Thomas lost a case after the use of a sponge tent from tetanus; in four other cases he witnessed inflammatory affections; Hildebrandt lost a patient from septicaemia, as also Olshausen. Instances of severe or fatal illnesses have been further recorded by Anderson, Blix, Sims, Griinewaldt, Winkel, Kiinecke, Zschiesche, Pernice, Aitken, Scanzoni (after the use of laminaria), and others.
In the days before the introduction of antiseptics, I have often seen metritris and parametritis follow on the use of the sponge tent, and not more seldom after the use of laminaria. The majority of these instances were slight, however, and I have seen death in one case, where the treat ment was directed against sterility, and where a portion of the tent having been left in the uterine cavity, there resulted parametritis, which ended in death at the expiration of a year. Since careful resort to antiseptics, I have never seen other untoward phenomena than pain, and in one in stance such great contraction of the cervix as to necessitate incision of the organ in order to remove the laminaria tent. Schultze, in over 1000 dilatations by means of laminaria, only witnessed five instances of slight parametritis.
The use of tents, in particular the sponge, is especially risky in the presence of great lesion of the mucous membrane, especially after remit wounds, where the conditions for absorption are most favorable. Con trary to the recommendation of many authorities, E. Martin for example, we would forbid incision of the cervix before the insertion of the sponge tent. This is often done and the wonder is that more cases of putrid ab sorption are not recorded.
At the menstrual period dilatation is accomplished most readily and quickly, but at this time there is risk of the occurrence of hasmatocele, as I saw in two instances, and the chance of absorption is greater, owing to the higher degree of congestion of the uterus. In case we can choose our time, it is preferable to dilate a few days after the cessation of men struation, since then the risks are less, and we have time for resort once to an operative procedure before the advent of the next period.
As contra-indications to the use of any tent may be mentioned acute inflammatory affections of the uterus or of its surroundings, collections of blood around the organ or within it (hEematocele, Inematometra), and, of course, pregnancy. In the hands of a skilled observer, as Schultze
has also pointed out, the use of the tent in cases of so-called chronic metritis and endometritis often leads to good results as regards cure. In instances where, notwithstanding the existence of great tenderness of the uterus or its surroundings, we are forced to resort to dilating meas ures, it is self-evident that oar precautionary and antiseptic measures should be stringently increased.
Although the examination after dilatation may give excellent results, this is still often a very difficult matter, and may lead to an erroneous diagnosis. Generally, as we have stated, it is the region just above the internal os which offers obstacles to examination, but the cavity itself may only be touche l with ease when it has been distended by large new growths, and when the parenchyma has become soft and distensible, else the walls of the uterus lying so close it may be difficult to recognize slight anomalies of the mucous membrane, in particular near the orifices of the tubes. In such cases it is of advantage to use a small sharp curette to remove portions of the mucous membrane for examination. It is self evident that after the use of a sponge tent we can draw no deductions as to the consistency of the uterus; still, many changes in consistency are of diagnostic value, and Spiegelberg claimed that lack of dilatability pointed to beginning carcinoma. Further, from the use of the sponge tent the surface of the mucous membrane will be so altered that we are liable to error. Long-continued pressure of the tent may have such an effect on excrescences, and even on fibrous structures, polypi, small myomata, that they become softened, thinned out, or entirely destroyed. On this factor Sims formulated a new therapeutical use of the sponge tent. This tent, of course, affects most markedly only that portion of the mucous mem brane with which it is in contact, and the portion higher up is scarcely altered. • For the sake of completeness we would simply refer here to Emmet's sponge dilator and to the water dilators.