ON THE MECHANICAL TREATMENT OF SOME OF THE DISPLACEMENTS AND DISEASES OF THE UTERUS.

BY R. BEVERLY COLE, M.D.,

CALIFORNIA.

WITHOUT entering into an elaborate description, giving the etiology, symptomatology, varieties, degrees, or treatment in detail of the displacements of the uterus, all of which are familiar to gynecologists and to most general practitioners, I propose to deal with this class of derangements at this time simply with reference to their mechanical treatment, whether complete or auxiliary.

From time immemorable, so to speak, pessaries of great variety of forms and materials have been used in the treatment of displacements of this most important organ-the uterus; but Dr. Hugh L. Hodge, of Philadelphia, was the first to properly appreciate the true principles of shaping and adapting the instrument to the axes of the vagina and straits of the pelvis.

Until his work, Diseases of Women, was given to the profession, no instrument was extant that fulfilled the indications in this class of cases.

The Hodge pessary, so familiar to us all, has, however, undergone many modifications, and the reasons for this are easily explained.

No gynecologist, who has enjoyed a large practice, has failed to encounter cases in which the Hodge pessary, nearly perfect as it is, has not fallen short of meeting every indication; hence he has felt himself not only warranted but called upon to so change the original shape as to enable him to adapt it to the case in hand.

In 1862, conceiving the idea that this pessary would be better retained in position by depressing its sides, so that the circular muscular fibres of the vagina would apply themselves to the centre of the instrument, and thus fix it, and obviate the slip

ping that occurred when the original was used, I gave to the profession the results of my ideas and experience. And later on, in 1863, discovering that in certain cases, particularly if the instrument happened to be too long, the inferior bar had a tendency to compress the urethra, and give rise to trouble in the act of micturition, I depressed this portion also, which entirely overcame the difficulty.

On visiting London, however, in 1864, and meeting my friend. Dr. J. Marion Sims, and comparing notes, he assured me that he had adopted the same expedient, and I. therefore, never attempted to establish my claim to the improvement.

Before and since these modifications, as we have already said, many others have been made by different gynecologists. Amongst those who have given special attention in this direction I will mention James Y. Simpson, of Edinburgh; Dr. Albert H. Smith, of Philadelphia; Drs. T. G. Thomas and Montrose A. Pallen, of New York; each from his standpoint either taking from or adding to the original instrument of Hodge, in accordance with his peculiar views as to improvement.

The former of these gentlemen was in the habit of modelling his instruments in gutta-percha for each individual case, which plan has its advantages, inasmuch as it enables the practitioner to take cognizance of the peculiarities of indications, and adapt or model the instrument accordingly.

This method consists in simply softening the refined guttapercha by placing it for a few minutes in hot water, and when of a doughy consistence rolling on a table, or other smooth surface, until of proper thickness, then bringing the two ends together so as to convert it into a ring-this done you can give it any curve or curves required, and whilst holding it in proper shape immersing it in cold water, which immediately hardens it, and gives you the instrument perfect-which we shall presently practically demonstrate.

Dr. Smith adopted the special features of both the Hodge and the Simpson pessary, producing in some particulars a superior instrument to either, and yet not without its faults.

But, as has occurred to each of us, cases present themselves from time to time, in which neither of the instruments extant seems to fulfil the requirements; and of these there is a class that perplexes and annoys us more than all others; it is that which is attended with great sensibility, due occasionally

to a neurotic condition, but more frequently to a subacute or chronic inflammation of the parenchyma of the organ itself, or of the tissue surrounding it.

Under the latter condition no one doubts that we should tarry before resorting to mechanical supports, and address our remedies to the end of subduing the inflammation; and yet when this is accomplished, for many months the tenderness is liable to continue, whilst the displacement contributes to its maintenance; therefore we consider it to be of the first importance, whether the case be one of neurosis due to retroversion, or an inflammation subacute or chronic due to the same, or other cause, that we should replace and retain in position the displaced organ.

To meet this indication and avoid pain and irritation, we have devised and used for many years the instrument here shown. It is simply Smith's pessary, shorter than usual, with the upper

Fig. 1.

G.TIEMANN & CO.
Retroversion.

uttermost angular curve or arm so straightened as to conform merely to the curve of the floor of the vagina, while springing from the lateral bars we have two segments of watch spring, supporting at their upper extremity a bar of hard rubber, which is designed to rest in the fornix of the vagina and uterus posteriorly. In a word, the instrument is so constructed as to be of the general form of Smith's, only less angular, and provided with two springs which give it an elasticity that enables the wearer to tolerate its presence without pain or inconvenience. (Fig. 1.)

All of us have observed that in the mechanical treatment of anteversion and flexions, whatever be the cause or attendants, we are much more liable to encounter this extreme tenderness or sensibility that has been described than in retroversions and flexions. This increased sensitiveness is in many instances conVOL. XXXII.-19

fined to the bladder, through which the pressure in the employment of all mechanical supports must be exerted upon the uterus. Hence any fixed support or point of pressure, such as is furnished by all anteversion and flexion pess tries that have fallen under my observation, is unbearable. And what applies to the bladder will also hold good as to the uterus itself.

Suppose that from long-continued displacement irritation is set up, aided, as it is, by many other factors, or that from the presence of a small fibroid in the anterior wall of the uterus the organ is bent forward and its fundus carried downward, the structures are liable to become the seat of great irritability and tenderness, and, the sympathy of contiguity becoming great, there is no relief except through mechanical support so adjusted and directed as to secure the elevation of the fundus of the displaced organ from exciting pressure on the bladder, and a replacement of the uterus.

In order to accomplish this most desirable end I have devised

Fig. 2.

A

G. TIEMANN & CO

B

Anteversion.

this instrument (Fig. 2), which in construction is similar to the retroversion, except that the direction of the watch-springs is reversed, and the ordinary Smith pessary is employed as the bed or support of the springs without any modification of the superior arm or angular curve of the original instrument.

I should have mentioned before, that the springs in both of my instruments are coated with rubber and then baked, so as to render them imperishable.

After nearly twenty years of experience in the use of this and the original instrument from which this has been taken, and which was made much more clumsily of silver, I have no hesitation in saying that, whilst it may not and does not in some cases answer the purpose, yet it is far, very far, the best I have either used or seen used.