompanies _subinvolution of the uterus_.

Certain cases in which the actual cause of the hæmorrhage is not evident are relieved by curetting; amongst these are such conditions as arterio-sclerosis of the uterine vessels.

(ii) _A leucorrhœal discharge_ is another symptom for which curetting is sometimes indicated.

It may be called for when the endometrium is congested and œdematous from such conditions as displacements of the uterus and chronic subinvolution.

It is better not to curette for a purulent uterine discharge; extension of the infection may be caused and give rise to pyosalpinx.

(iii) _Sterility._ Curetting should follow dilatation, in the hope that the new endometrium formed may afford a better nidus for the ovum.

(iv) _Frequent abortion in the early months._ Curetting often cures this by removing the diseased endometrium.

(v) _Inoperable carcinoma of the cervix._ Removal of the redundant portions of the growth by the curette, followed by cauterization or other measures, relieves the hæmorrhage and foul discharge. Great caution must be exercised, lest the peritoneum or bladder be opened into by the curette and the sufferings of the patient thereby increased. Cells of the disease may also be pushed into the pelvic lymphatics; considerable febrile disturbance may also follow the operation. In this condition a blunt curette (Fig. 60, B) may be gently used; the same instrument is safest in abortion up to the eighth week of pregnancy; after this date it is better to use the fingers only.

Fragments removed by the curette are subjected to microscopical examination _for diagnostic purposes_. The various conditions which may have to be diagnosed are:--

1. Carcinoma of the body of the uterus.

2. Retained products of conception.

3. Tuberculosis of the endometrium.

4. Chorio-epithelioma malignum.

=Operation.= The following instruments are required: a volsella (Fig. 55); a self-retaining weighted speculum (Fig. 37); uterine dilators (Figs. 56, 57); a uterine sound; a Bozemann’s tube (Fig. 58); Budin’s celluloid catheter (Fig. 59); and one or other flushing curettes.

There are many varieties of curettes, and each has its own adherents. The most generally useful is Murray’s sharp flushing curette, which has a groove for the recurrent flow (Fig. 60, A). There are many varieties of blunt curettes. The model depicted in Fig. 60, B, enables the operator to clear out the uterine cornua and is of the best shape.

The patient is placed in the lithotomy position and the various antiseptic precautions already described are carried out. A speculum is passed and the cervix is steadied by a volsella applied to the anterior lip.

The cervix is first dilated up to a suitable degree for the passage of the curette; up to No. 12 Hegar is usually sufficient. The curette is now taken and passed into the uterus. In performing the operation a definite plan should always be followed so as to ensure that no part of the uterine cavity is missed. The curette is passed up to the top of the fundus uteri with its cutting edge directed to the posterior wall. It is then drawn downwards with steady pressure to just below the internal os. It is then again passed upwards and the manœuvre repeated with just sufficient change of direction to ensure the curette passing over fresh tissue. This is repeated until the whole of the posterior wall has been thoroughly dealt with from side to side. The anterior wall and sides of the uterus are then treated in turn in the same way. Finally the fundus is curetted by a lateral movement of the instrument, especial attention being paid to the Fallopian tube angles, which are very apt to escape the curette.

A rasping or grating sound indicates that the endometrium over a given part has been removed and that the muscular walls have been reached. In spite of the most careful attention it is very difficult to remove the endometrium completely. If a uterus be scraped, as it is thought, thoroughly, and be examined _post mortem_, strips of mucous membrane will often be found untouched, showing the difficulties of complete removal.

After the operation an intra-uterine douche of 1 in 2,000 perchloride of mercury or some other suitable antiseptic is given with a Bozemann’s tube or Budin’s catheter. If a flushing curette has been used, this of course has already been done. After the douche, some application may be made to the interior of the uterus: the best is iodized phenol (liquid carbolic acid, 2 parts; tincture of iodine, 1 part). To do this the interior of the uterus is first dried with a Playfair’s probe armed with cotton-wool; another similar probe is then taken, dipped into the solution, and passed into the uterus. The vagina is protected by inserting a plug of cotton-wool into the posterior fornix. The uterus is then lightly packed with ribbon gauze. If there is hæmorrhage, the packing should be firmer, and a vaginal tampon should be placed in below the cervix. The packing should be removed in twenty-four hours. The patient may get up at the end of a week and resume her ordinary duties in a fortnight.

