It is not possible from a comparison of the risks following on bloodless dilatation and on discission to draw a conclusion in favor of the one or the other, and since the introduction of antiseptics discission has become practically an operation free from risk, although if we neglect antiseptic rules we may meet with very bad results. I have heard during the past few years of cases of death from sepsis after the use of a complicated and a possibly unclean uterotome, and I have myself had a fatal result after discission notwithstanding the use of stringent antiseptic precautions. Still, the risks from discission are much magnified by the opponents of the operation. Even in pre-antiseptic times but few unfortunate results could be collected, and from the statistics of Beigel, Tanner and Ballard, Sims, Emmet, Greenhalgh, Ilegar and Kaltenbach, Martin, C. Braun, G. Braun, Kehrer, and myself, it turns out that in more than 2000 opera tions there were only four deaths, and in twenty-two instances hemor rhage or inflammatory affections, the outcome of which was cure.
Altogether we are in a position to affirm that discission of the external os, performed with the proper precautions, may be ranked qmong the least dangerous operations, while that of the internal os is not to be ranked in the same category. As far as the external os is concerned discission is a more certain means of cure than dilatation. As for the internal os the results from discission are not much better than after dilatation. There are many stenoses, above all those due to thickening, swelling of the mucous membrane, which are best treated by tents or in some other way, as by the curette; and further, in case of congenital stenosis with in sufficient development of the uterus and absence of menstruation, the tents act also as emmenagogues.
There are but few absolute contra-indications to discission, but seeing that the operation is performed for the relief of something which is not dangerous to life, these contra-indications must be religiously borne in mind. All recent and chronic inflammatory processes in the uterus, its adnexa, the pelvic peritoneum and pelvic cellular tissue; great lack of development or atrophy of the uterus owing to the risk of injury to the parametrium; pregnancy, or the puerperal state; the presence of tumors or ulcers in the uterus or its surroundings, the secretion from which might infect the incision; the immediate use of a sponge tent; the pres ence of menstruation or its near approach—such are the factors to be guarded against. In the two cases of severiparametritis which I observed, the discission was performed a few days before the onset of the menses.
For the performance of bilateral discission, which may be taken as the type, we need at least one assistant, a duck-bill speculum, 4 depressor, a tenaculum or tenaculum forceps, a long-handled knife, an instrument for tamponing, and tampons. Anesthesia is seldom requisite, since the operation is rarely painful.
The patient is placed in the left lateral or in the elevated dorsal posi tion, and the cervix is exposed in the usual way. A tenaculum is inserted into the anterior lip of the cervix and the uterus is drawn slightly down wards. With the sound we again examine the cervix in regard to the degree of stenosis, and we cleanse carefully the field of operation by means of cotton dipped in a 5 per cent. solution of carbolic. Whenever the size of the cervical canal will permit, the uterine cavity is to be washed out, or if this is not possible I at least cleanse it with the cotton applicator and then insert an iodoform pencil. While an assistant holds the speculum, the tenaculum forceps is held in one hand, and one blade of Sims's scissors, which are curved on the fiat, is inserted into the cervix until the vaginal blade has reached the bottom of the vaginal fornix. The operator, of course, should be ambidextrous. The walls of the cervix are thus incised, first to one side and then to the other, below and above, if the patient is in the left lateral position. To make the incisions properly the blades of the scissors should be about 1 inches long, strong, and not feathering. Since during the cutting process the blades slip a trifle and we thus do not cut through all the tissue, Kuchenmeister has had a small hook affixed to one blade. A good scissors, because it can be bent at an angle, is Heywood Smith's. In case we desire to incise the internal os, the knife is inserted a trifle above it and cuts down, if possi ble in one stroke, to the end of the scissor incision. The incision with the knife is likewise made first to the left and then to the right.
The knife alone answer] quite well for the performance of the opera tion. I always use a simple, straight, small-bladed knife, which may pass even where there is marked stenosis of the cervical canal. (Fig. 63). We must only be careful to make the incisions exactly opposite, so that the anterior and the posterior lip may be opposite one another. In case we use, as does G. Braun, the lance-knife of Kuchenmeister, then it is passed deeply enough for the blunt extremity to be forced through the internal os.