The Speculum. This instrument is twofold in its use. It is one

of the most important aids in the investigation of disease, and at the same time a

necessary instru

ment in treatment. A great variety of specula are used, but two answer all requirements. Sims's speculum and Cusco's bi

valve, slightly

modified, answer

FIG. 3.-Sims's speculum.

GTIEMANN&CO.

every indication. In fact, Sims's speculum is all that is needed, except when an assistant or nurse can not be obtained to hold the specu

scribed, which should be near a window giving a good light. Occasionally it may be necessary to examine a patient upon the bed, but this is difficult, and should not be undertaken until the examiner has acquired by practice great facility in the use of the instrument, and only then, when it is impracticable to place the patient upon the table.

The position of the patient should be on the left side, semi-prone, with the left arm behind the back, the head upon a low pillow, and near the right-hand side of the table, the limbs drawn up, the right limb above and in front of the left, and the pelvis at the end of the table on the left-hand side. Fig. 5 illustrates this position.

In order to place the patient in this position, she should stand upon an ottoman or low chair, with her left side toward the end of the table. The skirts on the left side are then raised, and she is directed

to sit down on the table; her left hand is placed behind the back, and she is made to lie down on the left side, inclining forward. The

limbs are at the same time drawn up and placed in proper position. The skirts are then pushed up on the right side, and at the same

time a sheet is drawn over the limbs and arranged so as to expose the labia only.

The speculum is introduced by separating the labia with the fingers of the left hand, holding the instrument in the right hand by the handle; the point of the blade is placed upon the posterior commissure, and, while backward pressure is made, the speculum is passed into the vagina. Care should be taken not to touch the meatus urinarius. The free blade is then grasped with the right hand by the nurse or assistant, while with the left she raises and supports the natis and labium on the upper or right side. The position of the one who holds the speculum should be with the left side toward the patient, the fingers of the right hand surrounding the blade, while the thumb rests in the inside of the blade. The elbow should rest against the side, as a point of purchase to give ability to make steady traction. The left arm should rest upon

the right hip of the patient, while the hand supports the labium and natis to keep them out of the way (Fig. 6). Careful training is required to enable one to hold the speculum properly. The chief and essential requirement is to maintain the instrument for any desired length of time in the position in which the operator may choose to place it. The objects to be attained by the use of the speculum are, to distend the vulva by making traction upon the posterior commissure, and at the same

time to draw the whole floor of the pelvis or perinæum backward toward the sacrum, away from the pelvic organs above, which, from the position of the patient, gravitate toward the abdominal cavity. By these means the vagina is distended by atmospheric pressure, which gives space for the admission of light, and room for inspection or manipulation in operating. These facilities can be extended by changing the position of the speculum in the following manner: The assistant who holds the instrument can, by rotating the hand, cause the point of the blade in the vagina to describe the arc of a circle (Fig. 7). By moving the hand forward, the blade is made to point backward

FIG. 8. Second movement.

toward the rectum; and by moving the hand backward, the blade is caused to point forward (Fig. 8); and, finally, by raising or lowering the hand, the speculum is made to reflect the light upward or downward to either the upperor lower side of the vagina, according to the requirements of the examiner (Fig.9)..

FIG. 9.--The third movement.

At the same time that all these changes of position are being made, the required traction upon the perinæum can be maintained.

In using the Cusco speculum, the position of the patient is the same as for examination by the

touch. The labia are separated with the left hand, and the instrument introduced with the blades closed, the direction of introduction being downward and inward. When the speculum is in position the blades are separated. There is quite often difficulty in bringing the cervix into view through this instrument. This can usually be avoided by getting the point of the posterior blade well under the cervix before separating the blades. This speculum is principally used in the treatment of the simpler diseases of the cervix uteri, when an assistant can not be procured to hold a Sims's speculum. As a means of investigation it is quite limited in its use.

THE UTERINE SOUND AND PROBE.

There are three kinds of sounds: Simpson's, which is made of hard metal, and maintains an unchangeable shape; Sims's, which is of soft metal, and can be bent or molded to any curve; and a third, which is elastic and bends on the slightest pressure, but by its elasticity regains its original shape. There are two varieties of the latter: that made of elastic material like whalebone or rubber, and a metallic one, rendered elastic by a spiral arrangement in its mechanism, known as Jenks's. The stiff, unyielding sound of Simpson is ten inches long, being smallest at the end, and having a bulb two and

GEO TIEMANN & Co.

FIG. 10.-Simpson's probe.

a half inches from the point. It is graduated in quarter-inches up to six inches (Fig. 10). It is seldom used now, except in a modified

form. It is difficult to use because its shape can not be adapted to different cases; and it is dangerous, from the fact that it will not bend to light pressure.

G. TIEMANN-Co

FIG. 11.--Sims's probe.

Sims's probe is made of soft copper or pure silver, both of which metals have the quality of being easily molded. It is like the ordinary probe used in general surgery, only longer and a little thicker, and is provided with a handle (Fig. 11).

The probe which is most generally used, and the one which I prefer for ordinary use, is the same as Sims's, only thicker. It is stiff enough to sustain all requisite pressure, and yet can be easily

molded to any curve.

G.TIEMANN & CO.

FIG. 12.--Whalebone sound.

In practice it is well to be provided with this one as well as that of Sims.

The elastic probe is the same in form as Sims's, but is made of rubber, gum-elastic, or whalebone (Fig. 12).

The sound of E. W. Jenks is hollow and spiral for a distance of two thirds from the pointed end. This spiral arrangement gives it flexibility. It is also graduated and provided with a sliding sheath which is very convenient in measuring the depth of the uterus, the

arrangement being such that the examiner can run the sheath toward and away from him, the figures at the end of the sheath nearest the handle giving the measurement of the distance from the point to the distal end of the sheath (Fig. 13).

The sound or probe should only be used after the position of the uterus has been ascertained by a digital examination, and its sensitiveness tested as far as that can be by the touch. It is very important to know the position of the uterus and its relations to the other organs, in order that the sound may be curved to suit the direction