Only exceptionally can extreme dilatation and the after-examination be resorted to without anesthesia. The entire procedure is generally very painful, and, besides, narcosis makes easier the bimannal palpation. It is advisable, then to anesthetize, since we cannot know at the outset whether the examination is going to prove easy or difficult.
The many disadvantages accompanying the use of the sponge tents, such as their high price, the injury to the mucous membrane consecutive to their use, the difficulty in inserting them, the readiness with which the secretions decompose and the resulting dangers, have caused us to seek for a new absorbent dilating agent. In 1862 Sloan introduced the lam inaria tent into gynecology, and it was quickly adopted by C. Braun, Simpson, Kiibler, Ilegar and Kaltenbach, Schultze, Ahlfeld, Martin, Fehling and others. Still to-day it has•not entirely displaced the sponge tent. The sea-tangle or laminaria tents are of varying thickness, of moderate hardness, solid or perforated. (Greenhalgh.) Their dilata bility varies according to whether they are freshly made or not, but they are much slower in action than the sponge, although with greater in tensity. The perforated dilate more quickly than the solid, although not to as great a degree, and the dilatation is much more in the transverse than in the vertical axis. Either a large tent may be inserted or a num ber of thin ones bound together in a bundle by a rubber band.
When a laminaria tent is placed in water it becomes softer and in creases in size, so that we may bend it to any desired curve, but it also loses some of its alkali by which foul discharge is counteracted. When the tent dilates, it loses its cylindrical slitipe, and becomes angular. It may again be dried, however, smoothed off and again used, of course only if it has been placed in water, and not after having been used for purpose of dilatation. Laminaria can be made aseptic, as Schultze first pointed out. I am in the habit of placing the tent in a 5 per cent. hot solution of carbolic, and in a few minutes after it has softened a trifle I bend it to the curve which the use of the sound in the given case teaches me it must have. If it be next placed in cold carbolic, it will retain the
curve given to it. The possibility of giving the tent any desired curve is an advantage which the laminaria possesses over the sponge tent.
Before inserting the tent, the vagina, and when possible the uterine cavity also, should be thoroughly disinfected, the direction and width of the uterine canal determined by the sound, and the contra-indications, which we will shortly mention, to the use of any tent sought for. For the insertion, even as in case of the sponge, and more readily without the speculum, since the laminaria distends slowly, a dressing-forceps, or a so-called laminaria•carrier (G. Braun, G. Mann), or a simple stylet may be used. For the purpose of ready removal, a string is passed through the lower extremity of the tent. Since the laminaria distends very slowly, and is smooth and slippery, it readily falls out of the cervix. It is, therefore, advisable to use tents which have been previously dilated and then dried, and to hold the tent in place by the finger, until we are certain that it will remain in situ, for a tampon is an uncertain means of fixation. The laminaria may remain longer than the sponge, although it should be changed twice in the twenty-four hours.
The root of the gentian, recommended by Winckel, in 1867, has no advantages over the laminaria. It is chiefly advocated on account of its cheapness. In case it is deemed advisable to impregnate tents with medicaments as is urged by Winckel, Kristeller, Nott, Thomas and others, then the gentian tent is a good one to use.
Since 1883, the tupelo tent, recommended by Sussdorff, Landau, Mundt, Elischer and others, has been used more than sponge and lamin aria. The tupelo is the root of the nyssa aguatica. It is light when dry, having a specific gravity of 0.16, and it readily absorbs a large amount of water. If dried again after having been distended, it will not resume its original volume. It is readily compressible, by mechanical means, and it is then cut into various lengths and thicknesses, to a cylindrical shape, and its surface is carefully smoothed.