DILATATION OF THE CERVIX

=Indications.= Dilatation may be performed:--

(i) As a means of diagnosis. (ii) As a preliminary to the use of the curette or to removal of intra-uterine growths. (iii) As a method of cure for spasmodic dysmenorrhœa.

_Contra-indications_ to the rapid method of dilatation of the cervix are very few: a recent attack of peri- or parametritis would certainly be one, but when the effects of a salpingitis have quieted down there seems very little reason against its use. Where carcinoma of the body of the uterus is known to exist, and in old age, it should only be resorted to with the greatest caution, if at all.

=Methods=:--

(_a_) Rapid dilatation by means of graduated metal bougies. (_b_) Gradual dilatation by means of tents. (_c_) Combined gradual and rapid dilatation.

In a large majority of cases rapid dilatation is the operation selected. Its one disadvantage is that when a great degree of dilatation is necessary, or when the operation is performed too rapidly, the cervix is liable to be torn, an event which is especially liable to occur when the tissues of the cervix are rigid. These lacerations are longitudinal in direction and in the neighbourhood of the internal os uteri. They sometimes result in hæmorrhage, which can easily be controlled by plugging the cervical canal. Unless strict asepsis be maintained, these lacerations of course form a channel for infection of the pelvic cellular tissue.

It is obvious that dilatation will be easier to perform, and laceration less liable to occur, if the cervix is in a softened condition--a physiological state which is always present during pregnancy and labour. Efforts should therefore be directed, when possible, to ensure a soft state of the cervix before performing rapid dilatation.

Immediately after the cessation of a period, the cervix is soft and somewhat patent, and advantage may be taken of this fact. The introduction of a glycerine tampon two hours beforehand produces a certain amount of softening. But nothing ensures so much softening as the introduction of a tent into the cervix about twelve hours previous to the rapid dilatation.

It is therefore recommended in all cases, where possible, to perform dilatation by this latter means, viz. a combination of the gradual and rapid methods.

=Rapid dilatation= by means of graduated metal bougies. Hegar’s original dilators (Fig. 56) were solid vulcanite bougies, graduated from 1 to 26, the numbers corresponding to the diameter of the bougie in millimetres. Each was 5-1/4 inches in length, the handle measuring 1-1/2 inches and the bougie the remainder. The bougie formed a slight curve and tapered off to a blunt point.

These bougies were rather short and too sharply pointed, and they could not be sterilized by boiling. To overcome these disadvantages, uterine dilators are now made about the same length as a male catheter, with a sharper curve than Hegar’s original one, and a blunter point; the larger sizes are of hollow metal for the sake of lightness. There are many varieties of dilator, each with minor differences as to length, curve, handle, and shape of the point.

The author uses metal bougies. These have somewhat the shape of the ordinary uterine sound, are thirty-five in number, and graduated in size. Like the sound, the upper portion is bent at an angle of about 160° with the solid handle, a circular shallow depression indicating the 2-1/2 inch mark in the smaller numbers; in the larger this is not considered necessary.

=Operation.= Instruments: an Auvard’s self-retaining weighted flushing speculum; a volsella; a Bozemann’s tube or Budin’s catheter; a uterine sound; and a set of dilators.

