The following, with some modifications, is an abstract of a valuable contribution10 by Goodell of Philadelphia, in which he gives positive endorsement to rapid dilatation as proposed by Ellinger and others. The instruments recommended are two Ellinger dilators, which are preferred on account of the parallel action of their blades. The dilatation is commenced with the smaller instrument and completed with the larger, which has powerful blades that do not spring or feather. The light instrument needs only a ratchet in the handle, but the stronger one has a screw which forces the handles together and the blades apart. To prevent injury to the fundus when the instrument is open, the length of the blades is limited to two inches. The larger instrument has a dilating power of one and a half inches, and has a graduated arc in the handles which indicates the divergence of the blades. Goodell's modification of Ellinger's dilators is provided with serrated blades, to prevent them from slipping out of the canal during the process of dilatation.
10 American Journal of Obstetrics, 1884, p. 1179.
For dysmenorrhoea or sterility due to flexion or stenosis the method of operation is as follows: A suppository containing a grain of the aqueous extract of opium is introduced into the rectum, the patient etherized, and the uterus exposed by Sims's speculum. The cervix is held by a tenaculum, and the smaller dilator is introduced as far as it will go. Upon gently stretching open that portion of the uterine canal which it occupies, the stricture above so yields that when the blades are closed they will pass higher. By repeating this manoeuvre a cervical canal is tunnelled out which before would not admit the finest probe. Should the os externum or cervical canal be too small to admit the instrument, a pair of pointed scissors may be substituted, and by the same opening and closing motions the canal may be prepared for the introduction of the smaller dilator. As soon as the cavity of the uterus has been entered the handles are brought together. This dilator is then withdrawn, the larger one introduced, and its handles slowly screwed together. If the flexure be very marked, the larger instrument after being withdrawn should be introduced with its curve in the opposite direction to that of the flexure, and the final dilatation made with the dilator in this position. But in reversing the curve the operator should take care not to rotate the organ upon its own axis, and not to mistake a twist thus made for a reversal of the flexure; the ether is then withheld, and the instrument allowed to remain in place until the patient begins to flinch, when it is removed. The best time for the dilatation is midway between the monthly periods. In the majority of cases the dilatation should be carried to about one and a quarter inches. The infantile uterus which has failed to develop at puberty has thin, unyielding walls, and should therefore not be dilated more than three-fourths of an inch or an inch. In using the larger instrument it is usually necessary to have the assistant make decided counter-traction with the vulsella forceps to prevent the blades of the dilator from slipping out. The cervix is sometimes lacerated, but not sufficiently to produce unpleasant results.
Goodell's statistics include one hundred and fifty operations of full dilatation under ether, with no fatal result and without serious inflammatory disturbance. As precautions against cellulitis, peritonitis, and metritis the patient should be fortified for the operation with moderate doses of opium and full doses of quinine, and for two or three days after the dilatation this should be continued and supplemented by the application of an ice-bladder over the abdomen.
After forcible dilatation under ether the cervical canal rarely returns to its previously angular or contracted condition. The cervix shortens and widens, and the plasma thrown out thickens and stiffens the uterine walls. In a small minority of cases the operation must be repeated. Dysmenorrhoea or sterility, if dependent solely upon the flexure, is cured by the dilatation. The comparative safety of forcible dilatation in the hands of a skilful and experienced gynecologist may be contrasted with its great danger when undertaken by an operator unacquainted with the special requirements of uterine surgery. Peri-uterine inflammation is a positive contraindication to the operation.
Post-uterine inflammation, which has drawn the anteflexed or anteverted uterus upward and backward by the contraction of the utero-sacral ligaments, often produces traction upon the vesico-vaginal wall and neck of the bladder, with a constant desire to micturate. For the relief of this intractable symptom, which sometimes goes on to cystitis, Emmet has proposed a most satisfactory remedy known as his buttonhole operation of urethrotomy.11 He makes a longitudinal opening about five-eighths of an inch long through the urethro-vaginal wall, between the meatus and the neck of the bladder, without cutting through either. To prevent the opening from healing together, the margins of the mucous membrane of the urethra are united with fine catgut sutures to the margins of the mucous membrane of the vagina. According to Emmet, the operation relieves irritation due to traction on the neck of the bladder by freeing the pelvic fascia at the fixed point where it converges to its pubic attachment. The operation is equally applicable for the relief of this symptom when due to inflammation in any other part of the pelvis. The same result may be secured, but less satisfactorily, by forcible dilatation of the urethra.
11 Emmet's Principles and Practice of Gynecology, 3d ed., pp. 275 and 761.
From personal experience the author can testify to the gratifying effects of this operation. Vesical irritation caused by post-uterine inflammation and consequent contraction of the utero-sacral ligaments is often wrongly attributed to the mechanical pressure of the anteflexed fundus uteri upon the bladder, which is manifestly impossible, if the contracted utero-sacral supports hold the entire uterus back away from the bladder.
The various anteflexion and anteversion pessaries which have been devised for the purpose of propping up the corpus are almost useless. Their false reputation depends upon the relief which they frequently give to complicating prolapse, the symptoms of which have been wrongly attributed to anteflexion or anteversion. The same pessaries therefore may be applied as in descent. (See Etiology and Clinical History of Descent.) Intra-uterine stem pessaries designed to straighten the flexed uterus are sometimes effective, and always dangerous.