THE TREATMENT OF J l T V II I X m J> I K I* LiioiIIIIi^ FROM THE STAND-POINT OF A COUNTRY GYNAECOLOGICAL PRACTICE; ESPECIALLY RE GARDING THE EMPLOYMENT OF PESSARIES, BY JOHN LAMBERT, M. D., SALEH, N. Y., COEEE3FONDING UEMBZE OP THE GYNECOLOGICAL SOCIETY OF BOSTON, AND P3ESTDENT OF TEE MEDICAL SOCIETY OF THE COUNTY OF WA^RI^GTCN. (Communicated to the G. Soc. Sept. 17, 1872, and reprinted fromTthe Gynaecological Journal.) I do not propose to refer in detail to par- ticular displacements, and the best methods of treatment; this is unnecessary to the ob- ject of the present paper. I design rather to call the attention of intelligent, busy, country practitioners in a cursory and prac- tical manner, to some matters which, I hope, may be deemed worthy of consideration. I trust that the day is not distant when gynaecological fellowships shall be founded for such men as Pcaslee and Storer, who shall devote their ripened years to an ex- haustive examination and statement of all that is known regarding gynaeic science and art. In the meantime, let every laborer in this fruitful field bring in his sheaves, be they large or small; and let us be anxious that only the choice wheat remain after the winnowing. Our motto should be, nil propter opinionem sed omnia pro veritate. Having carefully noted for twenty-three years the results of other practitioners in the use of various pessaries, having myself had a somewhat extensive experience in their employment for the removal of uterine disease and displacements, and feeling, as I do, that the injudicious and almost unli- censed use of them, both in the city and country, has been justly an opprobrium to gynaecological practice, I desire to contrib- ute something to a more discreet apprecia- tion of the value and dangers of mechani- cal supports in the treatment of uterine dis- placements. Let it be borne in mind that, in discuss- ing the subject under consideration, I refer to views of practice largely applicable to the country where our patients, as a general thing, cannot place themselves under our immediate care, Y’herc. thoywre situated at great distances, and consequently cannot always be seen when necessary, and where gynaecological practice is peculiarly and doubly responsible, from the fact that the practitioner is, from force of circumstances, as relates to his professional brethren, placed at the disadvantage of being an es- pecialist rather than a specialist. The uterus is not maintained in situ by unyielding fibrous bands, like some other organs of the body; but that it may sub- sei % e its peculiar function, it is loosely sus- pended and kept in normal position by its ligaments, the contractibility of the vagina, and the pressure of surrounding organs.— Consequently among the prominent causes of displacement are increased volume and weight from whatever cause, relaxation of the ligaments and the vagina, and violent exercise. After determining carefully what dis- placements we have to deal with in a given case, our first duty is to ascertain intelli- gently its causation, and decide, if possible, whether its removal will be followed by a restoration of the organ to its natural posi- tion; or whether we are to treat the dis- placement and its cause conjointly. It is erroneous, I think, to adopt the view so strongly advocated by some, that to remove the cause of the displacement is to insure a return of the organ to its normal position; or vice versa, that to sustain the organ in situ by well-adjusted mechanical support, is almost always wise as a means to restore the organ to its normal condition. For six years I implicitly followed the views of practice laid down by that most eminent gynaecologist, James Henry Bennet, in his second addition of “ Inflammation of the Uterus.” I confined myself to such treat- ment as I deemed wise to remove tbe local disease and restore tbe general health, altogether ignoring pessaries; and I am sure that I had gratifying success in very many of my cases, although my signal fail- ures in others finally led me to overcome my prejudices against pessaries, and to em- ploy them in cases where before I would have considered their use mal-praclice. A case in point, which I was called to treat in 1860, Miss W., iEt. nineteen ; severe chronic endometritis; retroflexion and prolapslon; the vulvas greatly swollen; the vagina hot and sensitive; cervix and fundus very much Increased in volume and exceed ingly tender to the touch ; cervical canal almost ob- liteiateu at the point of flexion; in bed nine months; agonizing pain and convulsions obtained during the menses, which occupied two weeks of each month ; extreme emaciation and exhaustion ; hysteria. She had received heroic caustic treatment under the advice of a distinguished college professor. I scaiifled the vulvae, raised the uterus out of its lied, applied tannin, morphia, and glycerine, and Intro- duced an inflated French rubber pessary, under the protest of the former medical attendant, .-he was relieved immediately, and in two days was able to sit up half an hour. She was brought to my house on a bed, twelve miles. I employed a soft Meig’s ring; then a closed lever hardened rubber pessary; d ialed with sponge tent, etc. In eight weeks the menses were normal and recovery ensued. In this case the history disclosed a fall from a stone wall at eleven years; severe local symptoms supervened, and increas- ingly continued up to the date of my seeing her. Menses at twelve. I think, beyond question a displacement occurred from the; fall, as did also the local suffering and early menstruation. The case was over- looked during its earlier stages, and at a later date an error was committed in seek- ing to remove the sequences of the dis- placement alone; hut success crowned treat- ment directed to both cause and effect.