MECHANICAL TREATMENT 
OF 
VERSIONS AND FLEXIONS OF THE 
UTERUS 
A THEORETICAL AND PRACTICAL STUDY 
OF THE PESSARY 
BY 
ELY VAN DE WARKER, 
FELLOW OF AMERICAN GYNECOLOGICAL SOCIETY, BOERHAAVIAN SOCIETY, ETC. 
REPRINTED FROM VOLUME VII. 
oltynccologtcal Craittfactiong 
1883 MECHANICAL TREATMENT 
OF 
VERSIONS AND FLEXIONS OF THE 
UTERUS 
A THEORETICAL AND PRACTICAL STUDY 
OF THE PESSARY 
BY 
ELY VAN DE WARKER, 
FELLOW OF AMERICAN GYNECOLOGICAL SOCIETY, BOERHAAVIAN SOCIETY, ETC. 
REPRINTED FROM VOLUME VII. 
<Opnccological 
1883 MECHANICAL THERAPEUTICS OF VERSIONS 
AND FLEXIONS OF THE UTERUS. 
BY ELY VAN DE WARKER, 
Syracuse, N. Y. 
The mechanical therapeutics of uterine displacements 
is yet unsettled. No department in gynecology has been 
the object of greater interest, and no department of sur- 
gery in general has stimulated an equal inventive activity. 
With all this array of invention the mechanical problems 
involved are not advanced, nor the question of utility in any 
manner settled. It is doubtful if in the whole range of 
gynecology a subject can be brought up that will elicit such 
hostile criticism on one side, and such cordial approval on 
the other; but among the avowed friends of mechanical 
therapeutics there is even more irreconcilable conflict as 
to the mere forms of appliances, so that while the inflam- 
matory and mechanical schools of pathology stand at op- 
posite poles of science and practice, the former is yet more 
hopelessly divided against itself. 
There must be some reason for this state of affairs 
among a class of men, of whom I think I may say, that 
they are the peers of any for close and conscientious ob- 
servation. It is possible that this difference among those 
who practice mechanical reposition of displaced uteri 
comes from over-confidence in their methods, and the disap- 
pointment that is sure to result from this mental attitude. 
As a method of treatment a pessary can be no more blindly 
relied upon than a splint in a case of fractured limb. It 
requires to be used with intelligence, watchfulness, and 
with due regard to the conditions, changeable and obscure 2 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC'. 
as they often are, which demand its use. Do pessaries 
generally accomplish the purpose for which they are em- 
ployed ? This question is always in order, and brings us 
into the strife waged between the hostile schools. I have 
here proposed the problem from its mechanical stand-point, 
and in this view of the subject it must be answered. What- 
ever may be your theory of uterine pathology, if in any 
case a pessary has been applied, have you fixed for yourself 
an ideal standard of mechanical effect, and has this stand- 
ard been reached ? Dealing, as we are here, with mechani- 
cal agencies, and from which we ought to expect results 
that may be formulated with precision, it is singular how 
difficult it is to reach this ideal standard. My opinion is 
that this uncertainty results, in the first place, from expect- 
ing too much from the use of the pessary, and in the sec- 
ond place, from selecting an improper agent for want of 
more clearly defined ideas upon the absolute limitations 
imposed upon the action of pessaries, and which must gov- 
ern the mechanical results to be attained. That this con- 
fusion of ideas concerning these absolute limitations is one 
of the causes of failure is proved by the vast number of 
appliances invented, and the constant revival of obsolete 
forms of instruments to accomplish two simple mechanical 
results,—the straightening and lifting the uterine body 
either forward or backward. 
It is for the purpose of demonstrating this part of my 
subject that I have been careful to illustrate this mono- 
graph with nearly every form of pessary for the correction 
of versions and flexions of the uterus, to serve both as a 
guide and a warning to all who wish to invent a pessary. 
These illustrations are well worth study. They express 
to us graphically the history of a phase of thought. They 
show to us how the minds of many men seeking a single 
object halt at the same point, or revolve round a common 
centre. We can see in this apparent confusion of forms a 
common thought which links together the various groups, 
and a little study will show us that the members of these 
groups, into which I have divided them, are not different ELY VAN DE WARNER.. 
3 
instruments, but simply different expressions of the same 
form. 
In studying the mechanical principles involved in the 
theory of the pessary two things must be clearly defined : 
First, the limits imposed by the uterus and its appendages 
upon the mechanical agencies acting upon it; and, sec- 
ondly, the action of the mechanical forces under these limi- 
tations. These limits, both in their mechanical and uterine 
relations, are fixed and absolute. They are not to be evaded 
by skill, or ingenuity, and ought to be clearly understood. 
One is, however, reluctantly forced to conclude that the 
majority of pessaries are invented either in ignorance or 
defiance of these limits, and as if the only restriction upon 
their action was that of gravity. 
And first, the limits imposed by the uterus and its ap- 
pendages. Given a flexed or versant uterus, the problem 
is to restore it mechanically to a position which approxi- 
mates the normal, or if that is not possible, then to a suffi- 
cient extent to relieve symptoms. Now the normal position 
has never been, and cannot be, defined, simply for the reason 
that it is one of movement, not of stability. To be more 
exact, we may say that the mean of this mobility is the nor- 
mal, but in reality we cannot apply this mean position to 
any one woman any more than we can apply the average 
expectation of life to any given healthy individual. The 
difference between what is called a version and a normal 
movement, which may be equivalent to it in angular dis- 
placement, lies in the fact that the abnormal position is one 
of stability independently of the forces which induce 
changes of uterine position, and to which the healthy organ 
is responsive in a normal manner. A version, then, is a 
position of immobility not from fixation but from habit. If 
we restore this position to one that approximates the nor- 
mal mean we restore its mobility, and if this restoration is 
effected by mechanical agencies it must be with reference 
to this natural endowment of the organ. 
The correction of a flexion or version of the uterus me- 
chanically, with certainty, comfort, and safety to the sub- 4 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
ject, depends in the first place upon a few fixed and absolute 
conditions which cannot be violated. I enumerate them : — 
(a.) The limits imposed by uterine mobility. 
(b.) The limits imposed upon the action of pessaries by 
the vagina. 
(c.) A pessary must be adjusted with proper regard for 
the safety of the pelvic soft parts. 
(d.) A pessary must be so adjusted as not in any way to 
retard or arrest the function of any pelvic organ, nerve, or 
vessel. 
These must be considered in order to clear the way for 
the study of the pessary as a mechanical appliance in its 
various groups and classes. 
(a.) The Limits imposed by Uterine Movements upon the 
Action of Pessaries. — Nothing can be clearer than the 
statement that every mechanical means of support applied 
to the uterus must act without restraint upon those move- 
ments essential to the normal functions of the organ. If we 
regard the manner in which the uterus is supported, we shall 
see that one of the results of this method of suspension is 
extreme normal mobility in every direction. It is necessary 
to call attention here to but one fact, namely, that these 
supports are not attached to any fixed centre of suspension, 
but are distributed over a large part of the surface of the 
uterus. The idea of Aran and of those who follow him, 
that the uterus has a fixed centre of rotation, — an “ axe 
suspenseur,” — must, in view of this fact, be wrong. The 
uterus has an eccentric or cam-like movement, which may 
be defined by the expression that as the fundus is elevated 
the organ sinks in the pelvis, and that it is displaced later- 
ally in a direction opposite to that of its anterior rotation. 