The patient is anæsthetized and placed in the lithotomy position with the legs supported by a crutch. Strict asepsis must be observed; the labia must be shorn of long hairs; this is followed by cleansing of the vagina and a vaginal douche, and finally the vulva is washed with antiseptic lotion. The speculum is passed and held by an assistant, but if self-retaining, as in Fig. 61, the assistant is not necessary: a sound is then inserted to ascertain the length and direction of the uterine cavity. If anteflexion be present, the anterior lip of the cervix should be seized with the volsella and fixed by slight traction. If retroversion or retroflexion be present, then the posterior lip should be fixed. Traction by the volsella tends to straighten out the uterine canal, and thus makes the passage of the bougies easier. The bougies are now passed in order, commencing with the size which will pass easily. The bougie is passed by means of the right hand into the cervical canal until the internal os uteri is reached; resistance will now be felt. Firm and continuous pressure in the proper direction must be made, and in a short time the resistance gives way, and the bougie will pass into the uterine cavity. An interstitial fibroid produces a tortuous channel and much difficulty will often be experienced in passing a bougie in such a case. It will be found on attempting to withdraw the instrument that it is grasped by the internal os uteri; in the course of one to five minutes this spasm will relax, and only then should the bougie be withdrawn. The next in size should be ready and introduced in the same manner, and the succeeding ones are inserted until the required dilatation is produced. Sterilized vaseline or glycerine of perchloride of mercury may be smeared over the point of the dilator to facilitate its passage. Each succeeding bougie should increase in size by not more than 1 mm.: occasionally a case is met with where this seems too large a difference, and it is really better to have them made with a 1/2 mm. difference. As a preliminary to the use of the curette, dilatation up to No. 12 Hegar is necessary. The index-finger can be introduced into the uterine cavity after the passage of No. 19 or 20 Hegar, while full dilatation up to No. 26 is required for any operation with scissors or the écraseur on intra-uterine growths.

It is evident that the degree of dilatation for exploratory purposes will be governed by the diameter of the operator’s finger, or rather of its second joint, and this varies very much in different people. By means of the finger a uterus can be explored in which the cavity is much longer than the operator’s finger, if the viscus be forced down on to the finger by the pressure of the other hand above the symphysis pubis. The operator must not be satisfied until he has felt the whole extent of the uterine wall, especially the two cornua, which are favourite seats of disease. After completion of the operation it is well to give an antiseptic intra-uterine douche by means of a Bozemann’s tube. The uterus and cervix should be lightly packed with sterile ribbon gauze, 1 inch wide; the free end is left projecting through the os uteri. The packing should be removed in twenty-four hours, and an antiseptic douche given.

=Difficulties and dangers.= The difficulty due to non-dilatability is overcome by means of the preliminary use of a tent. The complication produced by a fibroid, altering the direction of the uterine canal, has been mentioned. Extreme anteflexion or retroflexion gives trouble during the passage of the earlier numbers, but as dilatation is effected this disappears.

The dangers are:--

1. Laceration of the cervix.

2. Rupture of the uterus.

3. Sepsis and its sequelæ.

4. Hæmatoma between the layers of the broad ligament.

_Laceration of the cervix_ has been referred to: it begins as a rule at the internal and extends towards the external os uteri; it may be deep or superficial, and is recognized as a sulcus into which the finger can be passed from above downwards: rarely, laceration into the peritoneum may take place.

_Rupture of the uterus_ is liable to occur when the uterine wall has been weakened by the changes which accompany the completion of the menopause, or has been infiltrated by carcinoma, or, more rarely, by vesicular mole.

_Sepsis_ may occur from absorption through a laceration if asepsis has not been maintained: it may lead to an attack of pelvic cellulitis or even septicæmia.

If the uterus is fixed or not freely mobile, and the condition is complicated by any tubal or ovarian disease, great care must be exercised in manipulation.

=Gradual dilatation= by tents. There are three varieties of tents--sponge, laminaria, and tupelo.

Sponge tents should never be used, for they are extremely difficult to render sterile.

The commonest and the safest to use, because they can be most easily sterilized, are laminaria tents, made from sea-tangle (_Laminaria digitata_). These are cylindrical rods, which expand evenly, from imbibition of moisture. Tupelo tents are larger than laminaria and expand more rapidly.

