FORCIBLE AND RAPID DILATATION OF THE CERVIX UTERI, FOR THE RELIEF OF STRICTURE, CHRONIC ENDO-CERVICITIS CONICAL CERVIX, FLEXIONS, STERILITY, Etc. BY JOHN BALL M. D., OF BROOKLYN, N, Y. [From a paper read before the N. Y. S. Med. Sac., June ifh, 1877.] NEWYORK: T. B. SlDEBOTHAM, PRINTER, 28 BeEKMAN STREET. i 8 7 7 • FORCIBLE AND RAPID DILATATION OF THE CERVIX UTERI, FOR THE RELIEF OF STRICTURE, CHRONIC ENDO-CERVICITIS, CONICAL CERVIX, FLEXIONS, STERILITY, Etc. BY JOHN BALL. M. D., OF BROOKLYN, N, Y. \From a paper read before the N. V. S. Med. Soc., June iqth, 1877.] NEWYORK: T. B. SIDEBOTHAM, PRINTER, 28 BEEKMAN STREET, 1877. FORCIBLE AND RAPID DILATATION OF THE CER- VIX UTERI—FOR THE RELIEF OF STRICTURE, CHRONIC ENDO-CERVICITIS—CONICAL CERVIX, FLEXIONS, STERILITY, Etc. JOHN BALL, M. D., of Brooklyn, N. Y. Mr. President, and Fellow-Members of New York State Medical Society : On the 16th of June, 1873, I had the honor to read be- fore the Kings Connty Medical Society a paper on this sub- ject, the practical part of which was published in the fol- lowing Oct. number of the N.Y. Med. Journal, and repub- lished in others—exciting so much interest among gynaec- ologists, and was so favorably received by the profes- sion generally, that I am encouraged to present some of my later experience as a contribution to the proceedings of this Society. And, in so doing, I shall not attempt to go into the histology or symptomatology of these dif- ferent uterine affections—presuming that the members are sufficiently intelligent on the subject—but will con- fine myself to a brief reference to some few of the meth- ods of treatment which have been adopted and practiced for their relief; and close with a short account of a plan which I have used, since the year 1868, with most grati- fying success. And, while I would not disparage the efforts of others, I cannot but claim for this mode of treatment superiority in point of time required, and its efficiency in producing a radical cure. The plan of Dr. Mackintosh, of Edinburgh, which he adopted some 40 years' ago, of producing divulsion of the cervical canal, by the use of bougies, was successful in some of the more simple cases of stricture. The use of tents has, also, been quite successful in relieving many cases of a similar nature. Again, the use of tlie 4 metrotome as adopted by Simpson, and practiced by many others, has its advantages—and has done much for the relief of stricture of the cervix uteri, etc.; yet, experience has confirmed some serious objections to its use, such as the interruption of the natural dilation of the cervix in gestation, caused by the cicatrices in its walls ; and, also, producing a tendency to miscarriage. And, besides, when it does not succeed in relieving the pa- tient, it is apt to leave her in a worse condition than before. Another plan, which I think more reasonable and suc- cessful, is that somewhat recently adopted by Dr. J. Protheroe Smith, of London, which consists in the in- troduction of bougies until a No. 10 can pass without pain, when he uses a dilator every day or two—always desisting when pain is produced. This he continues until his purpose is accomplished, occupying usually several weeks. But he never attempts manipulation until all unnatural sensibility is relieved—a precaution, which, I think, experience has demonstrated to be quite unnecessary. His cases, I believe, are confined to those of simple stricture and narrowing of the cervical canal, for which, barring its tediousness, it may do very well. But, in cases attended with chronic endo-cervicitis, as we often find them, it would require a long time to com- plete the cure ; if cured at all—whereas, by the plan of forcible and rapid dilatation, the worst of these cases, even those of years standing, can, generally, be entirely relieved within a fortnight. In the treatment of these and similar cases, I usually confine myself to the use of the dilator. There are cases, however, where I think it well to use the pessary. The treatment of a conical cervix, which some gynaec- ologists seem to think so formidable, and requiring the heroic remedy of amputation, I find very simple. In- deed, about as simple as the stretching of the finger of a newT glove, which it resembles ; for as you increase the diameter you shorten its length—which is all that is necessary. When the length of the cervix is not very great, and unattended with flexion, I usually succeed 5 by the dilator alone ; but, where the length is extraor- dinary, and especially when attended with flexion, I find it important to use the pessary, in order to prevent any retraction towards its abnormal condition. While I am not disposed to censure any one for adopt- ing the course which he thinks best adapted to the relief of suffering—and which may have afforded relief to many—you will allow me to say, that experience has convinced me, at least, that, for mere elongation of the cervix uteri, there is no necessity whatever for resorting to amputation. And, besides, if done with the galvano cautery there is danger of producing occlusion of the remaining os ; which would aggregate rather than relieve the difficulty. The pre-eminence of the plan of forcible and rapid divulsion of the cervix uteri, together with the use of the pessary, is in the treatment of flexions—for which, hitherto, no adequate remedy had been found. The knife, as used by Dr. Sims and others, has relieved many of the more simple cases of ante-flexion. I have had very good results from it myself. But, when the constriction at the os internum is great, as we often find it the case, it would involve the necessity of carrying the incision farther than we would be justified in doing. The use of the stem pessary, as practiced by Schroe- der and others, has given relief in some cases of both ante and retro-flexions, yet its advocates do not claim for it any permanent benefit except in the most simple cases ; whereas, by rapid divulsion as practiced by my- self and some others, a radical cure of the most aggra- vated cases can be effected in a very short time—gener- ally within a fortnight. It would be too much to claim for it infallibility, yet, allow me to say, that where the operation has had a fair test, in uncomplicated cases, the results have, generally, been complete and satisfac- tory. In one or two cases, where, by some inadvertence, the pessary had become displaced too soon, the results were not so complete as might have been desired. In regard to the feasibility of the operation, I would 6 say, that while we cannot claim for it entire immunity from