[Ill.u.s.tration: FIG. 53. THE Pa.s.sAGE OF THE UTERINE SOUND. _Entry of the sound into the uterine cavity._]

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 pa.s.sed 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 maitre_) (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 ca.n.a.l is straightened and the difficulty overcome. (2) Spasmodic contraction of the internal os uteri; this soon pa.s.ses off with a little steady pressure. (3) A fibroid may project into the lumen of the ca.n.a.l. (4) Congenital or acquired stenosis of the external os uteri.

When there is a septic discharge from the v.a.g.i.n.a, the sound should be pa.s.sed in the dorsal position and through a speculum.

REPOSITION OF A CHRONIC UTERINE INVERSION

=Indications.= Chronic inversion of the uterus, with severe haemorrhage and bearing-down pain. The uterine fundus presents in the v.a.g.i.n.a 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 anaesthetic in the dorsal position and the whole hand is pa.s.sed gradually into the v.a.g.i.n.a. The tips of the fingers and thumb should be pressed into the circular s.p.a.ce 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.

[Ill.u.s.tration: FIG. 54. CHRONIC UTERINE INVERSION. Aveling's repositor in place with elastic cords A, B, and C, in action.]

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 sc.r.a.ping 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 haemorrhage_ is the chief symptom which calls for curetting.

The causes of the haemorrhage may be _certain forms of endometritis_.

Thus haemorrhage 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 haemorrhage--the 'polypoid' or 'villous' form, which arises usually in women over forty years of age.

The haemorrhage 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 haemorrhage is not evident are relieved by curetting; amongst these are such conditions as arterio-sclerosis of the uterine vessels.

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

It may be called for when the endometrium is congested and dematous 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 haemorrhage 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.

[Ill.u.s.tration: FIG. 55. VOLSELLA FOR FIXING THE CERVIX.]

[Ill.u.s.tration: FIG. 56. HEGAR'S DILATORS (THREE SIZES) FOR DILATATION OF THE CERVIX UTERI.]

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 pa.s.sed 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 pa.s.sage of the curette; up to No. 12 Hegar is usually sufficient. The curette is now taken and pa.s.sed 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 pa.s.sed 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 pa.s.sed upwards and the manuvre repeated with just sufficient change of direction to ensure the curette pa.s.sing 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.

[Ill.u.s.tration: FIG. 57. METAL BOUGIES FOR DILATATION OF THE CERVIX.

_a._ As used by the author.

_b._ Ends of bougies considered unsuitable.

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 sc.r.a.ped, 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.

[Ill.u.s.tration: FIG. 58. BOZEMANN'S DOUBLE-CHANNELLED TUBE.]

[Ill.u.s.tration: FIG. 59. BUDIN'S CELLULOID CATHETER.]

[Ill.u.s.tration: FIG. 60. A, MURRAY'S FLUSHING CURETTE; B, BLUNT CURETTE.]

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 pa.s.sed into the uterus. The v.a.g.i.n.a 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 haemorrhage, the packing should be firmer, and a v.a.g.i.n.al 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.