Part 25 (1/2)
[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.