Mayer, Kilian, Detschy, Greenhalg, etc. The insertion of a stem pessary should be preceded by that of the sound, for purposes of diagnosis. Many writers, Olshausen for instance, advocate leaving the sound in the uterus for a few minutes to test the tolerance of the organ before insert ing the stem, while Veit, Winkel and others insert the stem at once. It was Malgaigne's practice to introduce the sound in order to determine the irritability of the internal os. The sound is also frequently used as an emmenagogue, being inserted a number of times before the expected menstruation, and being left in the cavity for awhile.
The dangers from the use of the sound are frequently much exag gerated. Still it is very essential that beginners should ever bear them in mind. Further, it is true, as Seanzoni says, that the more expert one becomes the less he uses the sound. The inexpert resorts to it frequently in the belief that it is an essential diagnostic means, while he is really more likely to do harm by means of it.
Since, in 1854, Broca reported the first case of death from the use of the sound, the number of recorded and unrecorded cases have largely increased, and still more numerous are the instances where slight and serious diseases have been caused by it. Every moderately busy gyneco logist is familiar with such instances.
The passage of the sound by the internal os is generally painful, and even in the hands of the most expert uterine colic may result, also sudden collapse, the result either of the closure of the cervical canal, or else from the excitation of the uterine wall or the fundus by the point of the in strument. Such colic results the more readily the more irritable the uterus, the narrower the canal, and the greater the degree of displace ment. Even the use of a not previously warmed instrument may result in irritation. Similarly more or less hemorrhage may result, although generally it is caused by direct injury to the ondometrium, generally at the isthmus.
The healthy mucous membrane ought not to bleed from the careful passage of the sound; but in case it is congested or not intact, as before menstruation, during the puerperium, or in the presence of new growths, then even the skilled insertion of the instrument may cause hemorrhage. Frequently such hemorrhage will give us information of importance in diagnosis, but the reverse, the absence of hemorrhage, does not mean that nothing abnormal is present, for even the insertion of the sound into the gravid uterus is not always followed by bleeding. Since it is often impossible to recognize gestation at its inception, and since the sound by rupturing the ovum or awakening uterine contractions may cause mis carriage, it is therefore always essential to bear this question in mind, for there are women who, in their desire to have a miscarriage induced, pur posely give such a history as will lead the examiner to pass the sound. Although as we have stated the instrument was formerly utilized for the diagnosis of pregnancy, and although its use does not always produce miscarriage, nevertheless, except with the intention of causing abortion, the instrument should not be resorted to in the presence of pregnancy. In order to impress this fact constantly on the physician, Cameron had the handle of his sound constructed in the shape of a foetus.
Inflammatory processes will always be intensified by the insertion of the sound, whether it be an acute inflammation of the uterus and its adnexa, or a chronic process which is rendered acute. In such instances great pain, hemorrhage, and increase in the intensity and in the extent of the disease, almost infallibly result. Above all are movements imparted to
the uterus dangerous since they may cause rupture of adhesions and hemorrhage into the peritoneal cavity.
Ordinarily the ill results from the use of the sound are injury of the endometrium, the parenchymatous layer, or even perforation of the uterine walls. I am personally familiar, however, with two cases of fatal septic parametritis which followed the use of the sound in expert hands, and where there was no obtainable evidence of injury to the uterus. In deed the greatest risk from the sound lies not in the mechanical injury but in the chance of infection. The more relaxed and succulent the tissue of the uterus, the narrower and more tortuous the canal, the more inflexible the instrument, the more likely the chance of partial or of com plete perforation. The internal os in case of flexion, and the fundus, are in particular likely to be injured. The results of such injury are gener ally slight hemorrhage, a traumatic inflammation of the uterine paren chyma or mucous membrane and its sequelce, and in case of perforation damage of the peritoneum. Still such perforation is not always followed by bad results, as is proved by the not rare instances on record of "sounding of the tubes." The dilatation and cauterization of the tubes advocated by Tyler Smith, R. Froriep, and others, is proved possible by the researches of Bischoff, Lehmann, and Biedert, which go to show that the ordinary uterine sound may be introduced into the opening of the tubes. This necessitates, however, the existence of abnormal patency of the tubes, and an easily movable uterus. In Bischoff's case, for instance, the ostium uterinum was funnel-shaped, and in Hildebrandt's first case the extremity of an intrauterine pessary had probably dilated the ostium. It is to be noted, on the other hand, that the cases recorded by M. Duncan, Veit, Hildebrandt (second case), Lawson Tait, Zini, were probably in stances, as Honing suggests, of perforation of the uterus. Introduction of the sound to the depth of seven inches has been noted by Simpson, Honing, Schroder, Martin, Noeggerath, Rabl-Rflckhardt, Lehmus, and others, and were believed to be cases of perforation, although ordinarily there was no reaction, but only a little pain and hemorrhage. Injuries of this nature do not usually concern the normal uterus, but that which is still largely in a condition of puerperal involution, where in other words the conditions favorable to perforation are present. The same injury may be inflicted in the presence of sarcoma and of carcinoma. In cases of complete perforation the sound passes deeply into the peritoneal cavity, and may be pushed in even up to the handle, the extremity being felt under the abdominal walls in the neighborhood of the umbilicus. Where the sound is sharply deviated to one side the idea of entrance into the tube is suggested, provided we have excluded developmental anomalies of the uterus.
The correct use of the sound requires more practice than we are justi fied in subjecting the living patient to, and therefore expertness should be acquired by experiment on the cadaver. I teach students to sound the uterus in the dead body and to endeavor to perforate it, and the re quisite amount of force is found to vary greatly. I have never found at the autopsy, however, as is claimed by Rockwitz, that the uterus lifted up on the sound was perforated.