THE DILATATION OF THE GENITAL TRACT.
The vaginal touch and the speculum require a certain degree of dilatability of the vagina and of its introitus, and the use of the sound necessitates permeability of the uterine orifices. Atresia and the like of the introitus, and of the vagina, as well as the treatment, will receive ample consideration under the subject of the special affections of these parts, and we content ourselves here with the statement that often for the purposes of careful diagnosis we must subject our patient to preparatory dilatation of the vagina and of its inlet. Aside from abnor malities in these parts, we meet with obstacles to examination, due to a short, non-distensible vagina. We obtain assistance in these cases by means of the persistent tamponade of the vagina, or by means of the colpeurynter, as Hegar advises, or by the use of a hard rubber or glass tube (like that of Ulrich, or Sims, devised for dilatation preparatory to the operation for urinary fistulae), or else by the insertion of Bozeman's oval or cylindrical vaginal dilators. By means of such methods the vagina is distended, its walls become softened, and cicatricial bands may even be caused to disappear. The tampons or the dilators are removed at the end of twelve to twenty-four hours, and the examination resorted to at once, bearing in mind the displacements of the pelvic organs and the changes in consistency caused by the distending process. (Heger.) For the proper examination of the uterine cavity the sound frequently is not sufficient, and it is generally impossible to push the finger in. We may often explore the lower part of the cervical canal, especially at the menstrual period and a few days after, but the internal os is generally patent for the finger only in cases where it has been dilated by the pas sage of tumors, or other contents of the uterine cavity. Ordinarily it is necessary to resort to dilatation of the orifices of the uterus, and of the lower segment of the organ, before we can examine digitally.
In 1844 Simpson introduced compressed sponge tents for purposes of dilatation, and this method has been universally used, although of late years the use of the curette without precedent dilatation has narrowed considerably the sphere of the tent.
The most common indication for dilatation of the uterine cavity is the existence of new growths in the uterus, or symptoms suggestive of their presence. The conjoined examination, and that by the sound, often yield negative results, and when we thus detect a tumor, its connection with the uterus and its quality are often in doubt. Ordinarily, from the sub jective symptoms, hemorrhages, watery discharges, pain, together with the evidence of enlargement of the uterus obtained by the bimanual and the sound, and the patency of the external and the internal orifices, there is suggested the presence of a foreign body, a fibroma, polyp, remnants of secundines, an adenoma, sarcoma, or the rarer carcinoma. Frequently examination by the sound gives results which call for dilatation, as where the instrument meets with some obstacle, feels tumors or roughness of the mucous membrane, and the dilatation leads to an examination whereby we differentiate between new growths, inflammatory processes of the endometrium, such as circumscribed swelling, polypoid or fungous vegetations, etc.
The uterus, however, is not dilated only, in order to permit digital ex ploration, but also, and much more frequently, in case of narrow orifice or stenosis of the cervix, whether congenital or else due to inflammatory processes or to flexion, in order to allow of the introduction of instru merits, such as the endoscope or the curette, to allow again the applica tion of medicaments or the injection of fluids into the uterus, and lastly in case of amenorrhea, dysmenorrhea, or sterility. Schultze further advocates dilatation before attempting reposition of the retroflexed uterus.
Dilatation of the uterus, hence, may be for purposes of diagnosis or of treatment. In the first instance it must be sufficient to allow the easy passage of the finger, in the latter it need not be so extensive. Dilata tion may be obtained in a number of ways, non-surgical (bloodless), and surgical (bloody). In the first category are ranged the tents, bougies and dilators, in the second discission of the cervix.