By the excision of segments of varying thicknesses and depths, accord ing as the knife is held more or less obliquely, or is inserted near or at a distance from the edges of the cervix, we obtain a more or less patulous os.
After the lapse of five to seven days, if we have operated antiseptically and placed our sutures carefully, we obtain union by first intention, and we may remove our silk or silver sutures. This operatiOn, granted the necessary dexterity on the part of the operator, leads to the best results and with the least risks. Of 350 operations of the kind SchrOder has not had a death, and neither Marckwald, Kfister, nor I have had any complication. In performing the operation we must be careful not to make the first transverse incision too near the mucous membrane, or else it may readily be perforated, and we must further take care lest in pass ing the sutures we cause rolling upwards of the cervical mucous mem brane. The operation is most likely to be interfered with by hemorrhage, the result of careless suture. In case the uterus is movable and the vagina is wide the operation may be readily and easily performed, but it is difficult in case of adherent uterus or narrow non-distensible vagina. In the latter instances the passage of the sutures is in particular trouble some, especially at the sides, and we need a curved needle-holder or even needles on a handle The operations which we have so far described aim at enlarging the cervical canal although not to such an extent as to be passable for the finger. Deep incision of the cervix, as performed in particular by Schro der, and which he prefers above all other dilating measures, is the diagnostic discission par excellence. The method is, however, as Martin points out, not free from danger, in the hands particularly of inexperi enced operators, and therefore it has not become popularized except in the practice of pronounced specialists. We are able to-day by means of other measures—as for instance, the curette —to dispense, in general, with digital exploration, although there are still cases where it is necessary to pass the finger and in addition instruments through the cervical canal in order to recognize and remove intrauterine polypi, myomata, sarcomata, remnants of placenta, etc.
Schroder's operation should be performed under recognized antiseptic rules, with the patient in the dorsal position and anesthetized. When necessary, ligature of the uterine arteries must constitute the first step. The uterus is drawn well downward by a tenaculum forceps and well to one side, we then usually feel the arterial pulsation to one side, but if we do not we insert our needle close to the reflexion of the vagina from the cervix; we should use a strong, not very long, sharply curved needle and pass it around the artery from in front backwards. The more tissue we include the stronger must be the ligature. The process is to be re peated on the opposite side. We next incise the cervix with knife and scissors, or, better, with the former alone, from the internal os outwards. The incisions are deepened until the finger can be passed. After the examination, or the operation has been concluded, the two portions of the cervix are to be re-united. The sutures are passed so that the first lies at the internal os, its point of exit and of entrance being in the vaginal fornix. The remaining sutures are more readily passed, only we must be careful to remain on the border of the cervical mucous membrane to forestall after-stenosis. The sutures of one side are inserted as far as the external os, and then the other side is similarly treated. If the sutures have been carefully passed there is no bleeding, but otherwise superficial sutures will be needed. The after-treatment is similar to that after the other operations. Union is ordinarily per primam. There is greater risk, however, of wound infection and of hemorrhage than after other methods of operating.