In case movement of the sound is free enough to enable us to draw some conclusion from the sensations communicated to the point of the instrument, then we may here and there draw certain inferences. We may detect the rough nodular projections from the tumor or the mucous membrane as the extremity of the sound passes over then. By means of the instrument we may determine the presence of small tumors, mucous or fibrinous polypi, or broad-based fibromata, but generally such small tumors escape us, since we are not able to explore the entire mucous mem brane with the point of the instrument, and we must never forget that there are instances, as in Fig. 15 for example, where the tumor lies closely against the surface of the uterus and can never be recognized by the in strument. In the case illustrated, where severe dysmenorrhoea was the symptom, the curette was necessary to make the diagnosis on the living, and yet the use even of a curette like the annexed does not preclude error.
Large tumors may ordinarily be detected by means of the hi-manual palpation, as well as the relation which they bear to the wall of the uterus, but even as in case of smaller growths exact data are only obtainable by resort to digital examination after dilatation has opened the way. Still, in connection with the depth of the cavity as ascertained by the sound, we may form a probable conclusion in regard to the size of tumors, and we may often differentiate between growths occupying the anterior and posterior walls, since in the former instance the instrument glides along the anterior, and in the latter the posterior surface of the growth into the cavity of the uterus. The direction of the handle of the sound together with the curve given to it give us information, but the result is more positive if we endeavor to feel the sound in the uterus through the rectum, bladder or abdominal wall. It is still more difficult to determine whether the tumor is sessile or pediculated. Only in case of small and of medium sized tumors is it possible to explore around the base of the tumor with the extremity of the instrument, and even then very exceptionally. The diagnosis between inversion of the uterus and polypi depends on the determination of the position of the uterus.
6. For the determination of the direction of the canal of the uterus.— The differential diagnosis here lies between tumors of the uterus and its displacement. The sound is often used for this purpose by those who believe it, essential for the determination of the position of the uterus, but the more carefully the hi-manual examination is performed the less the need of the sound in this connection. Only where the bi-manual palpa
tion is impossible, as for instance in case of hematocele or exudations around the uterus, or in case of small exudations or tumors which from intimate connection with the uterus render it impossible to make out the separation, or the fact that the uterus does not occupy its normal position, only then is it necessary to resort to the sound. We must never forget, however, that in such instances we are deviating from the rule never to sound a uterus the position of which we have not determined by the con joined touch, and this is a further reason for limiting resort to the sound to cases of absolute necessity. The direction of the uterus in case the sound is used is determined by the position of the handle and of the con cavity of the instrument. The diagnosis between a questionable tumor and the uterus is made by the direction which the sound takes. It enters forwards in case of anterior displacement, and backwards in case of pos terior displacement. Generally the question at issue is between tumors in the posterior pelvic space and retroflexion. In case the sound, directed forwards, penetrates to a sufficient depth, then, of course, we are not dealing with the retrqflexed body of the uterus, and movements of the uterus will further assist in differentiation.
In case of developmental anomalies of the uterus the sound is also of assistance in diagnosis. The presence of a septum, the uterus unicornis and bicornis, may be differentiated by the simultaneous use of two sounds.
7. For determining the movability of the uterus.—The bi-manual ex amination here as well gives more certain information in regard not only to the movability of the entire uterus but also as to that of a flexion. At any rate we should only attempt to impart movements to the uterus by means of the sound with the greatest caution. In case of large tumors the sound in the uterus is steadied by the hand, and then motion is im parted to the tumor by the other hand, and the effect on the sound noted. The opposite procedure, to move the uterus by the sound and to note the effect on the tumor, is to be considered dangerous, as also attempts to lift up or push down the uterus by means of the sound in order to detect adliesion3 and their effect on the organ. The tenaculum or forceps better subserve these purposes.