A few minutes after the insertion of a sponge tent, its surface becomes roughened, its diameter greater. The longer it remains the more it dis tends, its fibres penetrating the folds of the cervix and the ducts of the mucous follicles. After the lapse of a few hours, the cervix becomes softer, more succulent, indurations in its tissue melting down and dis appearing, the imbibition of serum extending to the body .of the uterus, and frequently there results from the arterial hypermmia an erection of the uterus similar to what we meet with previous to menstruation. These phenomena are accompanied by a number of subjective disturbances. The distension of the muscular structure of the uterus at the level of the ori fices, awakens contractions which may be of a very painful nature, and occasionally result in premature expulsion of the tent. There is usually present a more or less serous discharge, tinged with, or even consisting of pure blood. As long as the pains are of the nature of contractions, and there is no fever or tenderness, the sponge may be left in the uterus, or we may resort to further dilatation. But if fever sets in, and the thermometer should be used to detect it, or if the pain is constant, or if there is tenderness, then it is safer to remove the tent at once, and desist for a time from attempts at dilatation, unless there is urgent call for examination. We frequently meet a uterus which reacts readily against dilating measures, and yet at the second attempt will bear it very well.
We may counteract the foul discharge, and in a measure the dangers resulting from it, by administering every four to five hours during dilata tion an injection of a solution of permanganate of potass., carbolic, or other agent.
A sponge tent should never be left in situ longer than twelve hours. It must then be removed and replaced by another, provided we have not obtained sufficient dilatation. During its removal, and before the sub stitution of another, a, disinfecting douche should be administered. The second tent must be larger, not only because it must dilate more exten sively, but also because it must be inserted more deeply, since ordinarily it is not the internal os but the lower uterine segment above it—the so called isthmus of the uterus (Spiegelberg)—which is the narrowest part of the entire organ. Sometimes two to three tents and again five to six are needed to secure sufficient dilatation.
The removal of the tent is accomplished either through the speculum or else in the elevated dorsal position, which latter is advantageous for the after-examination, since it permits of the more ready resort to the bi manual. The string through the tent is seized in one hand, and a finger of the other hand is inserted into the cervix between the sponge and the cervical wall, and we endeavor by means of gentle oscillatory movements, even as in the removal of the placenta, to loosen the tent from its fre quently firm connection with the tissue of the cervix. (Sims.) Gener
ally we are thus able, without hemorrhage or injury to the mucous mem brane, to extract the dilating agent, and to penetrate at once into the uterine cavity. In case the sponge or the string tears, then a thin dress ing forceps or a double tenaculum is made to grasp the sponge, and by gentle traction it is removed. Often, especially when the tent has not been left in situ long enough, the internal os or the isthmus of thenterus contracts so speedily after removal, that the finger cannot at all or only with effort be made to pass.
Pediculated and small sub-mucous tumors, as the result of the con tractions induced by the tent, will frequently have been driven down against or into the cervix, so that the examining finger readily reaches them; in case of large tumors, and great thickening of the walls of the uterus, due to inflammatory affections, or to polypoid or sarcomatous degeneration of the mucous membrane, it is impossible to examine the entire uterine cavity, and in case of great depth of the cavity it may be impossible, notwithstanding the degree of dilatation, to reach the fundus. In case the uterus is movable, then by pressure from without, exerted by oneself or an assietant, we may press it down somewhat; and exceptionally the tissues of the uterus are so soft that by considerable pressure the vertical axis of the organ may be greatly lessened. We may then, in case the genital passage is not narrow, and there is not an excess of adi pose, penetrate to the depth of about five and a half inches and reach the fundus.
•The examination of the dilated uterus often necessitates the use of great force, especially in fat patients. In case the, finger can pass the isthmus, however, then through resort to the different combined methods of examination, we are able, seeing that the finger is gloved, so to speak, by the uterus, to bring any part of the uterine wall between the com bined fingers, and thus to recognize not only the site, origin, size, con figuration, movability and consistency of new growths, but also the state of the mucous membrane.
When the examination has been completed, we resort at once to careful disinfection, or, when necessary, to some surgical or therapeutic measure. A certain time is requisite before the uterus will return to the normal. Although the isthmus, the internal os, and later the external, close quickly, they remain for a number of days more patent than they were at the outset, and the succulency of the tissues lasts for twenty-four to thirty-six hours. It is advisable, even when the dilating measures have caused no disturbance, to keep the patients quiet in bed for a day at least, and for a number of days to guard them against exciting causes.