Braxton Hicks, John

English

Hochschulschriftenserver - Universität Frankfurt am Main

ON  SEhLANGLE TENT. BY  J. BIZAXTOX  IILCICH,  M.D.  8.11.8.  li'.B.C.P. pJ~ysicin?~-Acco~tc7~e21?',  m~zd  Lcelz~?+o?~  o?i. flZ'ithv@?,y cct  Cr'2qf's Ilosj~ilnZ,  ~tc. OB all tlie mnterials iisctl for dilt~tiiig  tlie cervix utcri tlicire nilo iione so cleaiily, eMiciei~.i;,  aiicl  convcliiei~t  aa tliose inacle froin i91e La.minn~iu  c7igitr1.l.n.  Altli0~1g11  110~  1:wgely  oinployecl by innliy, t,Eiey  nie not so w6ll  kriown  ne  tlicy  dcscrvc to bc ; snd tliei~e- fore allusioii to tl~e  sit'bjec.l; riiay  iint be  ,zI.togctlier x~seless,  iio~ sonie practicd liiiits iinnoccy)tnl)le  tts soilie reaclers. This  material onii  be ~iia.do  ixito  -1;ciits of  va~io~zs  fornis  ar-icl sizes, biit  :is  the  driecl  stciri of  tlie  nlgn usnnlly einlYioyccl does not exceeci  half  aiz  iricli  cIit~iiicl;cr,~  teiits  requirecl  of'  n laqor size iriust  be iiiade  by  faste~iiiig  togetlicr  a sifieicnt nuinbe~. They may be  ~oizpecl  ili  tl~ree,  five,  seven,  &C.  Btit  perl~nps it will be fo~~ild  inost; coiiveiiieiit fo'or  tlie very 1aii;i:ge size to coin- bine  potips  of  tliree iii  one lallge bundle ; tliey  may be tiecl togetlier  by twiile al; tl~e  base, btit  nt tlleir  apcx it will be best ,  to omploy a  sinall olnstic  baiid.  Tliose  caii bo  obtained  ready maile iip. Some 81-0  rnacle in  two Iialves peggcd together.  Sonie ai3e  mada tubiilar  to  perinit;  of  tlle iiit;i.ocluction of  a stillet, wliicll, pass- iilg two iilches beyoiicl  tlie eiicl  of  a catlieter, forms an easy coii- trivance foi~  reachiiig  tlie os witlioitt  tlie  speciilum,  a~id  also to permit the secretioi-is to flow tli~ough  it.  Tlie smallest sort, from & to  &  iiicl1 in cliai~ieter,  aro  usccl  for  dilating t11e  rigicl  or. contracteci  OS  ancl cervix, eitl~er  doiie, oi. preparatory f;o  the usc?. of  the hysterotome.  The tubtilai. form cannof;  be rnade below a, As oUicr lnrgci. vnriotios  of  nlgm will  licronftor probnlly bo foiiild  oqually iisefiil vvitli  tl~c  Lnvni?~u?.iu  digilirln, it is ilosirablc tl~r~t;  inv~~tigtttions  be  innrlu in tllis direation. ,-,erLain  size, as it is founcl iinl~ossible  to drill a hole tlirougll them if  too  attenuated. I llave  found  that they disteiid  to  aboiit  three  times  tllei~ diaineter,  ancl  tllat  ili  aii ordinnry stake  of  1;he secre- tions  they  resch  tlieis  full clisteiitioii in about  fiReen h~urs  ;  B of  coiirse  some  variatiou.  will  be  find iii  this  respeci;, t esl?ecidly  betweeli  tlie  differeiit  sizes,  for  the  lwger  tliey are,  tbe langer  the  time  occupiecl for tliein to becorno wet iii their  interior,  and  thereforo,  ,nenerdly  spmlciilg  tlio  lwge bundles procluce  their effect quiclcer tlls~il  if ~rincle  01 one picce of  an eqiial  diameter  to tI1e  combiiied.  These two poiizts  are important to bear in mind, becaiise wl~ere  we 1.inve to clilate t,l~.e oervix  to a consicle~able  size, aizd we  recpire to :follow in suc- cession, it is best to iiltrociuce tlie nexb sizcd teilt  ns sooii as tlie previous one hsls attaiilecl il;s f1111  clilat¿1Cioii. TO  lewc ii; iii bcyond that time not only delays tlie oper:~ti.ou  ~nselessly,  bnt ncirls  i~ziicli ? to  t;lie  ohnnces oE literine  irritati.011.  