A System of Operative Surgery Part 26

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 dysmenorrha.

_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 haemorrhage, which can easily be controlled by plugging the cervical ca.n.a.l. 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.

[Ill.u.s.tration: FIG. 61. DILATATION OF THE CERVIX. The patient is in the lithotomy position. Auvard's speculum has been inserted, a volsella attached to the anterior cervical lip and a bougie pa.s.sed. (_From a photograph._)

_d._ Right hand inserting bougie.

_s._ Speculum.

_v._ Volsella.

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 flus.h.i.+ng speculum; a volsella; a Bozemann's tube or Budin's catheter; a uterine sound; and a set of dilators.

The patient is anaesthetized and placed in the lithotomy position with the legs supported by a crutch. Strict asepsis must be observed; the l.a.b.i.a must be shorn of long hairs; this is followed by cleansing of the v.a.g.i.n.a and a v.a.g.i.n.al douche, and finally the v.u.l.v.a is washed with antiseptic lotion. The speculum is pa.s.sed and held by an a.s.sistant, but if self-retaining, as in Fig. 61, the a.s.sistant 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 ca.n.a.l, and thus makes the pa.s.sage of the bougies easier. The bougies are now pa.s.sed in order, commencing with the size which will pa.s.s easily. The bougie is pa.s.sed by means of the right hand into the cervical ca.n.a.l 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 pa.s.s into the uterine cavity. An interst.i.tial fibroid produces a tortuous channel and much difficulty will often be experienced in pa.s.sing 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 pa.s.sage. 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 pa.s.sage of No. 19 or 20 Hegar, while full dilatation up to No. 26 is required for any operation with scissors or the ecraseur 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 ca.n.a.l, has been mentioned. Extreme anteflexion or retroflexion gives trouble during the pa.s.sage 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 sequelae.

4. Haematoma 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 pa.s.sed 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 septicaemia.

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 v.a.g.i.n.al douche given. A Sims's speculum is pa.s.sed and the cervix seized and drawn down with a volsella so as to straighten the cervical ca.n.a.l. The direction and length of the uterine cavity is ascertained by pa.s.sing 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 pa.s.sed into the cervical ca.n.a.l, well past the internal os uteri. The end should project slightly into the v.a.g.i.n.a. The v.a.g.i.n.a 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 v.a.g.i.n.al end. The part of the cervical ca.n.a.l 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 pa.s.sed as in Fig. 62, and the raw surfaces are brought together.

_Circular amputation_, as carried out by Hegar, is more suitable for suprav.a.g.i.n.al elongation of the cervix, the result of prolapsus uteri.

The patient is anaesthetized 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 v.a.g.i.n.al wall. The raw surface remaining must be covered by uniting the v.a.g.i.n.al and cervical mucous membranes. Sutures are pa.s.sed in the following manner: a short stout, straight needle, threaded with a loop of silk, is pa.s.sed from the v.a.g.i.n.al 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 pa.s.sed at regular intervals and tied.

The sutures are removed on the tenth day and the patient should be kept in bed for fourteen days.

[Ill.u.s.tration: FIG. 62. MARCKWALD'S OPERATION FOR CONGENITAL HYPERTROPHY OF THE CERVIX. The wedge-shaped portions have been excised and the sutures pa.s.sed but not tied.