The same remarks are applicable to dysmenorrhea. Holst's researches on the cadaver are not of much importance. In regard to menstruation we are not concerned alone with the quantity of the blood, but also with the rapidity and the nature of the outflow. Further still, at the menstrual period the congestion of the uterine tissue and mucous membrane lead to narrowing of a previously wide orifice.
Not infrequently the results from discission in case of dysmenorrhea and sterility are to be laid to other causes than the mere widening, as, for instance, the loss of blood at the time, the relaxation of the tissues, the necessary applications of astringents and of caustics in the after-treatment. Frequently the stenosis is associated with a long cervix and induration of its tissue; only in the lesser degrees of elongation is hysterostomotomy of utility, in the higher degrees amputation being essential. Induration of the tissues calls especially for discission, seeing that all other measures with dilatation in view are uncertain, and of long duration.
Flexions and versions are frequent indications for discission. In the first instance, aside from the not uncommonly present stenosis, the aim is to make the uterine canal straight. With this end in view we resort to sagittal discission of the anterior lip in case of retroflexion, of the pos terior lip in case of anteflexion, and to lateral discission in case of lateral flexions, and in instances of dysmenorrhea, in particular, we thus often obtain brilliant results, although in marked cases simple discission is of no avail. We do not effect any special alteration in the uterus, but we see a beneficial result on the flexion by the production of a free outlet for the secretion. To incise the uterine wall at the flexion site, the anterior in case of anteflexion, and the posterior in case of retroflexion, certainly assists in straightening the uterus, but this is a very dangerous procedure, owing to the thinning out and generally atrophic condition of the wall of the uterus at this site, and is therefore not to be recommended.
Versions very frequently call for discission, on account of the stenosis the result of the accompanying metritis, and, further, because they directly interfere with the entrance of the spermatozoa owing to the fact that in anteversion the anterior lip of the cervix cuts off the lumen of the vagina, and in retroversion the os lies against the anterior vaginal wall and is hence inaccessible to the spermatozoa which are deposited in the posterior fomix. In the first instance the sagittal discission of the anterior lip, or
better still the removal of a wedge-shaped portion, assists matters, and in the second instance the sagittal discission of the posterior lip. In case of lateroversion we perform discission on the lateral wall of the same side as the version, in order to make the os patent towards the receptaculum seminis. In my experience it has been simply a coincidence when in these instances the lateral and sagittal discission has given better results than the bilateral.
A further indication for discission is hemorrhage in case of fibroids of the uterus.
Baker Brown, Tilt, McClintock, Nelaton, Spiegelberg, Matthews Duncan, West, GI. Braun, and others, perform the operation with more or less good results. The explanation offered for the manner of action is not sufficient. While Baker Brown claims that by section of the sphincter muscle at the internal os the chance is given the uterine muscle to lie close against the tumor—a species of self-tamponade—Spiegelberg sought the effect in the relaxation and retraction of the mucous membrane, and the shrinkage in the blood-vessels. To-day experience teaches us that the operation is in these instances uncertain and gives no lasting result, and that the chances of relief are far greater from cutting the capsule of the fibroma.
Finally, as an indication for discission of the cervix we have the necessity of thorough dilatation of the uterine cavity. Schrtider first incised sufficiently to allow of the easy insertion of the finger into the uterine cavity, in view of the length of time required by tents and the more or less danger consecutive to their use.
.There has been much discussion as to whether dilatation by tents or steel dilators was not preferable to discission. Dilating measures, how ever, which require a long time, are always accompanied by much trau matism, and are more likely to be followed by septic absorption, and, further, generally give no lasting results, almost uniformly so when the stenosis affects the external os and the tissues are indurated.