A Perineal Retractor for the Dorsal Position, with Ele- vator for the Anterior Vaginal Wall, Especially adapted for Applications of Electricity to the Uterus and Vagina. BY AUGUSTIN II. GOELET, M. D. REPBINTKD FROM Efic Neb Yovft f-Hctiiral Journal for February 23, 1889. Reprinted from the New York Medical Journal for February S3, 1889. A PERINEAL RETRACTOR FOR THE DORSAL POSITION, WITH ELEVATOR FOR THE ANTERIOR VAGINAL WALL, Especially adapted for Applications of Electricity to the Uterus and Vagina* By AUGUSTIN H. GOELET, M.D. While some conditions of the pelvic organs demanding electrical applications may be satisfactorily treated with the patient in the Sims position, and the external or inactive electrode on the lower part of the spine, there are many con- ditions which require the dorsal posture and the external electrode on the abdomen, and none of the instruments de- signed for this posture are suitable, because they do not permit sufficient expansion at the vulva to allow the intro- duction of suitable electrodes without considerable incon- venience to the patient. Besides being made of metal and not insulated, they must be withdrawn during the ap- plication. Another, and often a very material, objection is that they fix the cervix in an unalterable position. * Read before the Section in Obstetrics and Gynaecology of the New York Academy of Medicine, December 27, 1888. 2 A PERINEAL RETRACTOR The speculum here exhibited consists of two Sims blades so joined as to form a letter S. It is made of light speculum or bell metal, cast thin, and coated with hard rub- ber for insulation. In presenting it to you I do so with perfect confidence in its utility, gained by six months’ con- stant use. It is intended to be used as a retractor for the perinseum and posterior vaginal wall, to be held in the left hand of the operator, the patient being in the dorsal post- ure. The elevator for the anterior vaginal wall, to be used with it, is held by the nurse in her left hand as she stands on the right side of the patient. This is made of hard rub- ber, and is sufficiently yielding to allow free motion with- out causing the patient any unnecessary pain. This instru- ment allows enough space at the vulva for the introduction of electrodes of considerable size, and, being insulated, it does not need to be removed during an application of elec- tricity to tbe vagina, though, when its removal becomes necessary, it may be readily reintroduced for the withdrawal of the electrode. Vaginal ball-electrodes with any protect- ing covering can not be either introduced or withdrawn with- AND A VAGINAL ELEVATOR. 3 out considerable inconvenience to the patient, unless through a speculum. Such manipulations as the introduction of vaginal and uterine electrodes without a speculum must be characterized as crude and imperfect, and as showing utter disregard for the patient’s safety and comfort. With the instrument shown it is possible to alter the position of the cervix or uterus at will for the more easy introduction of intra-uterine electrodes. Although it was designed for the dorsal position, it may be used for the lateral position in place of the Sims instru- ment. My nurse, after a little practice, has learned to hold this speculum in the Sims position with as much ease as the ordinary Sims instrument; and the general practitioner will find it more convenient to hold than the Sims instru- ment. I have found it so convenient in many ways that I do not see now how I could well do without it. While it may be used with greater ease in the dorsal posture, when the nurse holds up the anterior vaginal wall with the elevator, a nurse is by no means essential, for the elevator is shaped so that it can be held over the pubes by the patient if she is willing to aid the operator, or the speculum may be used by the physician alone, aided by an ordinary depressor or the dress- ing forceps with a little cotton in its grasp to hold up the anterior vaginal wall. I often manipulate this speculum and introduce both vaginal and intra-uterine electrodes while the nurse is arranging the abdominal electrode. I do not wish to be understood as excusing the absence of a nurse in gy- naecological practice, for I believe her a necessity for the safety and convenience of the physician as well as for the comfort and convenience of the patient, and believe that any physi- cian who does much gynaecological work should always have one present; but I wish to show how conveniently the specu- lum can be used by a general practitioner, and do not liesi- A PERINEAL RETRACTOR 4 tate to say that it forms not only a perfect and satisfactory substitute for the bivalve and trivalve instruments in use, but is a much more useful and convenient speculum in many ways, forming as it does a perineal retractor for both the dorsal and lateral postures. The saving of time may be no object to the general practitioner who has to see only one or two gynaecological cases a day, but the busy specialist can readily appreciate any instrument or method of ma- nipulation which will economize his time. He will find frequent use for this speculum after he has once tried it. It often saves turning the patient on the side for a speculum examination when she has been first placed on the dorsum for digital examination. With it retrodis- placements may be detected with the sound which would be overlooked with the patient in the Sims position, because some are corrected by that position when the speculum is introduced and the vagina becomes filled with air. A pes- sary which may maintain a corrected position of the uterus while the patient is in the Sims position may, and often does, fail of its object when the patient assumes the erect or dorsal posture. This is the only speculum I know of which may be conveniently used in the dorsal position with- out removing a pessary from the vagina, and this fact alone would make it invaluable. The two blades are so nearly approximated at the shank that the couch does not often in- terfere with the manipulator’s hand in holding the outside blade ; but where this is the case a small leather-covered pil- low, such as is used with almost every couch or table, may be placed under the patient’s back to raise her. The proper cleansing of the vagina is an important matter before any manipulation of the uterine cavity or galvauo-puncture, and is to be insisted upon in every instance. As the douche is not reliable and is very inconvenient, I know of no instru- ment so useful as this speculum in accomplishing this end. AND A VAGINAL ELEVATOR. 