In Fig. i I have endeavored not to exaggerate this ec- 
centricity of movement. The straight lines i, 2, 3, express 
the uterine axes of various abnormal positions, while the 
dotted line e e would express the arc described by the fun- 
dus during these movements if the uterus moved upon a 
fixed centre of rotation. But what I believe to be the fact, 
that each change of position has its own centre of suspen- ELY VAN DE WARNER. 
5 
sion, is shown by the lines which represent the arcs de- 
scribed by the vaginal portion instead of the fundus, which 
latter movement is defined by the shaded line i°, 30. Thus, 
the curve b expresses the movement in the 3 0 of retrover- 
sion, the curve a by the 2°, and the curve c by the i°, while 
the curve d shows the movement of the vaginal portion in 
the 2° of anteversion. 
Fig i 
If the uterus moved upon a fixed centre of rotation it 
would be comparatively easy to so adjust mechanical sup- 6 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
port as to accommodate these movements ; but, this not 
being the case, it is a matter of extreme difficulty. 
Of equal importance to the proper application of the pes- 
sary are the minor uterine movements. These are the vari- 
ous respiratory movements involved in the acts of respira- 
tion, articulation, coughing, and the like ; postural move- 
ments, and those of walking and abdominal expulsion. 
Several years ago I gave this subject a careful study by 
means of the recording mercurial manometer, and which, 
owing to the medium 1 through which I sought the public, 
is but little known among those interested in gynecological 
study. It is almost impossible to give an idea of the char- 
acter of these movements without reproducing a few of the 
manometrical tracings published in my former monograph. 
Fig. a. 
Fig- 3- 
Fig. 4. 
Fig. 2 is a tracing of easy respiration movement; Fig. 3 
is an articulation curve ; Fig. 4 is the record of uterine 
1 New York Medical Journal, April, 1875. EL Y VAN DE WARNER. 
7 
movement in the act of coughing, and Fig. 5 that of walk- 
ing. Fig. 6 represents the movements of the mercury in 
the manometer during voluntary expulsive effort. 
Fig. 5- 
Fig. 6. 
It is of the highest practical importance in this relation 
to realize that the mechanical force involved in these ute- 
rine movements varies from less than one to about seven 
pounds, as actually measured by a column of mercury. If 
we regard the results arrived at by Poppel1 and Duncan,2 
that the minimum force exerted during labor is equivalent 
to four to eight pounds, as at all correct, the remarkable 
fact is forced upon us, that there exists in the average 
woman, non-pregnant, voluntary expulsive force equivalent 
to an easy labor, and which she may exert at any time. In 
view of this fact it is not singular that uterine displace- 
ments play so large a part in the sexual disabilities of 
women, and that their mechanical correction is a matter of 
difficulty. 
1 Monatsschrift fiir Geburtskunde und Frauenkrankheiten, Bd. 22, 
S. 8. 
2 Researches in Obstetrics. 8 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
Much of the pain and tenderness that develops from 
wearing a pessary are the result of the mechanical restraint 
imposed upon this free mobility. Even when over-disten- 
tion or stretching of the vagina is an evident element in 
the intolerance of the pessary, it is difficult to eliminate the 
restrained movements of the uterus as a co-factor to this 
result. 
From what the tracings of the manometer have taught 
me, I should say that at least three quarters of an inch 
ought to be allowed for unrestrained uterine movement in 
adjusting the pessary. Anything less than this would be 
certain to interfere with the movements of the organ, es- 
pecially in movements of the uterus attending defecation 
and forced inspiration and coughing. The fact must not 
be lost sight of anywhere in this paper, that I am speaking 
only of the mechanical correction of versions and flexions. 
(b.) Limits imposed upon the Action of Pessaries by the 
Vagina. — These limits are absolute and cannot be evaded. 
After we have elevated the uterus mechanically to the 
limits of the vagina, direct action of the instrument ceases, 
and if beyond this point any further effect is produced, it is 
by evoking the operation of other agencies. From the de- 
scription of many of the version pessaries, it is clear that 
the inventor and the practitioner who use them expect that 
by means of a curve, or the pressure of the upper extremity 
of the pessary, the depressed fundus of a versant uterus may 
be raised by the direct action of the instrument. But this 
is impossible. When the upward pressure is arrested by 
the vagina, it is evident that movement in this direction 
ceases. What has been accomplished so far has been a 
lifting upward of the vaginal vault, and to a corresponding 
degree that of the uterus in its same relative displacement, 
while the anterior wall is placed upon greater tension than 
the posterior, being the shorter limb of the vaginal curve. 
This simple upward pressure would relieve a retroverted 
uterus just as effectually if the force was applied in front 
of the vaginal cervix as behind it. This being the condi- 
tion of affairs when the vaginal limits interpose further up- ELY VAN DE WARNER. 
9 
ward movement, the vaginal walls themselves become the 
agents of any further change induced in uterine position 
by prolonging the upward pressure. To illustrate, let us 
take the familiar example of the Hodge closed pessary — 
lever, as it is improperly called, — by which instrument 
the force is applied to the posterior cul-de-sac, and the 
uterus lifted until the slack of the posterior vaginal wall is 
taken up, when, the same force being continued, the vagi- 
nal neck is drawn backward, the fundus moving to the same 
extent forward, if the uterine body is of normal consistency, 
by the vagina drawing over the upper end of the pessary 
as though it were a pulley. With this action of the pos- 
terior we always find the anterior vaginal wall under more 
or less tension, which could not be the case otherwise. 
This law is taken advantage of in nearly all version pessa- 
ries in use, but, unfortunately, the action is confounded with 
a lever instead of a lifting force. In the normal relation of 
the parts the vaginal roof with the uterus may be raised 
one inch and a half to two inches, and this not at the ex- 
pense of the elasticity of the passage, but by the erasure 
of its folds. Any mechanical elevation of the uterus to 
this extent must result in absolute fixation, and in a short 
time become intolerable if not dangerous. 
In every application of a pessary the mechanical walls 
must be regarded as a part of the mechanism involved. I 
believe this rule to be true in every successful replacement 
of a version, and it is by bringing into play this pulley-like 
action of the vagina upon the lower uterine neck that we 
are enabled to extend the action of a pessary beyond the 
limits of the vaginal sac. Any attempt by mere force to 
get a direct action of a pessary upon a depressed uterine 
fundus is practically violence to the vaginal tissue, and pre- 
vents the participation of its walls in the mechanical action 
of the pessary. This explains the difference in the action 
of pessaries in retroversions and anteversions of the uterus. 
