THE SURGICAL (BLOODY) DILATATION OF THE CERVIX.
The bloody dilatation of the lower uterine segment consists in the longitudinal opening of the cervix by means of cutting instruments. This operation, formerly, although incorrectly, called hysterotomy, is to day known under the various names of discission of the cervix, hysteros tomatomy or trachelotomy (Peaslee), stomato-plastice (Raster). Accord ing as the lateral walls or the anterior or the posterior wall of the cervix is incised, we speak of lateral or sagittal discission, and according as the incision extends above the internal os or only includes the vaginal portion of the cervix, we speak of internal or external discission. The lateral and sagittal discission may include both lips or one alone, bilateral, uni lateral discission. These types of the operation have been much modi fied, in particular by Fritsch, Kehrer, Raster, Marckwald, Schrader and others.
Discission of the cervix is indicated as well from a diagnostic as from a therapeutic standpoint, and generally from the latter. It is seldom resorted to in connection with other dilating measures, or to make more space for the insertion of anything through the cervical canal, and leas frequently still, in order to allow of digital examination.
This operation was discussed in the last century from an obstetrical standpoint, as a measure for expediting the first stage of labor, but was only introduced into gynecological practice about 1850. In 1843 both Simpson and Jobert resorted independently to discission, and before 1850 it was performed by Kennedy, Minckwitz, Margerie, Barett, Oldham, Malgaigne, Martin and others, but its general acceptance dates from the appearance of Sims's work on uterine surgery, notwithstanding the op position of Tilt, Duncan, Scanzoni and others, who claimed that the method was far more dangerous than other dilating measures The re marks in the above work in regard to the value of discission in the treat ment of sterility and the results obtainable, have led to a wide dissemina tion of mechanical views, so that many gynecologists consider discission the necessary indication for the relief of sterility, and in this respect the book had been of harmful influence on the non-critical reader. Notwith
standing, the publication of this work marks an era in gynecology, since in it are the first attempts to treat the diseases of the uterus on strict surgical principles, and such principles have from this time forth greatly influenced the course of gynecology.
In case we aim purely at opening up the cervix, then this organ may be incised at the point of narrowing, either through the speculum, or under the guidance of the finger. The deeper and the more numerous the incisions, the wider the cervical canal becomes, and we should guard against injury to the parametrium, the peritoneum the vagina. In case we only wish to open up the external os, then any straight or curved scissors will suffice. This measure is resorted to when we desire to gain space for the removal of a myoma or an intrauterine polyp. We cut, then, at that point where the finger detects tension, after having deter mined by means of two fingers in the vagina or one in the rectum, and one in the vagina, the thickness of the segment.
In all other instances the manner of operating will depend on the method selected. As typical of the operation, we may describe bilateral discission of the cervix, where both orifices are incised. With slight modifications this operation may be applied to the .external, the sagittal, and the radiating discission.
Originally Simpson used his well-known, single-bladed hysterotome, with which, under the guidance of the finger, he incised one side of the cervix and then the other, as he withdrew the instrument, the incision extending from above the internal os through the entire length of the organ. This instrument had the disadvantage of having to be used twice, and that the second incision was likely to be less deep than the first, since as the result of the first incision, the tissues were no longer on the stretch.