WB  1.n~ist  tlierclgre liave fit haud a series of  tliree for gciieral puq~ose& POT  iasta~ice,  wlieii vre ~ish  to dilate tlie cervix in order  Z;o  pass tlia fiiigcr iii ensily into  the  cavity,  supposiiig  we  begiii  witli  orie  of  4- iilcli diameter ;  the next  size sliould be iiesrly 2:-  iacli, niicl  tlie last (if  auother Be  required)  slioiild  bo iieailly 1  inch  cliaructer :  ns tllis  would  expand  to  nenrly  tlirec  iuches  nt  its  fiillest,  it wozild  not Be  requisite  to  allow ii to reiriaiii  in-ruliless  in  n case  of  pregnanc,y or imperfecii iniscnrriage, wlieorc  wo 'wuiit tlio fullest expansicm-so  long as to il;s coinplcte expaiision, sny for  2 ten hours.  Where sliglit dilatatioli oii1.y is recliii,reLL theii onc is sufficient, and it  should Be  rernoved iii  ttvelity  oor  tweiity-foi'oixr hours nt tke longest.  Por dilatiilg further,  we IT~ZLY  group tlie smaller biindles in auy numbers ws iilre, bizt;  it will selclorn bo requirecl to go beyoncl m  incli cliameter for tI1e last.  oiie.  If we wish  the tents to be more rapid, tlien it is best to soalc tliem i~i cold  water a short time bdore iiitroclizction, The purposes to whiclz they oan be al~plicd  for obsfeti'ic  pur- poses are niimerous.  Tliey can be employecl to dilatc tl~e  smallest OS and cervix uteri, either alone or in preparabioii foor  the 1iystei.o-  \  tome ; they can for this purpose be niacle as sma1ln.s requirecl,  111 case  of a traumatic closure of tlle OS uteri, I liave eil~ployeil oomplete relief.  In closiires of  t11e  vrigiila  fi.0111  injnry, also wliere  tlze  openillg is reduced  to a  pin-hole,  tliey nzay be employed  to clilate up the stricture, prel)ailatory to  some rnore radical  operation,  or  iii  some  cases  they  mny  be  employed entirely.  Tlie  effect  of-tlie litter plan, liowever  well  it  may succeed  it  ' tlie first, is liable  to pass  off, and tlie contractioii to resume its sway.  I I-IILVC  Eouncl  tliat  tlie bistoury liglitly clrawn over the coiltra,ctiori, iii  ni~ilierons  places,  attencled  by  mucli rnore  ~;ntisfactory  results  iil.tiinntely.  After  operation for opeii- ing either vagina or  OS  uteri, tliase telits Inay 73e  ei~iployed  from time to time to preveiit  tlie  closiire  recurriiig.  They inay bo employed  to clila1;e  klie  cervix to a,  size  s~~'I?Acient  to perinit  us to  explore  filze  iiiterior  of  cervix or the bocly of  tlze utcrus, iii Gases  wliere  polypus  is  suslsected,  or  wliere  tlie  reniriants  of 8x1 iinperfcct  ~~bortion  is sixpposed  to  exist.  Pop  tlie  mine piirl,ose  they aTe  of  greai: yali~e  'to pennit us to clingnosticate betweeii  polypus  aiicl  fibroicl  tumour  of  tlie  iiteriis,  wliere  tlie l~~emorrl~nge  is so great as  to recluire interfereiice. In cases  of  flexioii  of  u.l;erus tlicy will  assist  to strnigliten out tlie  caiza,l  of  tlie cervix, arid for R  time relieve  t11e  p~ltient; of tlle dysrnenorrla whicli frepeiitly accompailies i.t. Agaiii,  iiz  onses  of  clysmoizorrlicrta  ancl  sterility  i.n  mnrried wonien  fro-in  coiztractioii  of  cervix,  tliey  cm be  1  great ndvantage  ~isecl,  becaiise it  is  olear  if  tlie  sterility be  owing to tlie  occlusion  of  the  cervix,  tlzen  its expailsion  slioulcl  be attencied by imlliecliate relief ; otllerwise WC: ~iiay  coilcl~lde  tliat other  caiises exist wliich  give rise  to these stites, and  if &£her this dilatatioi~  tlie  patient  coiiceive,  then  a  perlllanent  cure results.  