— While of the posterior displacements, retro- flexion is said by Peaslee and others to oc- cur more frequently in the city, I have found retroversion to obtain in a majority of cases in married Mcn.cn hearing chil- dren, whose household duties and the na- ture of whose employments often require them to rise early from their accouchement, and to engage in just those exercises w hich most naturally produce this displacement. In married women not bearing children and unmarried patients, I find cases of re- troflexion predominating, largely the result of and associated with a diseased condition of the uterine organs. In cases of retroflexion appreciable by a digital examination, we usually find the fundus uteri near or lodged in the cul-du- sac of Douglas, and, in a majority of cases, tender to the touch, oftentimes exceedingly so, especially in endometritis. In such cases, we should endeavor to remove, as far as possible, the accompanying disease by appropriate treatment before resorting un- necessarily to mechanical support. A pes- sary sufficiently large to maintain the uterus in situ may do, and often does, even in skilful hands, serious harm, and, therefore, as a general rule, should be avoided, es- pecially in country practice where it can- not receive the requisite attention. In 1867 I saw Miss I)., set. 34, seven miles away; retroflexion; chronic corporeal and cervical en- dometritis; exceedingly painful and veiy profuse menstiuation; tendency to mental alienation. Alter months of preparatory treatment, she wore, with comfort and benefit, a closed lever, which i made especially for her case. She traveled with it several thousand miles. She considered herself well, though unwilling to part with the Instrument, as there was still a tendency to a return of the displacement on its removal. She had worn it months at a time dur- ing my supervision of the case. Apiil 19, 1870. l found her sulTeilng from fully developed metro-peritonitis. Two weeks before she assisted in carrying a bureau and other heavy articles of furniture up stairs, just previous to the menses. The ut erus and pessary were firmly wedged Into the Douglas’ cul-du-sac. bn removing the pes- sary and repi siting the uterus, there was a profuse discharge of dark, thin, and exceedingly foetid mat- ter. I ordered caiholized \nglnul enemas, fomenta- tions, and adopted the “opium plan” of treatment. There was a marked Improvement in her general condition. On the With, the bowels moved kindlv, and I was not without hope of her recovery till the 29th Inst., when she sank rapidly and died appar- ently from pyaemia. The following cases additionally illus- trate the necessity of caution in the em- ployment of pessaries in country practice: 1870. Mrs. G., iet. 79. Several children, very fleshy ; in perfect lit alt ft. except complete prociden- tia uteri, attended by a consideiable proiapsns ani. 1 sustained ihe uterus w ith a hardened rubber ring, tbe ordinary Meig's ring not being sufllciently firm. Tills, with plain and medicated enemas, gave im- mediate and satisfactoiy relief. As she had worn pessaries before, and was intelligent, 1 soon discon- tinued my visits, she promising to inform me di- rectly on the occurrence of the “slightest incon- venience.” Some six months subsequently she re- poited “ heat and slight pain in the lower poition of the abdomen, with some annoyance in passing wat- er ” An examination revealed a segment of the pessary, about an inch in length, posterior to and diagonally crossing the upper portion of the pubic arch, while the remainder of the instrument was deeply and firmly .Imbedded In the tissues of the vagina. I removed a segment of the pessary by means of a strong pair of dentist’s cutting forceps. Having a wholesome fear of the “ suctorial powers ” of the female urethra, from recent cases reported from the practice of ceitain wise men in the Kast, I was care- ful to rotate the cut extremity of tlie instinnient nearest it, (the urethra) towards the anus, which was patent, and to which the pessary exactly ap- plied and easily entered. I continued the rotation until the whole instru- ment was disengaged from the vagina. It required little adroitness to complete the operation. The va- gina contracted subsequently to such an extent that she has had almost no trouble since. I inclose the pessary as a gynaecological specimen. An old physician of considerable repu- tation, as I am informed, visited a certain locality, was waited upon by six ladies who were all found to need concavo-convex glass pessaries, which I think should never be used under any circumstances. Within two months one of the patients fractured her pessary, perforated the vagina, and died as a result; this''being the second in- stance of the kind which has come under my notice. I have met with a limited number of cases of inal-position where there has been complete inertia and want of sensibility of tbe uterine organs, and where the presence of pessaries not only served as a mechani- cal support, but also as an important rem- edial measure in arousing the tone and healthy action of these organs. In ISM) I treated Miss IT., set. 38. Retroflexion; extreme prolapsion; amonorrhoea; in bed nearly fifteen years ; a legion of difficulties, not the least of which were the direct sequence of gynaecological charlatanry. I had reason to fear that, the uterus was bound down by lirm adhesions, as an expe- rlencedlpractiti mer had failed in repositing it after a trial of more than an hour’s duration, and so difficult was it to move it from its bed. Guiding the sound with my left hand, and manipulating the fundus by means of a probang in the right, I succeeded in pass- ing the sound and replacing the organ, which I sus- tained by means of a modified Simpson’s intra-ute- rinc pessary, and which she wore uninterruptedly eleven week. The normal position and lost powers of the organ were restored, and the patient resumed her place in the household as a comfortable invalid. Every one of experience lias occasionally witnessed bow rapidly indurations of tbe uterus melt away under the pressure of a well adjusted pessary, interesting cases of which I might note, but I deem tbe country physician