danger, under some circumstances, yet, I think that experience will demonstrate the fact, that the risks are even less than from the use of tents, the knife, or the stem pessary—while the results, especially in cases of flexions, are so much more satisfactory. Permit me, before closing, to relate a few typical cases, one of a kind, out of a large number that have lately come under my observation. The first is a case of Stricture, with Hyperaemia of the cervix uteri: Mrs. N., aged 26 years ; married several years ; sterile. Prom her early womanhood she had suffered from dys- menorrhoea, and which, at the time of the operation, had become very distressing. On the 15th of Oct., 1876, I operated upon her—car- rying the divulsion to the extent of about an inch, in every direction. Within a fortnight all the unnatural sensibility had disappeared. She had a pleasant conva- lescence, and her menstrual functions, at last accounts, continued in good condition. Case of Chronic Endo-cervicitis attending Retro-ver- sion, with slight Flexion: Mrs. P., aged 28; had one child, 8 or 4 years of age. Not long after the birth of her child, she began to suffer from dysmenorrhoea. Her health failed generally, and she became very much emaciated and weak. On the sth of October, 1876, I operated upon her without the use of the pessary ; as there was so little flexion I did not think it necessary. She suffered but little from the operation. Had a good recovery, and soon regained her flesh with perfect health. Case of Conical cervix uteri: Miss 8., from Md.; aged about 83 years. Had suf- fered from dysmenorrhoea, more or less, from puberty, and which had increased upon her until her health was considerably impaired. In Feb,, 1876, she came to the city to consult me in regard to her condition. Upon ex- amination I found the cervix uteri to be a full half inch 7 or more too long, extending low down in the vagina and quite sensitive to the touch. On the 19th of February I dilated the cervix to the extent of about 7-8 of an inch, stretching it in every direction, which had the effect of‘shortening it to about its normal length. No unpleasant symptom followed the operation, and within a fortnight she was feeling perfectly well. I learn from her since that her general health is very much improved, and that she suffers very little, if any, at her monthly periods. Case of Ante-flexion, complicated with Ovarian disease; I mention this case, not because it possesses any pecu- liar interest in itself, but to show what good results may arise from such an unpromising outlook. Mrs. A., aged 34 years ; married a number of years ; sterile. Had suffered from dysmenorrhoea, more or less, during all her menstrual life, the difficulty increasing with her years. Upon examination I found a well- marked case of ante-flexion with hypersemia of left ovary and ligaments, and very sensitive to the touch. She had been rejected from the Woman’s Hospital, after a month’s stay, as incurable, on account of the ovarian complication. After which she went to the Herman Hospital, where the knife was used ; but, no permanent benefit followed the operation. She had, also, been treated, privately, by tents, without any benefit arising from their use. I must confess that I felt a great reluc- tance to operating in a case that had withstood so much, yet, as she was so very anxious to obtain relief by some means, I consented, and on the first of March, 1876, I performed the operation—and, strange to say, within three weeks afterwards, on making an examination, I found, not only the uterus, but the ovary and ligaments in a healthy condition. I removed the pessary about the fourth day, as I had some fears that, owing to the extreme sensibility of the surrounding parts, it might create some disturbance—which precaution was perhaps unnecessary ; but I wished to be on the safe side. Soon after the operation her health began to improve, and she 8 gained rapidly in flesh. Her dysmenorrhoea was not entirely relieved, but her suffering was very slight com- pared with her former experience. Case of Retro-flexion, attended with Chronic Endo- cervicitis: Miss K., aged 20; health rather delicate, and failing gradually. She had suffered very much from dysmen- orrhoea from her earliest womanhood. She had had a variety of treatment. Had been under the care of one physician continuously, for a year and more, without any permanent benefit. At last, knowing of my success in relieving some cases similar to her own, she concluded to place herself in my hands. Upon examination I found a great amount of flexion, attended with a great deal of sensibility of the parts. On Oct. 17, 1876, I oper- ated upon her. Very little constitutional disturbance followed the operation ; and, within three weeks all the soreness was gone, and the uterus restored to its normal position. Since the operation she has gained consider- ably in flesh ; has excellent health, and she menstruates without pain or inconvenience. After a thorough evacuation of the bowels the day before, my plan of proceedure is to place the patient upon her back with her hips near the edge of the bed, and when she is profoundly under the influence of an anaesthetic, I commence by introducing a three bladed, self-retaining speculum, when I sieze the os with a double hooked tenaculum, and then I first use as large a bougie as the canal will admit, followed by larger ones until a No. 7 is reached, which represents the size of my smallest dilator which I then introduce, and stretch the cervix in every direction to the extent of its capacity, and then, if necessary to carry the operation farther I use the larger ones : after which I introduce the pessary, in cases that require its use, and retain it in position for five to seven days by tapes crossed and secured before and behind by strips of adhesive plaster. I keep the patient upon her back and enjoin perfect quiet while wearing the pessary. THE OPERATION. 9 The following cuts represent the principal instruments used in the operation, and which will require no explanation, except the speculum, which I will describe very briefly: It is self-retaining, and I think, pos- sesses some advantages over ordinary speculums, in giving more room and freedom to the operator, which in some cases is very important, and from the fact that it can be converted very easily into a two-bladed instrument, by removing the third blade, when it can be used for the rectum also. Letter A, represents the screw that holds the third blade C, in any position required; B, the screw that throws it downwards; D D, the side blades.