In the former we bring into action the posterior vaginal 
wall upon the uterine neck with great facility; while in the 
latter, the anterior wall being shorter it draws the uterine 10 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
neck forward to a much less extent. This action is also 
antagonized by the posterior vaginal wall, more or less, de- 
pending in a great measure upon the fact whether the 
anteversion pessary passes into the posterior cul-de-sac or 
not. In case the instrument places the posterior wall of 
the passage upon the stretch at the same time lifting force 
is directed against the anterior wall, the strain of the in- 
strument is in opposite directions, and the lift upon the 
anterior wall is reduced to nothing. Any instrument de- 
vised upon this plan can be compared to nothing else than 
a man trying to lift himself over a fence by pulling up upon 
the straps of his boots. The vaginal limits to the action of 
a pessary are more marked in anteversion than in retro- 
version, and the same law holds that the fundus cannot be 
lifted except the cervix be drawn forward to an equal de- 
gree. That under the most favorable circumstances this is 
more difficult than in retroversions is shown by the prone- 
ness of the anterior wall to ulcerate under the action of an 
anteversion pessary. 
These remarks are true only of versions, and do not in 
any way apply to the correction of flexions. We have ab- 
solutely no means of redressing flexion mechanically from 
the vagina alone. I say this after a careful study of the 
subject extending over many years, and after experimenting 
with every form of pessary that gave the least promise of 
success. We may operate with the same results upon the 
vaginal portion mechanically in both versions and flexions ; 
the cervix moves to the same extent under the operation 
of the same force in both forms of uterine error. While 
the fundus is rotated in proportion to the cervical move- 
ment in version, and thus the displacement more or less 
corrected, in flexions the organ makes a partial rotation 
corresponding in extent to the movement of the cervix, but 
is still flexed. It may be said in objection to this idea, that 
vaginal supports of various kinds do relieve the symptoms 
in cases of uterine flexions. This is true ; but this relief is 
given not by correcting the flexion, but by lifting the ute- 
rus, and thus partially relieving the vessels and nerves of ELY VAN DE WARNER. 
11 
the organ. In proof of this I may mention an experience 
which I have often verified, that a simple globe pessary will 
afford this relief better than any of the complicated vaginal 
pessaries I have ever used, and in which case there can be 
no question that the flexion remains unchanged. These 
facts ought to teach us not to attempt to correct a flexion 
of the uterus by means of any force limited wholly by the 
vagina. 
(e.) A Pessary must be adjusted with a Proper Regard for 
the Safety of the Soft Parts. — Much of the ill repute attached 
to the pessary comes from the frequently published cases 
of injury to the vagina due to this instrument. There are 
two elements in this result of wearing a pessary. The 
most important one is injury due to an improperly fitted in- 
strument. This is not usually such a misfit as to be intol- 
erable to the patient at once, for in such a case the misfit 
is its own remedy, but is of such a character that at first no 
ill effects are noticed, and the patient only becomes gradu- 
ally aware that mischief is being done. Pressure needs but 
to be continuous to result in ulceration. A pessary that 
fills the vagina so closely that no play of the vagina upon 
the points of bearing is possible may very quickly result in 
erosion or ulceration. A pessary so large, or of such a 
kind, as to cause uterine fixation constantly exposes the 
woman to this danger. It may, on the other hand, be so 
small that erosion of the vaginal wall may result. The 
instrument gets out of position and is crowded across the 
vaginal passage, so that the tissues are confined between 
the extremities of the pessary on one side and the pelvic 
hard parts on the other. This question of fit is even more 
difficult to get a correct idea of than that of selecting a 
proper pessary to accomplish the object in view. Nothing 
but practice will enable one to acquire a skilled touch in 
this matter of a safe and proper fit. * 
Secondly, a pessary may be of a proper kind, and perfect 
in its adjustment, and yet do harm by imprudence in its 
use. Of this nature, no doubt, are many of the cases of 
injury that we read about. It has not been unusual in my 12 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
experience to remove a pessary which the patient had 
placed by her physician a year or more before. In the ma- 
jority of cases such a long continuous wearing of a pessary 
is the result of the carelessness or willful stubbornness of 
the patient. I remember an instance in my own practice 
which illustrates this. I was called by my friend, Dr. M. B. 
Fairchild, to see a patient, who, in consequence of a flexion 
of the uterine neck, suffered severe dysmenorrhea. I in- 
troduced an intra-uterine stem, which gave complete relief 
to pain and the locomotor symptoms. I left Dr. Fairchild 
directions about the removal of the instrument, but was 
surprised by the doctor informing me a year after, that he 
could not remove the stem, as the patient would not per- 
mit it. She dreaded the return of her old symptoms. I 
wrote her, as she lived at a distance, drawing as vivid a 
picture as possible of the consequences which might result 
from her stubbornness. She answered me that she was 
perfectly well, and she was sure that nothing had happened 
as I described, because she felt so well in the pelvic organs. 
It was six months after that I succeeded in getting the stem. 
Happily no bad consequences resulted from this continued 
wearing of the stem for a year and a half, and which I am 
sure was the result of the principle upon which I make and 
use my form of this instrument. 
A patient needs to be informed about the care of her 
person while wearing a pessary, and to regard herself as 
constantly under treatment. It is often necessary to give 
her very plain and positive instructions upon the matter 
of occasional examinations, and removing and cleaning the 
pessary. Pessaries are sometimes made of material that 
requires constant care. Pure gum or soft rubber instru- 
ments are very liable to become offensive and cause an 
irritating discharge, and which, in some patients, unless 
careful attention is given to hygiene, will result in vaginal 
erosion. 
(d.) A Pessary must be so adjusted as not in any way to 
retard or arrest the Function of any Pelvic Organ, Nerve, or 
Vessel — It would hardly seem necessary to give this sub- EL Y VAN DE WARNER. 
13 
ject any place, for the reason that the proposition is so self- 
evident that no argument can make it clearer ; yet, in the 
majority of cases, defeat in the use of the pessary comes 
from this source. An instrument may be theoretically cor- 
rect as to form, or its form may be entirely wrong, and in 
both instances be equivalent to the same error through vio- 
lation of this law. We may know that this condition is 
being violated by the symptoms resulting from the pres- 
ence of the pessary; or, at least, we may assign this as a 
cause when there is a peculiar wearing sacralgia, fixed, or 
radiating down the limbs, supra-pubic pain and tenderness, 
urine incontinence, or dysuria, pain in defecation or in pos- 
tural changes, and increased general nervous irritability. 
All these evidences of pelvic disturbance, except that of 
the bladder, may result from the violation of one function 
of the pelvic organs, namely, uterine mobility. As this will 
be referred to repeatedly later, it need not be taken up here. 
The next important organ liable to be disturbed by the 
pessary is the bladder. Some forms of the instrument which 
are very useful, like the elastic ring and the original form of 
the Hodge, are disposed to excite functional disturbance of 
this organ by the lower end tilting against the base of the 
bladder or upper urethra. It is remarkable how slight a 
pressure will do this if it is continuous. Force directed 
against the base of the organ will cause strangury, and 
upon the upper urethra will produce incontinence, so that 
it is not difficult to judge from the symptoms the point 
that is exposed to pressure. It is frequently one of the 
difficult points in the fit of a pessary to so shape its lower 
extremity as to avoid bladder disturbance. 