5 I use an antiseptic spray connected with a compressed-air receiver, and the vagina is sprayed with an antiseptic solution and wiped out thoroughly with absorbent cotton before an electrode or a sound is introduced into the uterine cavity or before a galvano-puncture is performed. And I find the elevator particularly useful in protecting the vagina and finger while passing the needle up to the seat of puncture. The speculum, which is made by Mr. P. II. Schmidt, of 1311 Broadway, is finished with nickel as well as hard-rub- ber covering for the convenience of those who desire it for other than electrical applications. To make this speculum more readily appreciated, per- haps it would be best to show you the form of vaginal elec- trode which I use. For a long time I was puzzled to know how I could protect the metallic vaginal electrodes so as to use galvanic currents of sufficient intensity to be effective. When we have to depend entirely upon the interpolar ac- tion, as we do in such applications, this is important, for mild currents are often inefficient and too slow. The usual cov- ering of moistened absorbent cotton or chamois-skin will not allow the use of over 30 or 40 milliamperes without in- flicting serious injury upon the vagina. WTitlx the electrode which I show you I have been able to use currents of from 60 to 150 and even 200 milliamperes with no more local effect than is produced on the integument of the abdomen by the large clay electrode of Apostoli. With currents of 50 to 100 milliamperes there is a scarcely perceptible in- crease of redness of the surface after an application of ten to fifteen minutes, which is not noticeable in any waj' after- ward. With the higher intensities the redness is increased, but no abrasion is produced to interfere with subsequent ap- plications. I use small copper discs of about the size and thickness 6 A PERINEAL RETRACTOR of a penny, with a spindle attached to the center, which al- lows it to be screwed on any ordinary insulated handle. This I cover with a thick layer of potter’s clay molded so as to cover the edge of the disc well. This is allowed to dry hard or it is baked, so as to make it retain its shape. It is then attached to the handle and covered with a piece of gauze held on by a rubber band around the shaft of the electrode, which aids in retaining the clay in position. When it is to be used it is covered additionally with ab- sorbent cotton which is well moistened. When once used, the cotton is removed and replaced fresh for every patient. I have used the metallic ball in this way also, but the clay will not adhere as readily to its smooth surface, and if the clay becomes soft, as it may do after many applications, the covering becomes thinner in some spot where the pressure is greatest, and the vagina may be cauterized in consequence. Besides, the current can not be so well concentrated with the ball as with the disc. For use with the positive pole I have the disc made of aluminium or hard carbon. The clay, when allowed to harden—or, better, if it is baked—will retain its shape for some time, and when well moistened is a good conductor, and forms a protection for the metallic electrode which greatly modifies the local action. When it has be- come necessary to increase the size of the electrode so as to multiply the intensity of the current, I have used a mixture of one third clay with two thirds plaster of Paris, which sets and remains firm, and is still absorbent. One very decided advantage in favor of the clay-covered AND A VAGINAL ELEVATOR. 7 vaginal electrode is that where suprapubic punctures of fibroid tumors is they can not be reached through the vagina, or, if frequent vaginal punctures have produced much local irritation, the current can be concen- trated through the tumor by using it connected with the positive pole either against the tumor in the vagina or against the cervix, using negative puncture only. I have been able to concentrate 300 milliamperes through the tumor without producing any local irritation in the vagi- na, and any pre-existing soreness is rather relieved by it. Puncture with both poles may thus be avoided. I did not believe at first that I would be able to get so much penetration through the small vaginal electrode ; but by using a thick carbon disc well protected with clay, I have been able to reach 300 milliampbres, using only 30 cells (Leclanche). Those who profess not to cauterize the vagina when cur- rents of over 40 milliamperes are used with a metallic elec- trode covered only with absorbent cotton or chamois-skin, confess that they do not use a speculum, which explains why they believe this to be true. It stands to reason that they must burn the delicate mucous surface of the vagina when it is necessary to protect the large external electrode to avoid a similar effect upon the skin. I knovv that under the same conditions they must produce the same effect that I do. I once asked a prominent electrician how he avoided this action of the internal electrode. His reply was: “Well, do your patients object to it?” I replied, that was not the question. I objected to it myself most de- cidedly. To those who would object to the high intensities men- tioned above I would say that they can form no idea of what can be accomplished by galvanism until they have learned how to use these intensities with safety to the pa- 8 A PERINEAL RETRACTOR. tient. I would not convey the idea that I believe high in- tensities are always necessary o^- even allowable, for there are certain conditions where they would be dangerous; but there are conditions which remain unaltered by low in- tensities. 243 West Fifty-fourth Street. REASONS WHY Physicians Should Subscribe FOK The New York Medical Journal, Edited by FRANK P. FOSTER, M. D., Published by D. APPLETON & CO., 1, 3, & 5 Bond Si 1. 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