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 passed. (From a photograph.)
d. Right hand inserting bougie.
s. Speculum.
v. Volsella.
Operation. Instruments: an Auvard’s self-retaining weighted flushing speculum; a volsella; a Bozemann’s tube or Budin’s catheter; a uterine sound; and a set of dilators.
The patient is anæsthetized and placed in the lithotomy position with the legs supported by a crutch. Strict asepsis must be observed; the labia must be shorn of long hairs; this is followed by cleansing of the vagina and a vaginal douche, and finally the vulva is washed with antiseptic lotion. The speculum is passed and held by an assistant, but if self-retaining, as in Fig. 61, the assistant 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 canal, and thus makes the passage of the bougies easier. The bougies are now passed in order, commencing with the size which will pass easily. The bougie is passed by means of the right hand into the cervical canal 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 pass into the uterine cavity. An interstitial fibroid produces a tortuous channel and much difficulty will often be experienced in passing 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the internal os uteri; in the course of one to five minutes this spasm will relax, and only then should the bougie be withdrawn.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 passage. 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 ½ 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 passage of No. 19 or 20 Hegar, while full dilatation up to No. 26 is required for any operation with scissors or the écraseur 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.
Difficulties and dangers. The difficulty due to non-dilatability is overcome by means of the preliminary use of a tent. The complication produced by a fibroid, altering the direction of the uterine canal, has been mentioned. Extreme anteflexion or retroflexion gives trouble during the passage of the earlier numbers, but as dilatation is effected this disappears.
The dangers are:—
1. Laceration of the cervix.