In a similar way the unilateral and sagittal discissions are performed. In case of the sagittal discission we must be careful not to insert the tenaculum in the centre of the os, else it will be in the way of the incision. After the completion of the incisions the field of operation is carefully cleansed, and we assure ourselves by means of the finger or the sound of the completeness of the discission. We next proceed to check the orrhage. Sims was in the habit of tamponing the cervical canal with cotton dipped in chloride of iron; Simpson passed a brush wet in liquor ferri; Martin passed a waxed sponge tent; Kehrer places an iron tampon in the vagina and only injects the styptic fluid into the cervix in case of hemorrhage; C. Braun gives a vaginal douche of a solution of sesqui chloride of iron; Olshausen recommends the immediate cauterization of the edges of the wound with the actual cautery; lIegar and Kaltenbach, as also Scanzoni, wash off the cervix with chlorine water, and depend on cold-water injections for checking the hemorrhage.
Whenever possible I dispense with the use of astringents, as also of solutions of iron. In general the careful tamponade with iodoform gauze, or, better still, with iodoform-tannin gauze, suffices. In case of greater loss of blood, styptic cotton should be used. I use for this purpose cotton dipped in a neutral solution of liquor ferri, thoroughly dried before use, and inserted by means of a tampon-carrier (Fig. 65). This consists of a cylindrical silver blade, slightly flattened anteriorly, the upper end of which is forked. This blade carries a slide. The blade is armed with the cotton, is inserted into the cervical canal, and there slipped off by the slide. Below this cervical tampon, I apply two to three layers of iodoform gauze,•which is preferable to glycerine or carbolic tampons in that it may remain in Situ for a number of days.
[The Sims slide applicator answers a similar purpose. The string attached to the cervical tampon should be of a different color from that of the vaginal tampons, so that in removal the former may be readily extracted last Ordinarily this cervical tampon dipped in the compound tincture of iodine will amply check the existing oozing and guard against the danger of secondary hemorrhage.—ED.].
While hemorrhage is being checked, special care should be taken that the tenaculum do not slip, since it would otherwise be quite a difficult matter to fix the anterior lip again amidst the discharge of blood. If after the thorough tamponade there is still bloody oozing, the cotton must at once be removed and a fresh supply inserted. The hemorrhage is rarely so profuse that we are obliged to resort to more energetic measures, such as the cautery or the suture.
The patient is then to be carried to her bed—on no account should she be allowed to walk—and for twenty-four hours absolute quietude should be enforced. It is exceptional that the rectum or the bladder
require artificial aid. In case the iodoform tampon has been used, it may be left for two to three days, unless there be profuse secretion, fever, etc. On the removal of the tampon the vagina should be gently douched with a lukewarm solution.
The risk now is of the occurrence of secondary stenosis from union of the wound edges. To forestall this we may insert cacao butter supposi tories, stems of hard rubber or of glass; some prefer the sound or the metal dilator. We believe that all these procedures should be desisted from, and that it is better to risk the necessity of a second discission, than by irritation of the wound to cause a possible metritis or parametritia.
Among the risks from discission, we may mention: 1. Injury to the neighboring organs, the parametrium, peritoneum, the ureters, all of which may be prevented by taking the precaution not to cut too deeply. 2. Hemorrhage, which is often very profuse, in particular after the sagittal discission. The use of iron will almost always check this, if we are care ful during the operation to cause a reliable assistant to steady the cervix. Secondary hemorrhage will, in general, only occur when the tampons become displaced through restlessness of the patient, or great abdominal effort. 3. Inflammations of the uterus, parametrium, and peritoneum, processes which it is evident from what has gone before are very excep tional. Affections of this nature generally result from uncleanliness, the after-use of a sponge tent, irritation of the cut surfaces from, for instance, the insertion of the finger, of the sound, stems, vaginal injections, resort to divulsion after incision. A predisposition to such inflammatory pro cesses exists in the presence of old adhesions, oophoritis, salpingitis, or near the menstrual period. 4. Abnormal adhesion of the newly-formed os, or of the cervix. If after discission the wounded surfaces are left to themselves, then the edges fall together and after union there remains only a linear cicatrix. But where after discission an iron plug is inserted, the edges tend to spread out, and the after-contraction leads to consider able narrowness of the os, more so, indeed, than existed previous to the operation. For this reason it may become necessary to repeat the dis cission. Further still, when the incisions are not exactly opposed, on union one cervical lip may be larger than the other, and the external os has a crescentic shape which may be covered over by a little valve-like projection from a cervical lip. In case, again, we incise the internal os too deeply, then, as Sims has pointed out, the longitudinal muscular fibres are stronger than the circular and the lips roll outward with a re sulting ectropi um.