In our endeavor to make all our manipulations as free front danger and as aseptic as possible, gynecologists have latterly been returning to the mechanical means of dilatation formerly in vogue. With all our care and precautions in the selection of material for tents the secretions may decompose, and even from the slight lesions of the mucous membrane there is risk of absorption. Further still, dilatation by means of tents requires considerable time, and often it is not possible to expend this on account of the reaction of the uterus against protracted irritation.
The rapid dilatation in favor to-day has its outcome from Schatz's metranoicter. Two intrauterine stems connected together by a metal crescent, are inserted closed into the uterus by means of a forceps con structed for this purpose. When the forceps is removed the stems separ ate and dilate the cervix according to the tensile strength they possess. Thicker stems are inserted until complete dilatation is obtained. By means of the metranoicter we may certainly work aseptically, since we may irrigate while the instrument is in situ, but the instrument is not likely to become popular since it causes great pain, and, further, is too complicated, dear, and difficult to cleanse.
For the purpose of rapid forcible dilatation of the cervix, instruments have been devised by Osiander, Carus, Aveling, Busch, Mende, Leblanc, Hunter, Nott, Atlee, Priestley, Ellinger, Miller, Wilson, Schultze, Ball, and others. Of this number I will describe only a few.
The Ellinger dilator, where the blades separate parallel one to another, is only useful in instances where we aim simply at slight dilata tion, seeing that the blades are slender; for cases, hence, where we wish to dilate before inserting an intrauterine stem, or before making appli cations, etc. The advantage resulting from the parallel separation of the blades is lost by the fact that the blades feather. The great objection to the instrument, however, is its complexity, which renders it difficult to cleanse except by heat. To remedy this objection I have modified the instrument somewhat, by making the cross-bars as well as the lock separ able, whereby I am able to take it entirely apart in order to cleanse it. • (Fig. 49.) A second instrument, incomparably stouter, and more especially use ful for purposes of rapid diagnostic dilatation, is that of Schultze. By means of this instrument, as also by another devised by Schultze which works transversely, we are able to obtain a great degree of dilatation, although not without in general superficial lesions of the mucous mem brane. As preparatory to this forcible dilatation we may resoPt to tents, once or twice, and use hot injections, measures which considerably soften the tissues. We may often begin to dilate with Ellinger's instrument and then complete the act with Schultze's, and in a very short time obtain sufficient dilatation for the application of therapeutic measures.
[Of instruments more at the disposal of the American practitioner we would mention the Palmer dilator and the Goodell-Ellinger. The Palmer dilator will dilate to an outside width of one and a quarter inches, which is sufficient for ordinary purposes of exploration. We have had a smaller Palmer constructed which will answer very well for slight dilatation in office practice and also as preparatory to the larger size. The blades of
the Palmer will not feather, and we are thus assured of equable dilata tion, and further the screw, by means of which the blades are separated, is a decided advantage, in that we may dilate slowly without tiring the hands. The Goodell modification of the Ellinger dilator (two sizes) is also an excellent instrument, somewhat stouter and bulkier than the Palmer, and dilating to an outside width of one and one-half inches. It has the advantage with the Palmer over the Sims (or the modified Wylie•Sims) of possessing a screw attachment for the separation of the blades, whereby the process may be gradual, by slowly causing the mus cular fibres of the cervix to yield to the applied pressure, rather than forcible.—ED.
Slower dilatation by means of bougies, sounds, etc., will generally suffice for the treatment of stenosis of the cervical canal. We may, how ever, through the use of instruments of greater calibre obtain sufficient dilatation in a short time to allow of examination of the uterine cavity with the finger, and this method is the one which I resort to almost entirely, often combined with brief use of a tent. The simplest and most easily cleansed instruments are the hard rubber dilators of Hegar, which come in sizes from .07 inches to one inch in diameter. On account of the ease with which the smaller sizes break, I use at the outset lead or copper sounds from .07 to .3 of an inch, and then resort to the hard rubber.
The dilator is dipped into a 5 per cent, carbolic or a .05 solution of sublimate before use, and the vagina is carefully disinfected, as also, when possible, the uterine cavity, which, in case of very narrow os, can only be done after the use of one or two numbers. The uterus is steadied with a tenaculum and drawn downward, and then with the patient in the dorsal or the lateral position, and through a short univalve speculum, one after another of the dilators are inserted. Anesthesia is certainly of assistance, and is only exceptionally not to be used, seeing that the ulti mate examination will be painful, and the patients are in a nervous and an irritable state after the dilating measures. Under the irrigation the dilators are inserted until the finger can be readily introduced. In gen eral, an instrument three-quarters of an inch in diameter will suffice, and the operation, which should be done slowly, lasts from a half to three quarters of an hour. In case we are dealing with rigid tissues, as in a nullipara with long cervix, then it is well to insert as a preparatory measure one to two tents, which will cause such softening of the muscu lar fibres as will render the examination far easier. The use of a tent after dilatation I cannot consider advisable, in the first place, because there are present lesions of the mucous membrane, and secondly because it is discouraging to the patient to supplement one operation by another.
After dilatation and examination, the genital canal is again cleansed, and when no therapeutical measure has been resorted to, an iodoform pencil is inserted into the uterus and the patient put to bed day or two. At the expiration of this period the canal has again closed, although for some time it remains more patent than it was originally.