Fig. 60. a, Murray’s Flushing Curette; b, Blunt Curette.
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:—