The rectum is rarely disturbed by the pressure of a pes- 
sary through its anterior wall, except in cases of fecal accu- 
mulation when the rectal contents are apt to lodge above 
the bow of the instrument, and when strong effort is made 
at defecation the pessary is sure to be seriously displaced. 
This is one of the chief causes of expulsion of intra-ute- 
rine stems that depend upon small vaginal supports for their 
retention. I have seen hemorrhoids which were in a great 14 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
measure ascribable to the backward pressure of a pessary 
on the vaginal wall. The simple ring is quite liable to do 
this, especially when too small, as the upper or posterior 
part is forced down, and the anterior upward, behind the 
pubes, thus placing the instrument at right angles nearly 
to the posterior wall, the hemorrhoidal veins bearing the 
greater part of the pressure. The same is liable to occur 
in case of very short vaginas, in spite of the greatest care. 
Sacralgia is rather a symptom of erosion, or ulceration at 
the posterior cul-de-sac, than of undue force. Pressure, 
from the presence of a pessary, so great as to excite neu- 
ralgia of the sacral nerves, could not be borne at all, and 
thus would suggest its proper remedy. The sacral pain is 
evidently reflex, of a nature similar to that due to erosion 
of the cervix. Any form of instrument may excite ulcer- 
ation of the vaginal walls if allowed to remain too long, as 
I have already said. I have known dysmenorrhea excited 
by obstruction to the menstrual flow. Intra-uterine stems 
are prone to do this when too large, or when the vaginal 
portion of the stem fits too closely about the os externum. 
Stems, as made by the instrument makers, are nearly one 
half too large, as a rule. A sharp or long anterior curve 
to the Hodge form of instrument may cause the same ob- 
struction by pressing the walls of the vaginal cervix to- 
gether. A very slight obstruction to the escape of the 
menstrual flow will excite expulsive pain. This fact must 
be always remembered, and precautions taken at the first 
signal of disturbance. 
Pain excited in the pelvis during postural changes is 
strong evidence of an ill-adjusted or improper pessary. 
This must never be overlooked or made light of, and the 
patients told, as they often are, that they will get used to it 
after a time. Even if no physical harm results, moral in- 
jury will be sure to follow as the patient is made uneasy 
and anxious. It is a wise precaution to have the patient 
put herself in a variety of postural changes, such as sit- 
ting, walking, standing, and bending forward, after a pes- 
sary is first introduced, in order to test this point, and any 
complaint attended to at once. EL Y VAN DE IVARKER. 
15 
Many pelvic conditions, such as peri- or parametritis, 
tumors, hematocele, and ovarian tumors and displacements, 
may act as absolute limitations to the action of a pessary, 
but they are of such a nature as to require no special men- 
tion here. 
The variety of pessaries is so great that an attempt to 
describe them without a proper classification would be vain. 
One might as well make a scientific description of a family 
of animals without grouping it into genera and species, as 
to make a mechanical analysis of pessaries without dividing 
them into groups and classes. 
When I had gathered together my immense material of 
pessaries, I found that I had entered a new field of research, 
and that whatever I intended to say and do within the lim- 
its of this field may have been said and done before me ; 
still it was all confusion because no one had studied it as a 
whole, and arranged and grouped its facts. This was al- 
together a different matter from looking at the pessary 
singly, or in its purely practical relations. Further, un- 
less one confined a paper of this sort to the limits of a 
mere catalogue, it would require a volume to separately 
analyze the mechanical principles of each instrument. 
It was a matter of considerable study to adopt a system 
of classification. An arrangement based purely upon the 
few mechanical elements involved would not only be diffi- 
cult, but, as this was in a certain sense a pioneer paper, it 
was liable to excite considerable controversy, as such a 
classification would frequently lead me to view an instru- 
ment in a totally different manner from the inventor. Fi- 
nally, I adopted the plan of defining three principal groups 
by the aid of the very manifest mechanical elements in- 
volved, and about which there could be no difference of 
opinion, and of describing the several classes under these 
groups by the mechanical results, or uterine changes in- 
duced by the presence of the instrument, instead of still 
further refining upon the minor mechanical principles shown 
by the various classes in each group. 16 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
Group I. — Those pessaries combined with support ex- 
ternal to the body. 
Class i. The simple intra-vaginal pessary with external 
support. 
Class 2. Those that combine a pessary acting by me- 
chanical displacement with support external to the body. 
Class 3. Those that combine absolute uterine fixation of 
the cervix with external support. 
Group II. — Pessaries acting wholly intra-vaginally. 
Class 1. Those pessaries acting by displacement. 
Class 2. Those pessaries that move the vaginal cervix 
by action of the vaginal walls in a direction opposite to the 
movement of version of the fundus. 
Class 3. Those which retain the vaginal cervix in a fixed 
position, and thus prevent rotation of the uterus. 
Group III. — Pessaries acting within the body of the 
uterus — intra-uterine stems. 
Class 1. Intra-uterine stems with support external to the 
body. 
Class 2. Intra-uterine stems combined with various forms 
of vaginal pessary. 
Class 3. Self-retaining intra-uterine stems. 
Class 4. Diverticulating intra-uterine stems. 
Class 5. Intra-uterine stems with simple vaginal attach- 
ment necessary for retention. 
CLASSIFICATION OF VERSION AND FLEXION PESSARIES. 
GROUP I. — Support External to Body. 
Class i. — Simple Intra-vaginal Pessary with External Support. 
Name. 
Form of Dis- 
placement. 
Plate. 
Figure. 
Reference. 
Priestley. 
Priestley, modified by 
Cutter. 
The same. 
Cutter. 
Retroversion. 
Retroversion. 
Retroversion. 
Retroversion. 
XII. 
XII. 
Text. 
XII. 
z 
2 
7 
3 
Cat. Obstet. Instruments, Obstet. Soc. 
Lond., p. 180, Fig. 178, 1867. 
Thomas, Prac. Treat. Dis. Women, 
p. 379, Fig. 142, ed. 1872. 
The same. 
Uterine Ver. and Flex., 1876, p. 20, 
Fig- 4- ELY VAN DE WARNER. 
17 
Class 2. — Displacing Pessary with External Support. 
Name. 
Form of Dis- 
placement. 
Plate. 
Figure. 
Reference. 
Priestley, modified by 
Thomas. 
Retroversion. 
(XII. 
1 Text. 
4 
8 
Thomas op. cit., p. 379, Fig. 141. 
Name. 
Form of Dis- 
placement. 
Plate. 
Figure. 
Reference. 
Wade. 
Cutter-Thomas. 
Weber. 
A. and R. flex, 
and version. 
Anteversion. 
Retroversion. 
XII. 
Text. 
Text. 
5 
9 
9a 
Amer. Jour. Obstet., 1878, p. 710. 
Thomas, op. tit., ed. 1880, p. 423, 
Fig. 166. 
Tiemann’s Cat., Part III., Fig. 428b. 
