Part 26 (1/2)

DILATATION OF THE CERVIX

=Indications.= Dilatation may be performed:--

(i) As a means of diagnosis.

(ii) As a preliminary to the use of the curette or to removal of intra-uterine growths.

(iii) As a method of cure for spasmodic dysmenorrha.

_Contra-indications_ to the rapid method of dilatation of the cervix are very few: a recent attack of peri- or parametritis would certainly be one, but when the effects of a salpingitis have quieted down there seems very little reason against its use. Where carcinoma of the body of the uterus is known to exist, and in old age, it should only be resorted to with the greatest caution, if at all.

=Methods=:--

(_a_) Rapid dilatation by means of graduated metal bougies.

(_b_) Gradual dilatation by means of tents.

(_c_) Combined gradual and rapid dilatation.

In a large majority of cases rapid dilatation is the operation selected.

Its one disadvantage is that when a great degree of dilatation is necessary, or when the operation is performed too rapidly, the cervix is liable to be torn, an event which is especially liable to occur when the tissues of the cervix are rigid. These lacerations are longitudinal in direction and in the neighbourhood of the internal os uteri. They sometimes result in haemorrhage, which can easily be controlled by plugging the cervical ca.n.a.l. Unless strict asepsis be maintained, these lacerations of course form a channel for infection of the pelvic cellular tissue.

It is obvious that dilatation will be easier to perform, and laceration less liable to occur, if the cervix is in a softened condition--a physiological state which is always present during pregnancy and labour.

Efforts should therefore be directed, when possible, to ensure a soft state of the cervix before performing rapid dilatation.

Immediately after the cessation of a period, the cervix is soft and somewhat patent, and advantage may be taken of this fact. The introduction of a glycerine tampon two hours beforehand produces a certain amount of softening. But nothing ensures so much softening as the introduction of a tent into the cervix about twelve hours previous to the rapid dilatation.

It is therefore recommended in all cases, where possible, to perform dilatation by this latter means, viz. a combination of the gradual and rapid methods.

=Rapid dilatation= by means of graduated metal bougies. Hegar's original dilators (Fig. 56) were solid vulcanite bougies, graduated from 1 to 26, the numbers corresponding to the diameter of the bougie in millimetres.

Each was 5-1/4 inches in length, the handle measuring 1-1/2 inches and the bougie the remainder. The bougie formed a slight curve and tapered off to a blunt point.

These bougies were rather short and too sharply pointed, and they could not be sterilized by boiling. To overcome these disadvantages, uterine dilators are now made about the same length as a male catheter, with a sharper curve than Hegar's original one, and a blunter point; the larger sizes are of hollow metal for the sake of lightness. There are many varieties of dilator, each with minor differences as to length, curve, handle, and shape of the point.

[Ill.u.s.tration: FIG. 61. DILATATION OF THE CERVIX. The patient is in the lithotomy position. Auvard's speculum has been inserted, a volsella attached to the anterior cervical lip and a bougie pa.s.sed. (_From a photograph._)

_d._ Right hand inserting bougie.

_s._ Speculum.

_v._ Volsella.

The author uses metal bougies. These have somewhat the shape of the ordinary uterine sound, are thirty-five in number, and graduated in size. Like the sound, the upper portion is bent at an angle of about 160 with the solid handle, a circular shallow depression indicating the 2-1/2 inch mark in the smaller numbers; in the larger this is not considered necessary.

=Operation.= Instruments: an Auvard's self-retaining weighted flus.h.i.+ng speculum; a volsella; a Bozemann's tube or Budin's catheter; a uterine sound; and a set of dilators.

The patient is anaesthetized and placed in the lithotomy position with the legs supported by a crutch. Strict asepsis must be observed; the l.a.b.i.a must be shorn of long hairs; this is followed by cleansing of the v.a.g.i.n.a and a v.a.g.i.n.al douche, and finally the v.u.l.v.a is washed with antiseptic lotion. The speculum is pa.s.sed and held by an a.s.sistant, but if self-retaining, as in Fig. 61, the a.s.sistant is not necessary: a sound is then inserted to ascertain the length and direction of the uterine cavity. If anteflexion be present, the anterior lip of the cervix should be seized with the volsella and fixed by slight traction.

If retroversion or retroflexion be present, then the posterior lip should be fixed. Traction by the volsella tends to straighten out the uterine ca.n.a.l, and thus makes the pa.s.sage of the bougies easier. The bougies are now pa.s.sed in order, commencing with the size which will pa.s.s easily. The bougie is pa.s.sed by means of the right hand into the cervical ca.n.a.l until the internal os uteri is reached; resistance will now be felt. Firm and continuous pressure in the proper direction must be made, and in a short time the resistance gives way, and the bougie will pa.s.s into the uterine cavity. An interst.i.tial fibroid produces a tortuous channel and much difficulty will often be experienced in pa.s.sing a bougie in such a case. It will be found on attempting to withdraw the instrument that it is grasped by the internal os uteri; in the course of one to five minutes this spasm will relax, and only then should the bougie be withdrawn. The next in size should be ready and introduced in the same manner, and the succeeding ones are inserted until the required dilatation is produced. Sterilized vaseline or glycerine of perchloride of mercury may be smeared over the point of the dilator to facilitate its pa.s.sage. Each succeeding bougie should increase in size by not more than 1 mm.: occasionally a case is met with where this seems too large a difference, and it is really better to have them made with a 1/2 mm. difference. As a preliminary to the use of the curette, dilatation up to No. 12 Hegar is necessary. The index-finger can be introduced into the uterine cavity after the pa.s.sage of No. 19 or 20 Hegar, while full dilatation up to No. 26 is required for any operation with scissors or the ecraseur on intra-uterine growths.

It is evident that the degree of dilatation for exploratory purposes will be governed by the diameter of the operator's finger, or rather of its second joint, and this varies very much in different people. By means of the finger a uterus can be explored in which the cavity is much longer than the operator's finger, if the viscus be forced down on to the finger by the pressure of the other hand above the symphysis pubis.

The operator must not be satisfied until he has felt the whole extent of the uterine wall, especially the two cornua, which are favourite seats of disease. After completion of the operation it is well to give an antiseptic intra-uterine douche by means of a Bozemann's tube. The uterus and cervix should be lightly packed with sterile ribbon gauze, 1 inch wide; the free end is left projecting through the os uteri. The packing should be removed in twenty-four hours, and an antiseptic douche given.