In the single  woinan,  however,  tlie  effects  are  less permanent, and iii cases of  severe obstructioii will be frequeutly the only ineans of  giving nilything lilre perinailent relief. In sonle  cases,  as  in  malignant disease of  cervix wliere  the resistance  is  consiclerable, I liave  employed tliis  substance to dilate, in orcler  to  deliver  prc~naturely. These  cases  Iiowever are rare wliere mucli  resistance exists,  arid in general it will be better  to eml~loy  R  softer  iziaterial,  as sponge  tolltJ or  elastic dilatiiig bag, bccause tliey aie Iess  likely to scratch and  &Ade by tlzeir extreinities tlmn tlie more rigid seatangle tents. They  can  be  introdizoed  into  tlle  cervix  uteri  in various TlTays. PiratJ  they mny be introdricecl by a loilg pair of  forceps.  Tlle beiug placed oii her  left sicle, the Sore-finger of  the left band, or still better two  fingers if possible, are to be passed  to the 0s  The tent, held  by the forceps,  is carrieil along tlie finger to tllo OS,  iuto whicli it is introcluced.  The hnildle of  tlle  4 forceps shot~ld  be then broilght weil against the l?eriu~uin,  so 3s F $0 tlirow tlie ten.t into the axis of  the xiteriis (in cases of normal ancl very gently pressed forwarcl ;  after iL  110s  passecl iii. neai;ly its wliole lengtl.i, tlie 10~orccps  should be tletnched, aiid  tlle fore-finger presses  gently slgainst the erd  or tlie teiit  to keep it im situ.  In order to retaiii it tliere, it; is well to pass a plq  of sporige with  halle  tied rvuud it so ~zs  ucayly Z;o  iill tlic vngiila. It  is -pell to see tlie iiretlirais not prcssed 011,  oi. scteritioii of  urine rniglit  ensiie,  causing  trouble  aiid  darni.  111  iriiiltil2nru: tliore is no  trouble in ernl>loyillg this plail, but ixi somo, l>ai*ticiilai.ly ili  virgins, tlie~e  is much  djfliculty in inbrotliiciiig klie  heilt  in 7 coiisequence  of  tlle  rigicliby m1d  dsstwing iip cjli  tlic licriiiziiin. Besicles,  unless  the  serrations  of  1;lie  f(  )rcttlmarc cnreliilly rounded off  at t110  edges, tlle vulvn a.iic1 vngirin rnny be scrnl;cl~ocl, not only causing pain, but adding Lo  the clillic~ilty  of  iiil,rodric- tion in conseqiience of  the moveinents of  thc ljnticilt. Anotlier,  ancl  in  my  experiencc  a  1)ctt;cr plau,  iii  cnses where the extremely snlall tcnts are not requircrl, js  tci  eiiiploy an elastic  catheter with a stillet.  A yo~tion  ol .I;lie  eilcl  of  tlie  - catlleter not quite so  long  as  tlie  tenC  slioulcl lia  cut of'l'.  This will ieave the stillet protruclirig.  011  tliis tlic tiibulnr tent sliorild  ? bo passed, care  being  taken  to  see  tlie sbillet  does  iiot  exteiid beyond tlie end of  the terit.  The striilg \vliic\li is attncliecl to fic lower  end  of  tlle tent being  ca~riecl  down  by the sirlc  of  1;Zie catlietei, is  held by tlle  smne  liaild.  