Class 3. — Fixation of Cervix with External Support. 
GROUP II. — Includes all the Instruments that act 
WITHIN AND ARE LIMITED BY THE VAGINA. 
Class i. —Pessaries acting by Displacement. 
Name. 
Form of Dis- 
placement. 
Plate. 
Figure. 
Reference. 
FaSe- 
Retroversion. 
Text. 
II 
N. Y. Med. Record, May q, 1876. 
Pafien. 
Anteflexion. 
Text. 
12 
Reynder’s Catalogue. 
Cole. 
Anteflexion. 
Text. 
14 
Med. and Surg. Rep., June 4, 1881. 
Cole. 
Retroversion. 
Text. 
15 
Loc. cit. 
Hitchcocks. 
Ante version. 
Text. 
13 
Trans. Am. Med. Assoc., xv., 104, 
Smith, Heywood. 
Retroversion. 
Text. 
l6 
105. 
Prac. Gynecol., p. 108, 1R78. 
Thomas. 
Anteversion. 
Text. 
17 
Thomas, op. cit., p. 422, Fig. 163,1880. 
Gehrung. 
Anteversion. 
Text. 
18 
St. Louis Med. and Surg. Jour., July, 
Vulliet. 
1877. 
Anteversion. 
XIV. 
, 5 
Trans. Obstet. Soc. Lond., xvii., 64. 
Thomas. 
Anteversion. 
Text. 
Tiemann’s Cat., Part III., p. 89. 
Hewitt, modified by 
Anteversion. 
Text. 
21 
Op. cit., Part III., p. 89. 
Thomas. 
Hewitt. 
Anteversion. 
XIV. 
I 
Hewitt, Dis. of Women, p. 523, Fig. 
Hewitt, modified by 
Anteversion. 
XIV. 
{ 2 
Beigel, Die Krankheiten d. weib- 
Beigel. 
( 3 
lichen Geschlechtes, Bd. i., S. 180, 
Fig. 1, A. and B. 
Hewitt, modified by 
Schultze. 
Anteversion. 
XIII. 
II 
Archiv f. Gynakol., Bd. iv., S. 387, 
Figs. 1 and 2. 
Thomas. 
Anteversion. 
Text. 
[23 
Thomas, op. cit., p. 422, 1880. 
Thomas. 
Anteversion. 
Text. 
25 
Thomas, op. cit., p. 421. 
Galabin. 
Anteversion. 
XIII. 
7 
Obstet. Trans., Lond., xviii., p. 177, 
Gehrung. 
1876. 
Retroflexion. 
Text. 
28 
St. Louis Med. and Surg. Jour., 
Gehrung. 
July, 1877. 
Anteflexion. 
Text. 
27 
Loc. cit. 
Pallen. 
Retroversion. 
Text. 
26 
Am. Jour. Obstet., July, 1877. 
Studley. 
Anteversion. 
XIII. 
9 
Am. Jour. Obstet., Jan., 1879. 
Thomas. 
Anteversion. 
XIV. 
8 
Thomas, op. cit., p. 363, Fig. 126. 
Gay. 
1872. 
Retroversion. 
XIV. 
9 
Copied from Beigel, op. cit., Bd. i., S. 
275, Fig. 92. 18 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
Class 2. — Pessaries that ad upon the Uterus by excitmg Action 
of the Vaginal Walls. 
Name. 
Form of Dis- 
placement. 
Plate. 
Figure. 
Reference. 
Hodge. 
Retroversion. 
XIII. 
|j 
Hodge, Dis. of Women, 415, Fig. 
a} 0, c. 
Hodge, modified by 
Retroversion. 
XIII. 
4 
Hewitt, op- cit., p. 521, Fig. 74. 
Hewitt. 
Hodge-Smith. 
Retroversion. 
XIII. 
1 6 
Thomas, op. cit., p. 446, Fig. 184, 
Hodge-Thomas. 
Retroflexion. 
Text. 
3° 
Thomas, op. cit., p. 44.6, Fie. 184. 
The same. 
Retroflexion. 
Text. 
3i 
Same reference. 
Chamberlain. 
Retroflex, and 
version. 
Text. 
|32 
( 33 
N. Y. Med. Record, viii., 396, 1873. 
Carroll. 
Retroflexion. 
Text. 
34 
N. Y. Med. Record, March 30, 1878. 
Woodward. 
Retroflexion. 
Text. 
35 
N. Y. Med. Jour., October, 1876. 
Scattergood. 
Retroversion. 
XIII. 
8 
Thomas, op. cit., 3801 Fig. 144, 1872. 
Archiv f. Gynakol., tv., 387, Figs. 1 
Schultze. 
Retroversion. 
XIII. 
IO 
and 2. 
Thomas. 
Retroversion. 
XIV. 
4 
Thomas, op. cit.,p. 378, Fig. 140, 1872. 
Class 3. — Pessaries that fix the Vaginal Cervix and prevent Rota- 
tion of the Uterus. 
Name. 
Form of Dis- 
placement. 
Plate. 
Figure. 
Reference. 
Hoffman. 
Retroversion, 
Text. 
36 
Thomas, op. cit., p. 57s, Fig. 136,1872. 
Hurd. 
( Retroflexion. 
XII. 
6 
Thomas, op. cit.,p. 395, Figs. 150, 151. 
Woodward. 
Anteflexion. 
Text. 
37 
N. Y. Med. Jour., October, 1876. 
Ut. Displacements Considered, Pam- 
phlet, Youngstown, Ohio, 1881. 
111. State Med. Soc. Trans., 1875, 
p. 207. 
Thomas, op. crt, p. 421, Fig. 158,1880. 
Dis. Female Sex. Organs, p. 175, 
Fig. 60. 
F owler. 
Anteversion 
or flexion. 
Text. 
38 
Fitch. 
Anteversion 
or flexion. 
Text. 
39 
Thomas. 
Anteversion. 
Text. 
40 
Schroeder. 
Retroflexion. 
XII. 
7 
Studley.' 
Retroversion. 
XIV. 
6 
Am. Jour. Obstet., January, 1879. 
GROUP III. — Intra-uterine Stems. 
Name. 
Form of Dis- 
placement. 
Plate. 
Figure. 
Reference. 
Simpson 
Version and 
Text. 
4i 
Simpson, Obstet. and Gynecol., p. 
flexion. 
703, Fig. 27. 
Winckel, Die Behandlung d. Flex. d. 
The same. 
As above. 
I. 
f 2 
( 3 
Uterus, S. 19, Taf. I. 
Kiwisch. 
Version and 
I. 
I 
flexion. 
Winckel, op. cit., S. 20, Taf. I., Fig. 
V. 
Valleix. 
Version and 
flexion. 
II. 
{ l 
Kilian. 
Version and 
III. 
I 
Winckel, op. cit., S. 20, Taf. II. Fig. 
flexion. 
VIII. 
Cutter. 
( Text. 
40 
Cutter, Ut. Versions and Flex., p. 89 
Flexion. 
\ iv. 
2 
(modified). 