fortunate who lias such a result rather than serious complications. I have found that patients with short vaginae, suffering from displacements, are usually more successfully treated by me- chanical support than those of long vaginae. In the former cases, the pessary, if a lever, can generally be fitted accurately to the fossa; behind tbe ossa pubis and to tbe up- per portion of the vagina posterior to tbe uterus, and it retains its position with toler- able certainty; while in the latter cases, it is quite more difficult to secure such a re- sult, and we may be forced to content our- selves with such advantages as we can ob- tain from the elastic ring, which does not distend the vagina laterally to any consid- erable degree. An almost insuperable dif- ficulty m the management of pessaries in the country, is that our patients cannot, as a general thing, intermit their daily avoca- tions, and it is nearly impossible to avoid frequent misplacement of the instruments, and consequent results. Not questioning either the intelligence or successful prac- tic of those who differ from me in opinion, I wish to put upon record succinctly the conclusions which I have reached regard- ing the use of pessaries. And— 1st. That displacements of the uterus are, in a large majority of cases, either a direct sequence of, or are associated with a diseased condition of the uterine organs— the removal of which, by appropriate treat- ment, usually restores the uterus to its nor- mal position. The employment of pessa- ries in these cases complicates treatment, and compromits successful results. 2d. That in a certain proportion of cases of uterine displacements, a comparatively small number, well fitting pessaries, iu the hands of intelligent and skillful gynaecolo- gists, are essential to the cure of not only the mal-position, but also of the abnormal condition of the organ which accompanies it. Satisfactory results can hardly be ob- tained by any other method. 3d. That a pessary of whatever kind, when employed forthe mechanical support of the uterus, is a foreign body, liable to do serious and perhaps fatal mischief, and never should be placed in situ without great circumspection and close subsequent atten- tion on the part of the attending physician. It has no miraculous power, and its potency for harm is very much underrated. Different pessaries answer given indica- tions in specific cases, and none should be employed unless the practioner has a clear notion of just what is needed, and he ought to be able to alter or construct his instru- ments, if need be. The phraseology so commonly used by some interested writers, the retroversion, the anteversion pessary, etc., as if there were some inherent virtue in this or that particular instrument, is a gynaecological absurdity, calculated to mis- lead, and trenches too closely upon, adver- tising empiricism. Regarding the different forms of instru- ments used in the treatment of uterine dis- placements, I am of the opinion that intra- Uterine, or item pessaries, should seldom be used. They most generally produce a very considerable irritation; cannot be long worn, interrupt the marital relation, and prevent conception. The same objections, in the main, lie against the various modi- fications of the stem pessary, which sub- stitute a cup or ring for the intra uterine stem. Of the various forms of intra-vaginal pes- saries in use, 1 most decidedly prefer, and commonly employ, the closed lever made of hardened rubber (the best known ma- terial for pessaries, on account of its light- ness; the high polish of which it is suscepti- ble, and its non corrosiveness, and the fa- cility with which its shape can he altered), anu the soft, elastic ring made of delicate strips of fine whalebone, covered with pure rubber—a beautiful article of which is fur- nished by Tiemann & Co. The closed levers in their various forms, as generally procured, are first made into rings, then moulded. These on being soft- ened in boiling water, or by the heat of the vagina, as once occurred in my practice, re-assume the circular form, and it is then difficult to manipulate them into the de- sired shape. If they are greased and heat- ed over a lamp or coal fire, as usually rec- ommended, they are very apt to become brittle and lose their polish. They should be first made oblong, with the ends round- ed, one of them move fully so than the other. These on being placed in hot water, become plastic, and are readily moulded into any required shape. In relation to the use of Mu' sound for (he purpose of ac- curate diagnosis and replacing mal-posi- tions of tlie uterus, I regard it essential, and do not see how we can dispense with it, and yet, I think the more proficient we be- come in the “tactus eruditus,” the less we shall depend upon it for diagnosis, and in a majority of cases the uterus is restored to its normal position satisfactorily by means of a probang and conjoined manipulation either with or without the use of the specu- lum, (Sims,) tints avoiding some of the complications which occasionally arise from the indiscriminate use of the sound. A word of caution to my country breth- ren who may conceive a bright idea.— Several years since, after much thought and experiment, 1 contrived the plan of one of the most popular pessaries of the present time, which I thought would over- come some of the prominent difficulties in mechanical support of the uterus. The plan was still incomplete in detail and per. fection. I incautiously communicated my idea to a peripatetic professional friend (?) who was interested in a number of patents. Two years after, I learned that my exact idea, incomplete as it was, had been patent- ed by a mere boy doctor, who could have had almost no experience in such matters. I was informed, by my instrument-maker, that the sales had already amounted to over twenty thousand dollars I am satisfied that my confidence was misplaced, and that the man whose name the instrument bears, never conceived the idea of it