Tlie arrailge~neiit  is tlieu introc~~~cec~  as  an ordii~ary  uterine sor~nd  : and wlieii tlie teilt is propesly  within the  cesvix,  tlie  stillet; is  witliclra~vn, tliereby leaving the tent in tl~e  corvix.  Tlie fiiiger wliicli is iii tlie vagiila shoulcl  be  placed  on tlie lower  encl  oi t1i.e  teiit  to  prcveiit it sliding  ont and  the  spolige ixitrocluced  ns  iisual.  A vcry con- venient little instrument based on tl~is  psinciple lias been mncle by Messrs. Weiss. C Theie  is another  mode  which  wili  be  convenieiit  in  some V  cases,  namely,  to pass  a  speciiliim.  IIaving  iiitroclncccl  tlie tent iiito the cervix as fnr. as possible by a forceps, the speeulom can  be witliclrawn  carefiilly.  A finger is tl-ieii passed   LI^ to tlie teilt, aiicl  gentle  pressure  being  niacle tlle  tent slides in.  Tliis plan is goocl in cases wliere retro- or ante-fiexioil exists, biit theii of coiirse it will be iiecessary wlleil pressjng the tent in with tlie finger to mi,ry its clirectioii, ei.tlier fortvarcl or backward according to the axis  of  tlze  body  of  uterus.  111  t11ese  cases  the tent is iiltimately  placecl  in  tho traiisverse  diameter  of  tlie  vngina. In  cnses wl-iere tlie inner cervix will not perrriit the tent to pass, I have inanaged to clo  so slowly, by lodging tlie' lower eiid against the  folcl iii tlie posterior wnll o.f  tlie vagiila, aiid tlzeii pliqging tliat canal as usiial.  Tlie little irritatioii proclucecl by this 118s caused tlie  levator  aizi  to nct, so tl-iat a  gentle  pressiire  is exertecl for some  time n.g,ziusf; the iiiiler  OS,  wliicli. has  iiltimately  yi.elcled. For  the largex groups of  tents, it will. be fo~'o-~ii~cl.  that tl;h foicepa will introdiice tlieiii most reaclily ;  for in  lnost OE i;he cases wliere we wish to iise lasge tents the  vagiiza is so well relaxecl, dacqlty is rare. It is very ir~lportant  in orclcr to efective dilatatioiz  tl-iat t11e teilt sl-iould pass tlie  i~iiier  OS,  in all cnses wliere i;he  cavity  of the uterus  is to be  exl~lorecl. Teiits  of  all lriiicls  may kil iii tliis particolai; for two reasoils : olle becanse tlioy may not Iiave beeil iiitrodiiced so far ;  aud aiiotliei; because tlley slils oiit.  This is particulnrly tlle  case witll tlie seatniigle teilts, bnt as tlzey can be niacle snialler tllaii aily other kincls tbere is ao  reasoii why, if olle will not; pass, a smaller slioulcl not be tried.  Bnt it must be also remninberecl that the  C~LISC  ,of i~ial[)ility  to pass  a  teilt may be  from a flexioii of  tlze  orgaii ;  this point  of  coLirse  should be fifirst; macle out before we conll-nence to pass the teilt. One inenils  of  'preveiitiiig  tliese  teiits  from  slipping oiit;,  ,zt least  after  tliey  begin  to swell,  is  a  plan  acloptecl  by  sonie ~nalcers  of  tying the string round the lower end, so tliat it cann'ot expancl so niiicli sis  t11e  iippei. : and this remiilcls me of  a fault iii many, narnely, the shortness of  the string attacl-ied to kie  lower eiid, aild  the imperfect securifiy of  tlie knot : so  that it is diß6- c~dt  oii tlie formei. accoiiilt to withdraw it, nnd  ou the latter tlle cause  of  niiicl~  tronble slnd  sonletimes  pain  ~vheli  we wisli  to reinove it. Before tlie introduction  of  these,  as  of  coul'se witli all tents, it i~;  isimportant  that tlie bowels be tvell  opeii the day previous, anCl  the bladder  evacuatecl imrnediately before.  