Beigel. 
Flexion. 
III. 
2 
Beigel, Krankh. d. weiblich. Gesch., 
1 . 
ii. Bd., S. 243, Fig. 71. 
Class i. — Stems having Support External to the Body. EL Y VAN DE WARNER. 
19 
Class 2. — Intra-uterine Stems attached to various Forms of Vaginal 
Pessary. 
Name. 
Form of Dis- 
placement. 
Plate. 
Figure. 
Reference. 
Detschy’s Hystero- 
Version and 
IV. 
I 
Schmidt’s Jahrbiicher, Bd. 83, p. 321 
mochlion. 
flexion. 
(>854)- 
The same; another 
Version and 
VI. 
6 
Thomas, op. cit. (Wieland and Du- 
form. 
flexion. 
brisay), p. 393, Fig. 149, 1872. 
Schultze. 
Flexion. 
VI. 
5 
Schultze, Archiv f. Gynak., Bd. iv., 
p. 414, Fig. 14. 
Schultze. 
Flexion. 
VI. 
7 
Schultze, loc. cit., Fig. 15. 
Amann, Zur. mechanischen Behand- 
Amann. 
Flexion. 
VI. 
2I 
lung d. Versionen' u. Flexioneu d. 
Uterus, p. 45, Fig. 7. 
Simpson, modified by 
Martin. 
Flexion. 
VII. 
i 
Beigel, op. cit., Bd. ii., p. 244, Fig. 73. 
Hewitt. 
Flexion. 
VII. 
2 
Beigel, op cit., Bd. ii., p. 24=;, Fig. 74. 
Winckel. 
Flexion. 
VII. 
3 
Winckel, Die Behandlung d. Flex- 
ionen d. Uterus, p. 23, Fig. 18. 
Winckel. modifica- 
tion of Valleix. 
Flexion. 
VIII. 
X 
Winckel, op. cit., p. 23, Fig. 15. 
Chadwick. 
Flexion. 
VIII. 
3 
Trans. Am. Gynecol. Soc., vol. ii., 
p. 444. 
Cutter. 
Flexion. 
VIII. 
4 
Cutter, op. cit., p. 128, Fig. 26. 
Schultze, Archiv f. Gynak., Bd. iv., 
Schultze. 
Flexion. 
VIII. 
S 
Winckel. 
Flexion. 
VIII. 
2 
p- 413, Fig. 13. 
Winckel, op. cit , p. 23, Fig. 16. 
Studley. 
Flexion. 
VIII. 
f 6 
Am. Jour. Obstet., January, 1879. 
Hodge, modification 
Flexion. 
IX. 
i i 
Hodge, Dis. of Women, pp. 411, 415. 
Barnes. 
Flexion. 
IX. 
3 
Barnes, Dis. of Women, p. 614. 
Trans. Obstet. Soc. Lond., vol. xiv., 
Williams. 
Flexion. 
IX. 
4 
p. 308. 
Kinloch, modification 
of Hodge-Simpson. 
Retroflexion. 
Text. 
I42 
I 43 
Trans. S. C. Med. Assoc., 1875, p. 
261, Figs. 2, 3. 
Tiemann’s Cat., Part III., p. 89, Fig. 
Thomas. 
Anteflexion. 
Text. 
44 
Thomas. 
Anteflexion. 
Text. 
45 
I* 
Thomas, Prac. Treat. Dis. of Women, 
p. 428, Fig. 169, 1880. 
Thomas. 
Anteflexion. 
Text. 
46 
Thomas, op. cit., p. 428, Fig. 169, 1880. 
Letter from Dr. B. E. Mossman, 
Mossman. 
Retroflexion. 
Text. 
5i 
Greenville, Pa. 
Thomas. 
Lateroflexion. 
Text. 
52 
Thomas, op. cit., p.452, Fig. 197,1880. 
Van de Warker. 
Anteflexion. 
Text. 
4* 
N. Y. Med- Jour., vol. xxiii., p. 561, 
49 
15° 
1876. 
Name. 
Form of Dis- 
placement. 
Plate. 
Figure. 
Reference. 
Unknown. 
Squarey. 
Van de Warker. 
Anteflexion. 
Any flexion. 
Anteflexion. 
Text. 
IX. 
Text. 
.53 
u 
54 
Tiemann’s Cat., Part III., Fig. 425. 
Lond. Lancet, 1874, p. 49. 
N. Y. Med. Jour., October, 1873. 
Class 3. — Self-retaining Form of Intra-uterine Stem. 20 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
Class 4. — Spring Intra-uterine Stems. 
Name. 
Form of Dis- 
placement. 
Plate. 
Figure. 
Reference. 
Kiwisch. 
Ante or retro- 
XI. 
Verhand. d. Gesellschaft f. Geburts. 
flexion. 
ll 
4th yr. Taf., Figs. I., II., III. 
Kiwisch-Mayer. 
Ante or retro- 
XI. 
( 4 
Winckel, op. cit., Fig. VII. 
flexion. 
15 
Wright. 
Anteflexion. 
X. 
{3 
Wright, Ut. Disorders, p. 86, Lond. 
1867. 
Wright - Chambers - 
Anteflexion. 
X. 
4 
Beigel, op. cit., Bd. ii.,p. 248, Fig. 78. 
Beigel. 
Chambers. 
Ante or retro- 
X. 
5 
Obstet. Jour. Gr. Br. and Ire., vol. i., 
flexion. 
p. 22. 
Aveling. 
Ante or retro- 
X. 
6 
Trans. Obstet. Soc. Lond., vol. vii., 
flexion. 
p. 156. 
Simpson. 
Anteflexion. 
X. 
I 
Lond. Lancet, 1866, p. 531. 
Class 5. — Intra-uterine Stems with Simple Vaginal Attachment 
Necessary for Retention. 
Name. 
Form of Dis- 
placement. 
Plate. 
Figure. 
Reference. 
Simpson. 
Ante- or retro- 
flexion. 
V. 
{: 
Winckel, op. cit., Figs. II., III. 
Simpson. 
The same. 
V. 
3 
Beigel, op. cit., 240, Fig. 68. 
Simpson. 
The same. 
V. 
4 
Simpson, Dis. of Women, p. 77Q. 
Fig. 141. 
Simpson. 
The same. 
V. 
5 
Simpson, op. cit., p. 778, Fig. 140. 
Lazaruvitch. 
Retroflexion. 
V. 
Trans. Obstet. Soc. Lond., vol. xi., 
P* 79- 
Schroeder, Dis. of Women, Ziem- 
Schroeder, after 
Anteflexion. 
V. 
8 
Simpson. 
Peaslee, after Simp- 
Retroflexion. 
V. 
9 
ssen’sCyc.,Eng.ed.,p. 174, Fig. 59. 
Trans. Med. Soc. S. N. Y., 1866, p. 
son. 
IOO. 
Tait, after Simpson. 
Anteflexion. 
VI. 
I 
Obstet. Jour. Gr. Br. and Ire., vol. i., 
p. 180. 
Conant. 
Retroflexion. 