To use tents that are not absolutely sterile is to court disaster, and in former times they were responsible for many fatalities from sepsis. The best way to keep laminaria and tupelo tents is in a solution of 1 in 1,000 corrosive sublimate in absolute alcohol. They may be kept in this for an indefinite period, and so are always ready for use.

=Contra-indications.= All septic states of the uterus and cervix, for the retention of pent-up discharges is very likely to lead to local or general infection. Tents should never be used then in such conditions as carcinoma of the body of the uterus, sloughing polypus, acute endometritis and cervicitis.

=Method of introduction of a tent.= The patient is placed in the lateral or lithotomy position and a vaginal douche given. A Sims’s speculum is passed and the cervix seized and drawn down with a volsella so as to straighten the cervical canal. The direction and length of the uterine cavity is ascertained by passing the sound. The most suitable size of tent is now selected, and, being held in a special form of tent introducer or suitable pair of forceps, is passed into the cervical canal, well past the internal os uteri. The end should project slightly into the vagina. The vagina should then be douched again and lightly packed with sterilized gauze. The patient must remain in bed.

The tent should be left in position for twelve to fifteen hours, when it will have exerted its full action. The action of tents is twofold: it causes (1) dilatation, and (2) softening of the cervix, the softening being accompanied by an abundant secretion of mucus from the cervical glands.

=Method of removal.= Tents are removed by traction on the silk thread attached to the vaginal end. The part of the cervical canal which exerts the greatest resistance to the dilating action is the internal os uteri, and after the tent has been removed a well-marked constriction is always to be seen at this point. If there is much resistance to removal by reason of the tent being gripped at the internal os, it should be taken in a pair of forceps and gently pulled and levered out.

OPERATIONS FOR HYPERTROPHY OF THE CERVIX

This is a congenital condition and there is no thickening of the mucous membrane and underlying tissues; hence the diameter of the cervix is not increased. The operation best adapted for the treatment of this condition is the wedge-shaped incision, recommended by Marckwald (Fig. 62).

=Operation.= The cervix is split bilaterally into an anterior and posterior portion by means of scissors, and out of each portion is excised a wedge-shaped piece of tissue, leaving a deep groove. The sutures are passed as in Fig. 62, and the raw surfaces are brought together.

_Circular amputation_, as carried out by Hegar, is more suitable for supravaginal elongation of the cervix, the result of prolapsus uteri.

The patient is anæsthetized and placed in the lithotomy position and the cervix is pulled down by a volsella and amputated transversely by a knife or scissors. A certain amount of retraction of the stump takes place, producing an inversion of the vaginal wall. The raw surface remaining must be covered by uniting the vaginal and cervical mucous membranes. Sutures are passed in the following manner: a short stout, straight needle, threaded with a loop of silk, is passed from the vaginal mucous membrane, across and beneath the raw surface of the stump, and emerges on the mucous membrane of the cervix (Fig. 63). From eight to ten of these sutures are passed at regular intervals and tied. The sutures are removed on the tenth day and the patient should be kept in bed for fourteen days.

TRACHELORRHAPHY.

=Indications.= This operation is performed for the repair of certain forms of laceration of the cervix. It was formerly practised in every case in which a laceration occurred: it is now only permissible in cases in which there is extroversion of the mucous membrane with certain symptoms, such as hæmorrhage or free leucorrhœal discharge accompanied by backache on exertion and general ill health. It was formerly considered that there was a direct relation between cervical laceration and cancer, but further inquiry has failed to corroborate this view.

The instruments required are: a Sims’s or Auvard’s speculum; long-handled, angular-bladed knives (right and left); Emmett’s scissors (right and left) (Fig. 64); toothed dissecting forceps; short stout needles with sharp triangular points, straight or very slightly curved.

=Operation.= As it is usually found that subinvolution is present and kept up by the laceration, it is best to perform a preliminary curettage (see p. 154) before proceeding to the operation proper.

