The use of the sound for the purpose of determining the presence of inflammatory affections of the organ is only countenanced by its firmest adherents, as for instance Thomas. Aside from the fact that the use of the sound is here dangerous, it is painful and causes hemorrhage, and we are able to reach a diagnosis of inflammation in other ways much better.
As for the therapeutic uses of the sound, as early as 1808 Osiander lifted up the retroverted uterus by means of it, and after him Carus, Meissner, Kiwisch, Velpean, Depaul, Valleix, and a host of other cham• pions of the intrauterine, orthopedic, method of treatment. For this purpose, in case of retroflexion, the instrument is introduced with its concavity downwards, and it is then turned through an arc of 180', de scribing a half-circle the radius of which is coincident with the curvature of the instrument, during which manipulation the uterus is subjected to not inconsiderable pressure unless it describes a similar circle. On this account Sims devised a uterine elevator, by means of which the lateral movements are dispensed with and the direction of the repositing force is in a straight line. Mitscherlich, Gardner, Emmet, Noeggerath, and Howe, have devised similar instruments, and Hertzka aimed at the same result by inserting through an elastic catheter in the uterus stylets of varying curvature.
The advantages of making the uterine sound spell an elevator have been made clear by Ruch. His method consists in introducing the sound into the uterus and moving it in its long axis, the fixed point of the in strument being at the external os, and the handle describing a large half circle in the same way as the " tour de maitre " is performed with the Catheter, so that the part of the instrument which was originally placed downwards becomes uppermost In this way all twisting of the uterus is avoided. If now the finger in the vagina is placed against the sound at the external os, and we use if. as the fulcrum, we may lift the uterus by sinking the handle of the sound which rests against the uterine wall, the pressure being distributed along the anterior surface of the instrument even as when Sims's elevator is used.
Tiemann of New York has devised a very ingenious ropositor. known as Elliot's, and which consists of two feathering blades within an elastic catheter, which may be bent backwards or forwards to an angle of nearly 180° by turning a screw in the handle of the instrument. Still the com bined manipulation, assisted by the tenaculum and possibly dilatation of the uterus, are preferable methods. On account of the difficulty of cleansing these instruments they cannot be recommended.
[For the purpose of elevating the retroflexed, retroverted uterus, the fingers assisted by posture are, wherever possible, preferable to any in strumental means. It is surprising with what ease this may ordinarily be accomplished, and with absolutely none of the risks or pain involved by the use of the sound in particular. In case the fingers fail, one or
another repositor (Sims's or Emmet's) is preferable to the sound, seeing that except in the hands of the most expert this latter instrument may readily injure the uterus. For manual reposition the patient should lie in the left lateral (Sims's) position, so as to obtain the assistance of gravity, when all that remains is to lift the uterus into the vertical axis and the organ will fall forward. The examiner should, by preference, stand well behind the patient, and insert the index and middle finger of the right hand well up into Douglas's fossa, the dorsum of the fingers being directed against the cervix at the vaginal junction. Now by forward and upward pressure through these fingers the organ is lifted in the same direction as much as possible, and there held by one finger while the other is transferred anteriorly and pulls the cervix backwards. In this simple way the uterus may in the vast majority of instances be readily ante verted. Exceptionally this method will fail because of the impaction of the fundus under the promontory of the sacrum. The best method then is to cause the patient to assume the knee-chest position, to expose the cervix through Sims's speculum, and, hooking a tenaculum into the an terior lip of the cervix, to pull the uterus gently downwards, which dis lodges it from the sacral hollow, and then to push the cervix backwards by means of the instrument. Only very rarely will one or another of these means fail in anteverting the uterus, and when they do it is because the fundus is adherent, when, of course, instrumental reposition will fail as well. The more practised the examiner, indeed, the less frequently will be resort to the sound or the repositor for anteverting the uterus.— ED.] Simpson was in the habit of using the sound for the purpose of assist ing involution of puerperal uterus, as also Lehmann, and in more chronic cases Furst, and the first two gentlemen also resorted to the in strument in case of flexion as a means of causing the uterus to assume its correct form. It is undeniable that involution may be assisted by the passage of the sound, seeing that thus the flexion which interferes with the circulation is lessened and the cervical canal is kept open, and it is also true that even the simple passage of the instrument has occasionally sufficed to relieve dysmenorrhoea and to cure sterility; still it is essential to remember that such results are not obtained through any dynamic powers peculiar to the sound. In addition to the use of the sound for the purpose of straightening the uterus, we have at our disposal various intrauterine pessaries, such as those of Kiwisch, Simpson, Valleix, C.