A NEW INSTRUMENT FOR DILATING THE CERVIX UTERI, AND RESTORING THE INVERTED UTERUS.

BY HENRY O. MARCY, M.D.,

MASSACHUSETTS.

THE instrument which I have the honor to present to you today is the result of two years' experimenting, and may be considered sufficiently complete to merit your criticism.

It was first designed to aid in returning an inverted uterus. One considerably long band of moderately thin, pure rubber was split at each end, nearly to its middle; this part was placed over the inverted fundus, and each of the four ends was threaded through four firm metallic rings, which had been securely stitched into the cervical portion of the uterus. These ends were drawn through a fenestrated wooden tube, the distal portion of which ended in a cup-shaped depression, to receive and support the fundus.

Elastic tension was thus secured, which could be graduated as desired.

It was thought that the same force could be equally well used to produce the dilatation of the cervix uteri.

The instrument presented was modified, as shown in Plate I, after using for a period the elastic rubber bands, carried through two or four rings, securely stitched into the cervix uteri, and then as in the case of inversion of the uterus-through a fenestrated tube, terminating in a cone-shaped point, which could be carried at pleasure, with such force as was deemed advisable, into the cervical canal.

Having ascertained by experiment that rings thus fixed would not cut out under tension, one of the first things to be desired was to know the amount of force used, and this ascertained, to keep it at work under intelligent control. For this purpose, it seemed not only necessary to know the progress made, by frequent examination, but also the exact pressure used.

This is accomplished by a spiral spring, and the force applied is marked upon a scale graduated in pounds; by turning the end of the instrument, as in the ordinary écraseur, this can be increased or lessened at will.

It is graduated to register a pressure of fifteen pounds, much more, as I believe, than will be required in actual use. A constant elastic force thus obtained in the use of the spring, the rubber bands were no longer needed, and dispensing with these, enabled us to do away also with the rings, and thus the operation is simplified to the use of two, four, or more threads, single or double, as may be preferred, to be carried through the cervical tissue, and tied over the projecting ends of the slide upon the barrel of the instrument covering the spring, and the force adjusted as deemed desirable.

I have used this instrument under very varying conditions of the cervix. The threads have never cut the tissue, and it is surprising that so little pain is experienced during dilatation. Inflammatory action has never supervened; but I believe it a wise precaution to wash the vagina carefully with a one to twenty solution of carbolic acid at operation, and after to use a light carbolized vaginal tampon.

As will be seen, there are a number of different sizes, even to one that is one and a half inches in diameter, as also a cupshaped end to be used in cases of inversion of the uterus.

In the multiplicity of surgical inventions of the present day, it may be held that no one has a right to present a new instrument, unless it can be asserted that it will accomplish the object to be attained better than anything hitherto offered. In certain ways, we claim this much for our new instrument. A wellknown and most serious objection to every uterine dilator now in use, from the tent of sponge or other material to the Barnes (or Molesworth) dilator is, that it is and must be an irritant to the cavity of the uterus.

Many fatal accidents have occurred from this cause alone. Where the least resistance is offered, there the material used expands soonest, and the uterine cavity is usually filled completely, before the dilatation of the constricting fibres of the uterine neck commences. When we remember the delicate mucous membrane with which the uterine cavity is lined, the utricular glands which in immense numbers open into it, and the vascularity of its body, we can only wonder more serious

accidents do not happen from the use of the ordinary intrauterine tents. All such danger is avoided by the application of elastic dilatation as used with this instrument.

The uterine cavity is undisturbed when care is exercised, and the force is expended only upon that portion of the uterus designed to be manipulated, and, as is well known, the cervical portion of the uterus may be subjected to surgical treatment with comparatively little danger. The needle to be used should be without cutting edges, and should be passed directly through the firm tissue of the cervix.

When one size of the dilator has served its purpose, it is readily detached and replaced by a larger, until the desired dilatation has been accomplished. A moment's reflection will teach that which at first surprised me, viz., that the cervical portion is elongated and thinned by tension from above downward, in ratio corresponding to its dilatation. This produces a more radical change in its condition than that resulting from dilatation with tents, and for certain conditions, e. g, a sharp anteflexion, with stenosis, gives a manifest advantage.. I am under obligation to Messrs. Codman & Shurtleff, of Boston, for painstaking care in perfecting the instrument as here presented, and allow me its commendation to you for trial and criticism.