retroverted; an anteflexion less anteflexed; an anteversion less anteverted.

(b) In treatment.-In this the volsella is one of the most useful instruments the gynecologist possesses. Thus it helps greatly in the examination of the aborting uterus; in replacement of the gravid or non-gravid retroverted uterus; in insertion of sponge and tangle tents, or stem pessaries. In operations such as Emmet's for repair of the cervix, Sims' division of the cervix, amputation of vaginal portion of cervix, excision of the uterus through the vagina for cancer, it is indispensable.

Details on its uses in these cases will be given under the special descriptions of the operations; and it will also be shown in the chapter on specula, that by using the volsella the speculum may be dispensed with in certain cases.

5. Contra-indications.-It should not be used in acute peritonitic or cellulitic attacks, in distended Fallopian tubes, in hæmatocele or in advanced cancerous disease. No pain should be caused by its use provided that only the vaginal aspect of the cervix is laid hold of.

Fig. 79.

Sims' Tenaculum.

The amount of traction to be made will vary with the necessities of the case. In many instances only a mere steadying action is requisite ; in others the cervix has to be drawn half-way down the vagina. In special cases the cervix is drawn down to the vaginal orifice or beyond it, as in amputation of the cervix or excision of the uterus. simply steadying the cervix, Sims' tenaculum is of service (fig. 79).

For

CHAPTER X.

VAGINAL SPECULA.

LITERATURE.

Barnes-Op. cit. Goodell-Op. cit. Hart-Structural Anatomy, op. cit. Mundé— Op. cit. Sims, J. Marion-Clinical Notes on Uterine Surgery: Hardwicke & Co., London, 1866. Thomas-Op. cit.

WE have already seen that the segments of the pelvic floor are separable when a woman assumes certain postures; that the sacral segment can be hooked up, and that by this means we get a view of the vaginal boundaries of these segments and of the os uteri. This is the natural method of opening up the pelvic floor; or the natural specular method.

Gynecologists had used various instruments for enabling them to look into the vagina: but all of these proved unsatisfactory until Marion Sims, noting the natural postural dilatation of the vagina, introduced his famous duckbill speculum.

We take up the consideration of four typical specula, viz. :1. The duckbill or Sims speculum,

2. The tubular or Fergusson speculum,

3. The Neugebauer and its modifications,

4. The bivalve of Cusco.

We note under each its nature, the method of employing it, and the theory of its action and uses.

1. The SIMS or DUCKBILL SPECULUM is shewn at figs. 80, 81, and Plate V.

Its nature. Each instrument in reality consists of two specula, which are of different size and connected by a handle; usually however we speak of these specula as the blades of the speculum. The real Sims' speculum is light, has each blade slightly concave on its anterior aspect, and has the blades at right angles to the intermediate handle.

Modifications of Sims' speculum are numerous. Indeed, it seems difficult for gynecologists to resist modifying an instrument, and rare to find them improving it. The most widely known modification is Bozeman's; it is heavier than Sims', has the blades meeting the