Otlierwise tlie &stmbance caused by tlie  action of  iilie bowcls is siificient to cause expanaion of  the tent ;  witli regard to tlxe urine, its aassage of  necessity be  requisite twice at least clwiilg tlle &,mity- foiV  h0ui.s the teut is  clilating ; but  as ib is advi~able  tliat the patient  should not rise iip, she should be di~eckecl  to pass uiae without rising : or still better,  if tlic catlieter ca.11  be einl?luyed, tllat it should be used. Upon your visit  at tlie  end  of  twenty or tweiity-four lionus the sporige  plug is to be removecl  first, aiid  tlien tmlie  tsnt, nncl the  vagina  syringed  wit11  warin  water,  to  whicli  a  litt1  oi' Coady's solution should  be  adcleci.  By this means aiiy absorp- tion  of  the  unpleasant  discliasge  (whicli  is  alinost  always present) throngh  any abrasio11 is preveiltecl.  Tliis is cspoci,zlly useful mlzere a series  of  tents 1im-e to be iiil;rodu.cecl.  It  is not a bacl  plan to sot~k  the sporige plugs iii  a lotioil ol pernianga- nate  of  potass  before  introcluction.  Some  spongo  tents  nre made  enclosing mtiseptics,  so  tlmC  wlieu  tliey expand by thc meltiiig of  the  wax this material  is  seh  fTee.  Ilie sairle plaii might Be  adopi-ed in the ti~bulm  seaweed tenks, but tlle q~iantity set free would not bc so muoh. Bitt tlie teilt itsclf>  indepcilcleiit of the  plug,  does  not  produce miicll  iinpleasniit  odoui;  wliile IAe sponge tents do so. After  the process  of  clilating tlie  cervix by tlie  teilt, I con- sider  it  important,  indeed  I  lnay  say  iinperative,  tliat  t11e patient  shoiild  keep  quiet.  Iii  hospital  practice  I  always enjoin a week's rest, aiid  this plan  I  adopt in private, iiiiless a %.  couch  can be  substitutecl  after a  few  dnys for  the becl.  The vagina is washed  gently out  witli warm water  twice a day, to prevent  accumulation of  tlie discharges, aild  irritation resulting from them. T00 much care  camot be taken after the einploymeiit of  Llie tent,  especially if  done  rapidly  ancl  to a  considerczblo  exten.1;. The irritation  in  and  around tlic  izterua  cloes  not  si~bsicle  fos some  days : I should  say a weel:  or more, ancl  if  excitemeiit of an3'  sort arises, especially by exercise, this is apt to iiluyuaso anti l~ecome  a .matter  of  serious import.  I havc  sec11  a  Gase  encl ffit@ll~,  where  there  had  been  dilatatioil  n  ~~reek  pyevio~~s  ; mental  shoclr  sncldeiily  ligliting  up  tlze  infiaminatioil  aiid extelzdiilg it to the peritoileurn.  I would tllorefore tient clilata- tion of  the uterus  as  aii  operation  of  mucli  inore  iiniportaizce tliaiz it is by some pra~t~itioi~ers  ;  wlzo,  liaving intioclucecl the teilt at their own liouse, liave sent the patjeiits hoine, wifl-i directions to  remove it in  SO  Inan7 houis.  In olle  snch case  tlie string broke awny and tlie patient could not remove tlie teilt.  Severe cellulitis  aud  metritis followed,  wliich  laid  her  up for  many moiltl-is. 13~1t  witli tlle  care above  eiijoined, this uizl~lezlsant result; is obviated  to a g~eat  extent.  