FIG. 41.-The author's uterine dilator.

dilatation is effected by shoving up
against the pulling down. The pro-
cedure has always seemed to me a bit
ridiculous. The curettes are of Sims'
pattern (Fig. 42). They are all sharp,
and the staff while stiff can be bent

JOHN REYNDER-CO.

NEW YORK.

O~

FIG. 42.-Sims' curettes. Showing the blades only.

3

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to operate in very flexed organs. The
instrument of Recamier has too long
a curetting surface. I have abandoned
the cervical specula through which to
pack the uterus (Fig. 43). The heavy
applicator can be adjusted to the curves
of the organ, and with it I pack more calibres of the in-
thoroughly than is possible with the tra-uterine
speculum. I always use a double cur- gators.

4

FIG. 45.-Four

irri

J. REYNDERS &CO..

R

FIG. 44.-Fritsch-Bozeman double-current irrigating tubes.

rent irrigating tube (Fig. 44). It is improper to inject irrigating fluid into the uterus with a bulb syringe. Such an instrument can not be cleansed, and no provision is made in it for the return of the fluid. I use the Fritsch-Bozeman uterine irrigator.

EXPLORATORY VAGINAL SECTION.

The bar to a thorough inspection of the pelvic cavity through the vagina is the uterus; and a great embarrassment experienced in the procedure is prolapse of the intestines into the vagina. If a posture can be secured which will prevent the latter, and an incision adopted which will remove the uterus out of the way without injuring it, vaginal exploration of the pelvis will supersede the abdominal. The author believes that his procedure secures both the desirable factors essential to

success.

It must be remembered that the distance from the vulva to the cul-de-sac is even less than from the abdomen. Therefore the cavity explored from below is not as deep as when sought from above. The ability to see the pelvic structures through the vagina is then dependent upon the space secured. The space is not so much limited by the vulva as by the condition of the tissues about the cervix. If the vaginal incision posterior to the cervix is one and a half inches from side to side, the elastic tissue will yield under the pressure of the retractors to make the opening at least one and a half inches wide by over two inches antero-posteriorly. But in the rare cases of pronounced sclerosis the elasticity of the vaginal vault may be found so limited that sufficient space cannot be secured through which to make an adequate visual inspection. The operator will then have to depend wholly upon his sense of touch. Still this contingency is not as often met in the vaginal operation as in the abdominal.

137

Operation.--The local and general preparation of the patient will be found on pages 161 to 163. The patient is placed upon the (Fig. 47) table in the lithotomy pos

FIG. 47.-The cul-de-sac is opened. The posterior vaginal wall is held down by the retractor, while with the trowel the uterus is shoved up against the bladder. The space obtained is estimated by comparing the length of the operator's index finger with the distance between the blades of the retractors. In this case it was 24 inches.

ture, with the ischial tuberosities over the edge of the table. The perineum is retracted by a short Jackson speculum, and the uterus is pulled down. The uterus is curetted and swabbed out, but not packed with gauze. The vagina is wiped dry. Upon shoving the cervix upward a fold will be seen to form just opposite the cervico-vaginal junction (Fig. 48). The vagina is incised here, scissors being used for the purpose. The scissors

cut through vaginal mucous membrane only. The incision is commonly an inch long and extends to the lateral borders of the cervix (Figs. 49, 50). There now remains

FIG. 48.-The fold behind the cervix which lies over the cervico-vaginal junction is weil shown. The vagina is to be incised here (from life).

but one layer of tissue to sever,—the peritoneum. The uterus is held firmly down, and the operator pushes his index finger into the cul-de-sac. In doing this he is careful to keep the point of the finger accurately

139

in the middle line and pressed up against the posterior uterine wall. If after pushing the tissues up to the level of the internal os the finger has not entered the peritoneal cavity, the point of the finger is directed backwards

i

FIG. 49.-The vagina is incised, and the point at which the peritoneum is reflected from the uterus is shown as the deepest part of the cut. The peritoneum is to be torn through at this point (from life).

and pushed into the cavity. If the peritoneum is very thick it is caught with toothed forceps and incised with scissors. Commonly serum escapes when the cavity is entered.