The patient is placed in the lithotomy position and an Auvard’s speculum is inserted. A piece of stout silver wire or a tenaculum is passed deeply through the anterior and posterior lips of the cervix; steady traction can be made through these and the uterus kept fixed while denudation and suturing are carried out. Should marked extroversion be present, with hypertrophy of the cervical glands, the curette should be freely applied to the diseased surface.

The uterine sound is passed to mark the situation of the internal os uteri, and an antero-posterior linear piece of lining membrane, about a quarter of an inch in breadth, must be allowed to remain untouched. This is necessary to prevent total occlusion of the cervical canal when the denuded flaps are sutured (Fig. 65).

_Denudation._ The right half of the anterior and posterior lips of the cervix (upper and lower from the operator’s point of view) are first pared by means of the angular knives and scissors, great care being taken to see that the deep angle of the reflexion is not overlooked. The other side is then treated in a similar manner. The tissues will be found extremely hard and resistant, especially if there be much cicatrization about the angle of the laceration.

_The passage of the sutures_ (Fig. 65). The short stout, triangular-pointed needle is first doubly threaded with silk or stout chromicized catgut so that a loop of three to four inches in length is produced. The needle and the silk suture are passed as in Fig. 65, two on either side.

The triangular-pointed needle must be held in Schauta’s specially strong holder (Fig. 73), and should be made to pierce the cervix near the raw surface on one lip, and pushed through the tissues immediately below this to emerge on the strip of unpared cervix already mentioned. It is then carried across the sulcus and is made to emerge through the opposite lip of the cervix. A stout wire is now hooked into the loop and pulled through the needle track. When the two wire sutures are inserted on either side, the flaps are brought together and the wires twisted together.

=Results.= Primary union is the rule, and the wire sutures may be removed at the end of the tenth or twelfth day. The cervix has the appearance observed in the nullipara, and may lead to complications in any ensuing labour from difficulty of dilatation.

Dührssen modifies Emmett’s operation by a flap-splitting procedure which, however, does not appear to possess sufficient advantages to warrant its general introduction.

VAGINAL FIXATION (Hysteropexy)

This operation consists in the fixation of the retroverted fundus uteri in an anteverted position, by suturing it to the anterior vaginal cul-de-sac.

=Indications.= These are somewhat uncertain, and the field of utility of the operation is rapidly becoming more limited. Advocates of this procedure recommend it for backward displacement of the uterus with or without adhesions. It is considered specially applicable to cases in which slight retroversion is complicated by moderate prolapsus. The results which have so far obtained do not appear to be so good as those resulting from the use of a well-fitting pessary.

=Operation.= The technique recommended by Dührssen appears to be the most satisfactory, and is as follows: The patient is anæsthetized and placed in the dorsal position with the knees supported by a Clover’s crutch. After purification of the parts (see p. 126) the cervix is pulled down as far as possible by means of a volsella: a curettage is then carried out as a preliminary measure (see p. 154). If cervical hypertrophy is present, amputation by Marckwald’s method (see p. 160) should be performed, as an elongated cervix acts as a preventive to satisfactory anteversion of the uterus. A transverse or T-shaped incision is now made as in vaginal hysterectomy (see p. 169), and the cellular tissue pushed up by the index-finger until the peritoneum is reached. The peritoneum is now seized with a volsella and cut through, and the edges sutured to the lips of the vaginal wound. The uterine fundus is then anteverted by means of a sound: by pressing the handle of the instrument towards the perineum the fundus is brought into the wound. By means of a rectangular curved needle a stout silk suture is passed through the anterior wall of the fundus as high up as possible: the vaginal flaps are not included, as the suture is to be used for traction only. The uterus is now forcibly pulled down and two other sutures are introduced in the same manner higher up. Three sutures of catgut are passed through the uterine wall, including the vaginal and peritoneal flaps. The silk traction sutures are now withdrawn and the permanent ones tied. The vaginal wound is carefully sutured by means of fine silk.

=Difficulties and dangers.= The risks of the operation are peritonitis and wounding of one or both ureters or the bladder wall. Absolute rest for fourteen days is necessary and no local after-treatment is called for.