Probahly  in the sliglit,  clilatc~tion procluced  by the use  of  tlie tent  for  a  few hoixrs,  tlle rislc' in this  respect is perlia11s coilsiderably less, aiicl  pexl~aps  it is less wheii softer materials are iisecl tliaii tlie seatailgle teilt ;  but svhere f~ee  exl~msioii  of  the cervix  Iias  beeil  prodiicecl,  thc rislr  of snbseqiient trouble is reaclily seen if  c~re  be 11ot'talcoii, a1~1  this ~isk  is inuch iizcreased proportionetely to  tlie  time ocoiipied  iii tentiilg.  I would say that tl~e  13ati.ciit sliould  iiever, if  at ,a11 avoidable,  bs unclor  tlle  contiuiioirs  actioi~  of  tbese tents for niore  tl~ail  two  and  a half  days,  at  outside  t11.ree.  For tlzis rcasoiz  tlie  tents should follow olle  another as cpiclcly 8s  COU- sisteut with eiliciency. Diiriiig  tlie presence  of  tlie  tcut  in  the  cervix,  it  js  not uilieq~ieatly  fouiicl  tlzat  klie  iiterixs  becomes  irritable,  and. exl~ulsive  paiiis  occur.  To  preveiit  tl-iis,  as  wcll  as  tlie  cou- sequent  extriision  of  tlze  tent,  it  is  well  to  give  an  opiate, espccially  shoiild  the  paiizs  appear.  This  will  also  lrill  the blaclder  aizd  rectiiin,  aild  thereby  preveut  their  iiiflilence  ex- tending to the uterus. In conclusion, I may poini out tlie special advztnta,ges of  teilts rnnde of  seaweed. Ist, They can bemade of  aily size, particiilnrly iniich smaller ,  ,  tllaii sponge teilts. Sd. Tliey liave  mora  disteiiding power.  Tlie rigidity  of  the inner  OS uteri  is  sornetinles so  great  that eveii  tliese teiits a,re clistinctly marlcecl by it; buk tlie  sponge tcilts not at all iiiifre- qumtly ai.e  nnecyiial  to procluce aiiy marJrecl  iinpression on tlie constriction.  .  ,. NO.  XIV.  EI 3d. They clo  liot  retaiii  the ~~cretioils  SO  as  to procltlce  so ~~~ch  offeiisiveness, consequently there is less rislr  of  Irreit a  t'  ioil * locally or gene~ally. 4th. By their greatei. iligidity they can br, rilore reaclily applied, especially in a tortiions cand. TIley have, however, soine clisiclvailtages :- Tlieir  rigidity ala1res tliem noi;  so suitable in cnses wliere  tl~e irterus is reaclily bleeding, or very tender ;  nor iri cnscs whero tlie' OS  is  somewhat  clilated by  a  polypns  or growtll distencli1ig it. JIere  a  sponge tent is  best  ~inless  tlie  OS  aiicl  cervix are very rigid. Their great cclistensive foree rnalres thern less aceaphble w1iei.o tl-ie iiterus is very irritable. They shoulcl be  in al1 cases  so macle  that no slin1-13 edge Ise notice~ble. In tlie  tiibl~lar  tents  this  is a  point liable to Ise ovei.loolrec1. Ailcl for  the clilatatiosl of  the OS  uteri in a  natural state ~OT puyposes  of  inductioil  oi! pron~ature  labour tliese tents are not by aiiy nieails  so  suitable  as tl.ii3  spoilpe teiits, or as tlle Iildin- rubber 13~~~s. 3VitI1 these exceptions, in clennliness, certai.slty OE  nctiosl, ease of  introcluction, ancl  rninuteness, tliey aro cei.I;~~inly  not eq~~alled by nny otller inaterial at present in use. 

On seatangle tent

Abstract

Similar works

Full text

Available Versions

Hochschulschriftenserver - Universität Frankfurt am Main