VI. 
3 
Tiemann, Cat., Part III., Fig. 422. 
Edwards. 
Retroflexion. 
VI. 
Tiemann, Cat., Part III., Fig. 427. 
Braun, C. 
Ante- or retro- 
VII. 
{ t 
Winckel, op. cit., Figs. XIII., XIV. 
Martin, E. 
Anteflexion. 
VII. 
6 
Winckel, op. cit., Fig. XV., et Mar- 
Text. 
tin, Neig. u. Beug. des Ut., p. 78. 
Sims. 
Ante- or retro- 
57 
Also published. 
flexion. 
Van de Warker. 
Retroflexion. 
Text. 
( 55 
\ 56 
Buffalo Med. and Surg. Jour., April, 
1874. 
Donaldson. 
Ante- or retro- 
Text. 
53 
Donaldson, Contributions to Prac. 
flexion. 
Gynecology, p. 61. 
This classification may appear complicated ; but take all 
of Group III. as an example, and we perceive that each 
of the classes is designed to act upon different principles, 
either in the correction of uterine distortion or of reten- 
tion. With these differences I do not see how the classi- 
fication of this group could be simplified. The same may ELY VAN DE WARNER. 
21 
be said of Group II., which is exceedingly difficult to clas- 
sify and describe. 
Group I., comprising all those pessaries that act upon 
the uterus by support external to the body, represents one 
of the oldest forms of version and flexion pessaries. Much 
of the disrepute historically attached to the intra-uterine 
stem came from its fatal connection with this means of re- 
tention. The theory upon which this group of instruments 
was based was becoming obsolete, when it was revived by 
securing a place in Dr. Thomas’s text-book. 
The simplest form of this group is Class i, being a sim- 
ple firm loop passing into the posterior or 
anterior vaginal cul-de-sac, and retained in 
place by elastic support connected with an 
abdominal belt. Its modern form, known as 
Cutter’s pessary, is a survival of an old form 
(PI. XII., Fig. i), which gained no repu- 
tation. It was invented by Priestley. 
This theory is connected with another 
principle of mechanical change in uterine 
position, that of displacement. This consti- 
tutes Class 2 (Fig. 8). I apply the term dis- 
placement to the introduction 
of any mass within the grasp 
of the vagina, sufficiently 
large to elevate the vaginal 
vault and displace the uterus 
from any position it may oc- 
cupy in the direction of the 
least resistance. This im- 
plies freely movable walls. 
In combination with the 
Priestley form of instrument, 
the principle of its action is 
violated, for, the posterior 
vaginal wall against which 
the bulbous enlargement A, 
Fig. 8 (PI. XII., Fig. 4) impinges, is fixed by the strong 
Fig. 7. 
Fig. 8. 22 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
upward pressure of the external support, while the mass A 
displaces the cervix forward in the ratio of its bulk, and the 
posterior vaginal wall antagonizes this forward movement 
by backward traction in proportion to the upward pressure 
of the external support. This enlargement of the upper 
part of the instrument was added, probably, for the purpose 
of increasing the bearing surface of the loop, seen to better 
advantage in Fig. 7, and thus obviating one of the dangers 
of this form of instrument, ulceration of the vaginal wall. 
It will be seen, however, that, from the counter strain upon 
the posterior vaginal cul-de-sac, it is exposed to more dan- 
ger from this form than from Class 1 of this group. 
In Class 3 we have presented a still more dangerous 
instrument (PI. XII., Fig. 5), in which the upper part is 
formed into a coil which encircles the cervix, and thus 
causes absolute fixation. In this form by Wade we have 
united every bad principle that can be combined in a pes- 
sary. In another pessary (Cutter, PI. XII., Fig. 3) we have 
nearly the same form with less incarceration of the ute- 
rine neck. In this class, in which absolute fixation is the 
distinguishing trait, we must also include Thomas’s mod- 
ification of Cutter’s pessary. In this instrument there is 
an anterior loop prolonged backward until it meets the 
descending limbs, which connect it with the external sup- 
port (Fig. 9).1 It is designed to correct intractable forms 
of anterior displacement, but in view of the 
limits to upward displacement due to the 
anterior vaginal wall, it is difficult to under- 
stand how it could materially change the 
relative position of the uterus with safety 
to the part. 
There is necessary only a brief comment 
upon this group of pessaries. Nothing but 
an extraordinary combination of pelvic con- 
ditions would warrant the use of a version or flexion 
pessary that violates every rule for the proper adjustment 
of the instrument. Certainly, if the “physician possess 
Fig. 9. 
1 Thomas, Pract. Treat, on Dis. of Women, p. 423, 1880. ELY VAN DE WARNER. 
23 
only little skill in the use of pessaries,” he had better em- 
ploy an internal pessary, but not one connecting externally 
with a band. This form violates the law of uterine mobil- 
ity ; it interferes with the function of near parts, and by 
over-tension tends constantly to weaken the vaginal column. 
The principle involved in the mechanism of this group be- 
longs to the correction of total prolapsus uteri, and even 
here it is not easy to get the subject to wear the instru- 
ment. 
A form of pessary that must be classed among those 
having support external to the vagina is Weber’s (Fig. io). 
Here the T-shaped part passes in the posterior cul-de-sac, 
and is designed to correct a retroversion, and is kept in 
place by the stem passing backward over the perineum and 
attached to what resembles a pile instrument inserted in 
the rectum. The idea is an old one. Bond1 
invented a pessary of the same character. 
Weber’s instrument is shown here as a me- 
chanical curiosity, and as an evidence of 
what absurd things have been, and probably 
will be again, invented and called pessaries. 
Group II. includes all the instruments that 
act within, and are limited by, the vagina, 
and are the most useful and scientific of all 
the mechanical means for overcoming a 
version. Notwithstanding the great variety of outline pre- 
sented by the members of this group, the mechanical ele- 
ments involved are few, and we may thus reduce them to 
comparatively few classes. It is difficult to demonstrate 
these mechanical elements, and equally so to prove the re- 
sult of these elements upon uterine position. It is evident 
that the inventors have in many instances taken a wholly 
different view, both of the principles of construction and of 
the effects gained, from myself. And this seems the proper 
place to ask the indulgence of all my friends who have in- 
vented pessaries, and which I may classify and comment 
upon in a manner that does not meet with their approval. 
Fig. io. 
1 Am. Jour. Med. Sciences. April, 1849. 24 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC 
Class i. — Those pessaries acting by displacement, re- 
duced to the simplest proposition is that of one bulk dis- 
placing another. This implies a more or less fixed point, that 
of counter-pressure, and the movement of contiguous parts 
in the direction of the least resistance. We may be able 
to get my idea of the theory of mechanical displacement 
from the diagram (Fig. n). The cube E, E, E, is forced 
up in the elastic tube A, B, F, G. The line C D repre- 
sents the direction of the least resistance, and the line 
A B the direction of counter-resistance. It follows, there- 
Fig. ii. 
fore, that as the line A B cannot yield, and as the cube is 
forced onward, the yielding will be in the direction of C, the 
least resistance; the line I H is deflected in a manner 
represented by the dotted lines corresponding in direction 
to the upper angle of the cube. The extent of deflection 
in the line I H would be limited by the amount of com- 
pensation in the line F G, and would be at its limit an 
absolutely fixed quantity. 
