Even in case of the most favorable results, it may be noted that the intra-uterine stem acts as an irritant on the uterus, and this alone may be considered the special cause of untoward sequelse.
The generally recognized contra-indications are: Every inflammatory affection of the uterus and its adnexa (Schroder excepts very old rem nants of inflammatory trouble), all affections of the genitals which inter fere with the movability of the uterus, such as peritoneal adhesions, cica trices and exudations in the pelvic cellular tissue, tumors of the uterus and of its adnexa, tumors of the vagina, etc. Diseases of the mucous membrane of the uterus and the vagina should first be controlled, in cluding hemorrhage, aside from those due to pure flexion. Winkel very justly states as a further contra-indication " abnormal sensibility of the uterus, and a general lack of tone in the patient." Lastly we must men tion great relaxation of the uterine tissue, the puerperal state, and natur ally the suspicion of pregnancy.
Before the introduction of a stem the depth of the uterine cavity and the width of its orifices must be determined by the sound in order to estimate the dimensions of the stem and of its cup. The sound also gives us information in regard to the sensibility of the uterus, and for this purpose the instrument should be left a few moments in the cavity. Preparatory treatment or modification of the sensibility by means of the sound is, however, generally unnecessary; indeed it is far preferable to resort to the stem at once for this purpose. Where the orifices are too narrow precedent dilatation of the cervix may be required, and this is obtainable by tents (Elischer), or by discission. That the stem should only be inserted after healing of the wound is, of course, apparent.
For reposition of the retroflexed uterus, the sound is used, and thereby the flexion is lessened, and the insertion of the stem rendered easier; fre quently, however, the straightened uterus must be still placed in its nor mal position by means of the bimanual palpation.
Schroder and others use the intrauterine stem at the outset for reposi tion of the organs.
In extreme degrees of flexion, especially where the cervix is markedly displaced backwards, and where the vagina is narrow, it is often very diffi cult to insert the stem. The simple stem may be introduced, the patient.
occupying the dorsal or lateral decubitus, by the hand, or else it is im pinged on a conductor or on the point of a blunt sound. The latter is the readiest means, although we must guard against the stem being too firmly fixed on the sound. After thorough disinfection of the vagina and of the uterus, under the guidance of the finger, the stem is inserted into the cervical canal and generally it passes without difficulty as far as the internal os. In order to overcome the resistance at this point, in case of anteflexion the handle of the conductor, or if this is not used the cup of the stem, is pushed backward, so that the axis of the instrument corresponds to that of the uterus, and then, generally under slight • pressure on the cup, the apex of the stem passes the internal os. In case of retroflexion these steps are, of course, reversed. A second method of inserting the stem through the internal os consists in pushing the uterus into its normal position by the finger in the vagina, in anteflexion, for instance, by raising up the organ, for thus the curvature of the organ is lessened and the stem readily enters the uterine cavity.
It should never be forgotten that the stem, particularly when carried on the point of the conductor, should be introduced with exactly the same precautions as hold for the sound alone. The uterus should in no wise be injured, and, therefore, the insertion should not be accompanied by hemorrhage.
Hildebrandt, Winckel and others, have advocated inserting the stem on the sound, but this, although often possible, cannot be considered especially advantageous. Without question the intra-uterine stem is best inserted through a duck-bill speculum, the cervix being seized by a tenaculum or by the tenaculum forceps, and drawn downwards, which step diminishes the degree of flexion. The cervix, however, must be hooked by its external surface, for otherwise the tenaculum interferes with the insertion of the stem into the external os.