that, when the middle finger is at the knob, the flat surface of the handle rests on the ball of the little finger, against which it is steadied by the flexed little and ring fingers.

The sound is introduced into the uterus in the ordinary way. The fingers are passed into the vagina as for a vaginal examination, and the sound grasped as in fig. 97. The thumb rests on the symphysis pubis. While the middle finger steadies the sound, the index is in the anterior fornix, and the external hand placed as in the ordinary bimanual.

This method is specially useful (a) when the uterus is flaccid; the sound stiffens it, and enables the external hand to define it: (b) when, from the presence of small fibroids or pelvic deposits, there is doubt as to what is the fundus uteri; the sound, felt by the external hand in the uterus, indicates the fundus.

RELATION OF SOUND TO BIMANUAL AND RECTAL EXAMINATION.

Before Sir James Simpson introduced the use of the sound, gynecological examination was confined to the exploration of the vagina and cervix.

Simpson gave an immense impulse to gynecology, by placing in the hands of gynecologists an instrument which explored the uterine cavity above the cervix and thus enabling them to obtain a perfection of diagnosis before undreamt of; thus gynecological examination was made up of a vaginal examination, and then a passage of the sound, due attention being given to the non-existence of pregnancy. J. Y. Simpson recommended, further, the elevation of the uterus with the sound, and its definition with the upper hand.

The next step in gynecology was the use of the two hands-the bimanual and rectal examinations-which in the last twenty years has developed immensely. Consequently, the use of the sound has become more limited. The teaching in this chapter has been based on a recognition of this fact, inasmuch as the use of the sound is recommended only after the bimanual, rectal, and volsellar examinations have been carefully employed.

CHAPTER XII.

THE SPONGE TENT AND OTHER UTERINE DILATORS.

LITERATURE.

Simpson, J. Y.-op. cit. Sims, J. M.-op. cit. Landau: Ueber Erweiterungsmittel der Gebärmutter Volkmann's Sammlung No. 187. Mundé-op. cit.

HITHERTO We have considered only the means which have placed the vagina and cervix within range of digital examination. In this section we take up the methods by which we get digital examinations of the uterine cavity-methods of the highest practical value, which, like the sound, we owe to the genius of Sir James Simpson.

We therefore consider

I. Means of slowly dilating the Cervical Canal by Sponge Tents,
Tangle Tents, Tupelo Tents;

II. Means of slowly dilating the Cervical Canal by graduated hard
rubber Dilators-Tait's, Hank's;

III. Means of dilating the Cervical Canal by incision and screw Dilators; this last will be described under Sims' operation for pathological anteflexion.

Under each we take up

1. Material or instrument,

2. Purposes for which used,

3. Preliminaries to and method of use,

4. Dangers and contra-indications to use.

DILATATION BY SPONGE, TANGLE, AND TUPELO TENTS.

1. Material. The sponge tent is a cone of good, unbroken, thoroughly dried sponge, impregnated with some antiseptic and then firmly compressed into small transverse bulk, its original length being preserved. When thus prepared and placed under conditions where it can absorb moisture, it swells up and in thus expanding dilates any dilatable structure which may grasp it.

Good sponge tents of various sizes may be had from all chemists.

In order to prevent the antiseptic from volatilizing, the sponge tents are covered with grease. They are provided with a tape at the base to aid their extraction from the cervix after use.

Tents are also made from the ordinary sea tangle (laminaria digitata) (fig. 98) and from tupelo wood (nyssa aquatilis). It is alleged that the

Fig. 98.

Shows on the left a straight and a curved laminaria tent and on the right these tents after expansion. Note how one has been gripped by the os internum (Mundé).

tupelo expands more rapidly than either tangle or sponge. Fig. 99 shows its power in this respect. Tangle tents may be had hollow ; this facilitates the imbibition of moisture but weakens their expanding powers.

2. Purposes for which used. Sponge tents are used as follows:(1.) To restrain hæmorrhage in cases of abortion and at the same time dilate the cervix for further interference ;

(2.) To dilate the cervix and uterine cavity and enable the practitioner to ascertain and remove the cause of pathological uterine hæmorrhage

whether due to endometritis, sarcomata, polypi, or incomplete abortion;

Fig. 99.

Diagram to show relations between size of Tupelo Tent, before and after expansion. The dotted outside line indicates the size of the tent after expansion (Mundé).

(3.) To correct pathological flexions of the uterus, to dilate a stenosed cervix.

Fig. 100.

Expanded Tupelo Tent with constriction at os internum (Mundé).

Tangle and Tupelo tents have the same scope as the sponge tent. These do not, however, expand so well and thoroughly. Their special advantages are due to their smaller size, and the fact that several may be passed into the same cervix. They are specially useful, therefore, in

cases of narrow cervix and flexions. Tupelo tents are highly praised by Landau and Mundé, but are still on trial.

Fig. 101 shows a drawing of the uterus, which contained a polypus-obtained from a patient of Sir James Simpson's, who died from the hæmorrhage it caused. It was this preparation which suggested to him the sponge tent.

3. Preliminaries to and Method of use.-Tents should not be passed during an ordinary menstrual period, although they often require to be used when pathological bleeding is going on. They should always be passed at the patient's own house; and she should be kept strictly in bed during their use, and for some time after. Before their use, the vagina should be thoroughly washed out with warm carbolic lotion (1-40). Schultze, in passing tangle tents for flexions, first ascertains the uterine curve with the sound; if blood follows its use, he postpones the introduction of the tent for forty-eight hours, in the meantime applying pure carbolic acid to the endometrium. Before using the sponge tent it is advisable to remove most of the grease covering it. Sponge tents may be passed in various ways.

(1.) The patient is placed in the genufacial, or better, in the semiprone posture. Sims' speculum is passed, the anterior lip of the cervix laid hold of with a volsella and drawn down. The sponge or tangle tent, held in forceps, can then be passed into the cervix (fig. 102).

(2.) The tent is fixed on the spike of an appropriate instrument and is then passed just as the uterine sound; i.e., with the patient placed