Fig. 88 shows a useful modification of this by Barnes, known as the Crescent speculum.

The Neugebauer and Crescent specula are useful in making cervical and endometric applications, and are better specula than the Fergusson. 4. The Cusco or BIVALVE SPECULUM is shown at fig. 89. It is composed of two blades jointed on to one another at their bases. The blades are opened to the desired distance by pressure on the thumbpiece and kept open by a screw. It is introduced with its blades right and left and then turned so that they lie anterior and posterior, that with the screw being posterior. It is then pushed onwards, and the blades opened and fixed by the screw.

Care should be taken not to catch any of the perineal hairs in the screw; and, in withdrawing it, not to pinch up the vaginal walls.

The Cusco speculum is self-retaining and useful in cervical and endometric applications.

If the patient be placed in the genuvectoral or semiprone posture, the posterior vaginal wall hooked back with the fingers and the cervix drawn down with a voisella, a useful view can be obtained without the aid of any speculum.

USES AND COMPARATIVE VALUE OF THE VARIOUS SPECULA.

The Sims is undoubtedly the best and most scientific speculum we possess. When properly used and aided by the volsella, it leaves nothing to be desired. For operative cases its use is imperative; and it is the only speculum which does not distort the split cervix. It is objected by some-on insufficient grounds-that it is difficult to manipulate, requires a skilled assistant, and exposes the patient unduly.

The Fergusson is easily passed, involves only slight exposure, and is good in very minor gynecology. It gives only a limited view of the vaginal walls. The student should note that it brings the flaps of a split cervix together and somewhat conceals the lesion.

The Neugebauer, on the other hand, opens up the cervical split, and may do this so effectually as to give the impression that there is none. The Fergusson, Cusco, and Neugebauer are all self-retaining.

CHAPTER XI.

THE UTERINE SOUND.

LITERATURE.

Simpson, Sir J. Y.-Memoir on the Uterine Sound, Selected Obst. Works: A. & C. Black, Edinburgh, 1871. See Munde's Minor Gynecology and Thomas as to Huguier & Lair.

IN considering this important gynecological instrument, we take up1. Its nature :

2. Preliminaries to its use; when not to use it :

3. Method of use; difficult cases:

4. Employment for diagnosis and treatment:

5. Dangers attending its use:

6. Relation to bimanual and rectal examination.

NATURE.

The sound of Sir James Simpson is not only the classical instrument, but, taken all in all, is probably the best. We describe it, therefore, as a type of the instrument, and then consider its modifications.

Fig. 90.

Sir J. Y. Simpson's Sound. The 13 in. notch is not shown. (a.) 2 in. knob.

Simpson's sound is a rod of flexible metal 12 inches long, specially graduated and provided with a suitable handle (fig. 90). It is made of copper, nickel-plated; this is sufficiently pliable to be moulded and yet sufficiently stiff to retain any special shape given to it. Instrument makers often make this sound too unyielding. It should be always pliable enough to be bent with two fingers.

The handle has the shape shown at fig. 91. Note that it is roughened

H

on the same side as that towards which the point of the instrument lies. Consequently, when the sound is in the uterus, we can tell the direction of the point by noting this roughness on the handle.

The graduation is important. 2 inches from the point is a rounded knob this is the length of the fully developed unimpregnated uterine cavity. Other markings are at 3 inches, 4 inches, 5 inches, and so on up to 8 inches. The notch, 1 inches from the point, is of little use and weakens the instrument.

The modifications of this instrument are numerous. The changes are chiefly in its flexibility, lightness, and in the use of another material.

Prof. A. Russell Simpson has modified the instrument by making it shorter, abolishing the 1 inch notch, and squaring the handle (fig. 91): this gives a very handy and useful instrument. Sims, Emmett, and Thomas have each a special sound. Thomas' is made of hard rubber or whalebone, and he claims that it is specially useful in the case of submucous fibroids. Other modifications are by Matthews Duncan, Protheroe Smith, Aveling, Jennison, Hanks, &c.

Fig. 91.

Russell Simpson's Sound.

PRELIMINARIES TO ITS USE.

No instrument should have the preliminaries to its use more carefully considered. The rash and careless use of the sound may do immense mischief to the patient. Note then when not to use it :

(1.) The sound is not to be passed during an ordinary menstrual

period.

(2.) It is not to be passed in an acute inflammatory attack of
uterus, ovaries, pelvic peritoneum, or connective tissue.
(3.) It is not to be passed in cases of cancer of the cervix or body

of the uterus.

(4.) It is not to be passed if the patient has missed a menstrual period. This is a safe rule, but admits of limitation as we shall see afterwards.

Before using it—

(1.) Ascertain that the patient has not missed a period.

(2.) Do the bimanual carefully. If in doubt, use the rectal exam

ination aided by the volsella.

(3.) Place the patient in the left lateral posture.

(4.) Give the sound the curve you find the uterus to have.

METHOD OF USE.

After the preliminaries mentioned above, take the sound in the hand and oil its first 3 inches with carbolic oil 1-20.

Pass the two

Fig. 92.

First stage of passing the Sound.

fingers of the right hand into the vagina and touch the anterior lip of the cervix, i.e., in front of the os. Guide the sound along the vaginal fingers and make the point enter the os uteri (fig. 92). Pass it in for an inch or so, to fix it.

If the uterus be retroverted then carry the handle towards the sym

physis, when the point of the instrument will glide into the uterine cavity until arrested by the fundus (fig. 93). No force is needed. If force seems necessary, the instrument should be withdrawn and a more careful bimanual performed.

Fig. 93.

Second stage of passing the sound when Uterus is retroverted.

If the uterus lie to the front, the procedure is different. Pass the sound as already described until it has entered the cervix for an inch or so (fig. 92.) Note now that the point of the sound looks back, whereas the fundus lies to the front. Clearly we must make the point look to the front. This is done by turning the handle so that its roughened surface looks to the front. To do this we do not twist round the handle on its long axis, but make it sweep round the arc of a wide semi-circle as in