NON-SURGICAL (BLOODLESS) DILATATION.
For the purpose of dilating the cervical canal by expansile substances, Rodericus a Castro, although not with diagnostic intent, used the roots of gentian, aristolochia, bryonia, cyclaminis, etc.; but of the different agents which have been recommended and used, only three are to-day found useful: sponge, laminaria and latterly the tupelo.
Simpson's directions were to prepare the tents from thoroughly cleansed sponges, cut into a conical form, of varying size, and about the length of a finger. The cones were dipped in a solution of gum arabic, and then tightly wrapped with a stout string. As soon as they were thoroughly dried, the twine was unwound, and the surfaces made smooth by sand paper. To guard against the foul smell which the cone assumes from absorption of secretion, they were impregnated with deodorizing sub stances, such as carbolic (Ellis), permanganate of potass (Aveling), etc.; but these agents have been found to render the sponges brittle, so that on removal a piece may be left behind. Latterly, on Bantock's recom mendation, the cones are prepared with wax and oil, and the search is ever towards making them thoroughly antiseptic. Before use, the cone should be rubbed over with iodoform, and in the Vienna general hospital, the tents are thoroughly iodoformized during their manufacture, and I am in the habit of using only sponge tents prepared in this way.
In order to guard against the abrasion of the tissues by the tent, Ward, Massari, Ingfort, Emmet, and others, have advocated inserting it in a rubber bag or in a gold-beater's skin. Through the large end of the cone a string is passed to facilitate removal. This string, however, is a fruitful source of infection, and I am, therefore, accustomed to dispense with it, or else to substitute a piece of fine silver wire.
The tent is inserted through a valvular speculum with the patient in the lateral or the dorsal position. But both the vagina and the uterus must first be carefully cleansed, and I am accustomed to insert an iodo form pencil into the uterus. The cervix is to be drawn down and steadied by a tenaculum hooked in one or another lip, according to the position of the uterus, and the tent is passed as far as possible into and beyond the cervical canal. The insertion may be accomplished by means of any curved dressing-forceps. As a general thing, the mistake is made in the choice of too large a size, the result being that the tent does not pass through the internal os, and only the lower part of the cervix is distended.
The entire manipulation is thus complicated, because, when we endeavor to insert the next tent, we find that the internal os is still more contracted as the result of the reflex irritation of the first. It is, therefore, the rule to choose at the outset a long and thin tent which will pass at once through both orifices of the cervix. The tent should, further, not be inserted too deeply, but its base, with the transfixing string, should pro ject below the external os. Otherwise the lips of the cervix may close over the tent, and its removal will be a very difficult matter, indeed it may be necessary to incise the external os. For the insertion of the tent the tubular speculum is not useful, since it presses the lips of the cervix together. The Cusco speculum, or the multi-valve may be used.
When the external os is not too narrow, or displaced overmuch an teriorly or posteriorly, then the tent may be readily inserted, guided sim ply along the finger with the patient in the lateral or the dorsal position. The tent is grasped in the forceps or impinged on a conductor, is pushed into the cervical canal, held there by the tip of the finger, and the conduc tor is withdrawn. We next seek to direct the tent in the axis of the canal, and it is pushed deeply in, the hand on the abdomen making counter pressure. Seeing that the majority of tents are perforated throughout their entire length, we must be careful lest the conductor slip through the tent, and thus injure the uterus. The thinner the sponge tent and the greater its absorptive powers, the more quickly must we insert it, since otherwise the apex becomes soft and swollen, and we will be unable to insert it through the narrow os. It is further useful when inserting the tent without the speculum, to steady and draw down the uterus by a tenaculum fixed in the cervix. When the tent has been pushed into the uterus and the conductor has been removed, the finger should remain in the vagina against it until we are satisfied it will not slip out. Such a method is preferable to inserting a tampon. In case we aim at complete dilatation then the patient should remain in bed, but this is unnecessary when we only wish slighter dilatation, and the tent will be left only a few hours.