The Sims curette should be gently introduced to one cornu and then drawn methodically over the whole of the uterine surface, removing the endometrium in parallel strips, the length of each strip being equal to the distance between the internal os and the fundus. The curette may be withdrawn from the uterus and washed in distilled water as each strip is removed, or withdrawal and washing may be done after two or three strips have been removed. The Martin curette should then be introduced to one cornu and scraped over the fundus, as there is usually in this situation a narrow strip of endometrium that is not removed by the Sims curette.
The uterus should then be washed out with warm sterile water or with a 1:4000 bichloride solution. The washing may be done by holding the cervical canal open with the small dilator and introducing the long tubular syringe nozzle, or by some form of reflux tube ([Fig. 122]). Opportunity must always be afforded for the escape of the irrigating fluid.
Fig. 122.—Irrigation of the uterus.
The operator should always remember the danger of perforating the uterus by the curette. This accident, which has happened in the hands of the best surgeons, occurs usually as the instrument is introduced, not as it is withdrawn. It is much more liable to occur after labor or recent abortion, when the uterine tissues are soft, than in the conditions now under consideration. If perforation should happen, the uterus should be carefully washed out with the bichloride solution, the vagina should be lightly packed with gauze, and the patient returned to bed. A hypodermic injection of ergotin should be administered, and afterward, when the woman recovers from the anesthetic, small repeated doses of fluid extract of ergot should be administered to ensure uterine contraction. If the operation has been performed aseptically, it is probable that no harm will result from the accident. If peritonitis should develop, celiotomy must immediately be performed.
After curetting the uterus some operators are in the habit of packing the uterine cavity with sterile or iodoform gauze. This procedure is liable to obstruct the escape, rather than favor the drainage, of any discharges from the cavity of the uterus. Elevation of temperature and uterine pain are often caused by it; therefore it is best, after the operation of curetting, merely to pack the vagina lightly with sterile gauze, which should be removed in forty-eight hours. Daily douches of a 1:4000 bichloride-of-mercury solution should then be administered as long as the woman remains in bed. The vagina should be carefully dried after the douche, as already advised.
Hemorrhage is never profuse during curetting, and usually ceases after the endometrium has been removed and the uterus has been washed out.
In cases of gonorrheal endometritis it is advisable, after the uterus has been douched and the bleeding has ceased, to apply carbolic acid thoroughly over the whole interior of the uterus, because infection may lurk in the distal ends of the utricular glands, which are not removed by the curette.
Fig. 123.—Microscopic section of the normal endometrium, showing the utricular glands extending into the muscular tissue (Beyea).