THE EXAMINATION BY MEANS OF THE SOUND.
Probably the use was limited to measurement of the vagina before the introduction of the speculum, and it is so described by Paulus Aegina and Soranus. The instrument was then forgotten up to the middle of the eighteenth cen tury, when it was re-introduced into practice by Levret and S. Lair, but it was not elevated to the rank of a diagnostic measure until the days of Simpson, Kiwisch, and Huguier. It was at once utilized by tho majority of gynecologists, and results claimed for it which practically it is unable to attain. The chief use of the instrument is for the purpose of deter mining the position and the size of the uterus. Simpson, Rigby, Kiwisch, Tilt, West, Martin and others, deemed the sound unnecessary for such purposes, while others, such as Sims, and above all Thomas, claim that no diagnosis of disease of the uterus can be considered complete until the sound has been used. To-day the majority of German gynecologists do not agree with Scanzoni in regard to the manifold usefulness of the sound, and while we do not consider the instrument as absolutely useless for purposes of diagnosis, we claim that its use should be combined with that of other measures, especially the bimanual palpation, from which we may obtain the most certain results.
For the purposes of examination with the sound, any blunt or knob pointed flexible rod, at least seven and three-quarter inches long, or any elastic catheter armed. with its stylet will suffice, but on account of the greater ease in manipulation, a number of uterine sounds have been de vised. The most generally used are those of Kiwisch, Simpson, and Sims, while those of Valleix, Kugelmann, Lazarewitsch, Cambanis and others, being more complicated, are less in demand.
A useful and conveniently handled sound should possess the following characteristics: It should have a length of at least seven and three-quarter inches exclusive of the handle, and should end in a round or egg-like point. It should be constructed of such material as to enable it to be bent to any desired curve, which it will retain, and yet not be so soft as to be unable to pass a slight obstacle. Its surface should be smooth, or at least the measure markings should not be roughened, and finally the handle must be so constructed as to tell us the direction of the convexity of the instrument when it has been inserted into the uterine cavity.
The instruments most frequently used are those of Simpson and of Sims. Latterly almost every gynecologist has devised his own sound, which differs as regards curve (Schultze), material, marking, etc. I have for a long time dispensed with all instruments which have knobs, markings, or complicated mechanism, on account of the difficulty of keep ing them clean and the danger of infection, and I use entirely instru ments constructed of silver or nickel plated copper, and which bear on their surface a slight swelling about two inches and a half from the tip, and slight depressions anteriorly, which divide it into millimeters. We
need, of course, a number of varying thicknesses.
The insertion of the sound is ordinarily a very simple matter, but in case of abnormality of the uterus, in particular flexion, it may become a difficult matter even for the experienced. The use of the instrument must always be preceded by the bimanual palpation in order to determine the position and the shape of the uterus.
After thorough disinfection of the vagina, and when possible of the uterus, the sound is introduced with the patient occupying the dorsal position, the thighs widely separated, or else with the patient in the lateral position. Examination in the latter position, as also in the erect, which is favored by Kiwisch, interferes with the coincident resort to pal pation. In the dorsal posture a finger is inserted into the vagina up to the external os, and the previously warmed sound is guided along this finger up to the os and into it. The handle of the instrument is held between the thumb, index and middle finger. (It goes without saying that both hands should be trained to use the sound.) When the external os is normal in position and in size the instrument readily enters; in case of displacements of the uterus, however, or where the orifice is nar row or distorted, the insertion requires extra care and expertness. Many examiners insert the middle as well as the index finger into the vagina, steady the cervix and pass the sound into the os between the opposed fingers. In case of great displacement it is useful to steady the cervix by means of a tenaculum. When the sound has passed through the external os and reached the cavity of the cervical canal, it may ordinarily glide in to the extent of about f of an inch, although it may catch in the folds of the cervical mucous membrane, and this is the more likely to happen the more slender the sound used. For this reason, and in order not to injure the mucous membrane, it is preferable to use thick sounds. In case it catches, the instrument must be pulled out a trifle and the attempt made to pass it in another direction. Frequently the end of the sound must be bent in order to pass by Nabothian follicles or mucous polypi, and the instrument must often be made to traverse the lateral, anterior and posterior surfaces in order to overcome the obstacle.