The lines A, B, F, G, may express the vaginal walls, and ELY VAN DE WARNER. 
25 
for the cube we may substitute any possible form of pes- 
sary that, by mere bulk, will displace the line /, H, which 
expresses the vaginal vault. Theoretically I have repre- 
sented the displacing force as a cube; in practice it would 
make no difference what shape the displacing body may 
have, provided it is of such a shape as to displace or sepa- 
rate widely the vaginal walls. So far as results are con- 
cerned, the instrument may as well have been made solid. 
One of the most perfect of this type is Page’s “ dumb-bell,” 
Fig. 12. 
Fig. 13. 
(Fig. 12). There is no attempt to disguise its action, and 
it represents all the others of this class here figured. (Fig. 
Fig. i4- 
13), Pallen’s anteflexion, and (Fig. 14), Hitchcock’s ante- 
version, act upon the same principle. 
Fig. 15. 
Fig. 17. 
Fig. 16. 26 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
Fig. 18. 
A more modern type under this class and group has the 
displacing force acting from its bulk combined with an 
elastic or spring force. Of this nature are Cole’s ante- 
version (Fig. 15) and retroversion (Fig. 16), Heywood 
Smith’s retroversion (Fig. 17), and Thomas’s anteversion 
(Fig. 18). Under the most favorable circumstances it is diffi- 
cult to estimate accurately the value of a spring force ; but 
when a force of this nature is concealed in the vagina we 
have triple difficulties to contend with ; we are in doubt as 
to the tension of the spring, also as to the degree of force 
opposed to it, and lastly, that this opposing force is con- 
stantly, and to an unknown extent, changing in intensity. 
An elastic force is one that living tissues cannot contend 
with. They must yield before it. Witness the effect of 
the elastic ligature in surgery. On these grounds one 
would say that such an instrument as Fig. 15 represents 
could not be worn with comfort or safety, especially as the 
anterior wall is exposed, which is prone to ulcerate un- 
der the best conditions. Fig. 17, 
Heywood Smith’s, being a retro- 
version instrument, combines a de- 
fective theory with a defective 
principle ; the lower bow, having 
somewhat the Hodge form, carries 
the posterior vaginal wall back- 
ward, but the tendency of the vag- 
inal cervix to follow it, and thus 
elevate the fundus, is defeated by 
the upper bow which crowds it 
forward and expends the force of 
the instrument upon the posterior cul-de-sac. 
Fig. 19. ELY VAN DE WARNER. 
27 
The antetype of this form of forward displacement pes- 
sary is Priestley’s, shown in Fig. 19. It is simply an ex- 
aggeration of the modern form, and is figured here for its 
historical interest. The displacement of the anterior vagi- 
nal wall is so great that probably it could not be borne but 
for a few hours. 
This displacement theory is generally applied to forward 
displacements, and is assigned any form of action to suit the 
idea of the inventor. In theory these instruments are suf- 
ficiently correct; but in practice it is surprising to what a 
limited extent the uterus may be lifted by a displacing force 
acting upon the anterior vaginal wall. If we conceive the 
upper angle (C) of the cube in Fig. 11, so turned that it 
will displace the line F G, the extremity of the line G be- 
ing fixed, we shall understand how slight will be the deflec- 
tion that will result. Displacement will result in little 
more than tension. 
Fig. 20. 
Fig. 21. 
Fig. 22. 
Fig. 23. 28 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
For introduction or withdrawal. 
Fig. 24. 
Fig. 25. 
Fig. 27. 
Pestary in situ. 
Fig. 26. 
Fig. 28. 
Fig. 20 is Gehrung’s anteversion ; its antetype may be 
seen in PI. XIV., Fig. 5, in Vulliet’s form, which has also 
been used in prolapsus, and in which it proved useful for 
its powerful displacing qualities. Figs. 21 and 22, Thom- 
as’s anteversion, must, when open as in Fig. 22, place the 
anterior vaginal wall under such tension as to defeat the 
purpose for which it was applied. Fig. 23 is Thomas’s mod- 
ification of Hewitt’s pessary, and is the most scientific ap- 
plication of this mechanical principle. We see its original 
form in diagram in PI. XIV., Fig. 1, and in the same plate, 
Figs. 2, 3, Beigel’s modification is shown. By comparison 
with Thomas we see that the latter has diminished lateral 
displacement by contracting the ascending and descending ELY VAN DE WARNER. 
29 
limbs, which is an improvement. Fig. II, PI. XIII., is a 
still further modification, that of Schultze, with displa- 
cing power greatly lessened by lowering the apex. In Figs. 
24, 25, 26, Thomas’s anteversion is represented in different 
positions. Fig. 26 shows the instrument in position, and 
gives the reader a realistic idea of its displacing qualities. 
Another of Thomas’s 
anteversion pessaries is 
shown in Fig. 27. It is 
essentially the same as 
Fig. 24 in action, and is 
probably the parent idea. 
It is defective by fixing 
the vaginal cervix in its upper 
portion, when the cervix ought 
to be allowed to move downward 
and forward as the fundus uteri 
is raised. In PI. XIII., Fig. 7, 
Galabin’s anteversion pessary is 
shown. Radically it is con- 
structed upon the theory of Hew- 
itt’s. It is a curious fact that, 
by curving down the extremity A, 
Gehrung has converted it into a 
retroflexion pessary. Galabin an- 
tedates Gehrung about a year. 
Gehrung’s retroflexion instrument, 
Ffig. 30, and his anteflexion, Fig. 
29, are excellent types of this 
class. For anteversion, Fig. 29 
is fully equal to that of Hewitt, 
or Thomas’s, Fig. 27; 
but for anteflexion, 
unless in a very re- 
laxed organ, it could 
avail nothing. Pal- 
len’s retroversion, 
Fig. 28, combines the 
Fig. 29. 
Fig. 30- 30 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
Hodge form with displacement. Notwithstanding the dif- 
erence in form, and the absence of the spring attachment, 
the effect is that of Heywood Smith’s, Fig. 17. 
PI. XIII., Fig. 9, shows Studley’s anteversion, which is 
constructed upon the excellent plan of an adjustable dis- 
placement force in the upright tongue, the only instrument 
of the kind yet constructed. 
Class 2. — This is the most inter- 
esting class of this group, and with 
the widest range of usefulness. 
The vaginal wall is, by this class 
of instruments, made to play its 
part in the reposition of a retro- 
verted or anteverted 
uterus. The law o f 
uterine mobility is taken 
advantage of to replace 
and retain the organ 
in a position that ap- 
proximates the norm. 
Hodge disclosed to 
gynecologists this wide 
field of uterine mechan- 
ical therapeutics. Yet 
Hodge did not seem to 
have a clear idea of the 
principle upon which his 
pessary acted. If its 
mechanism was that of 
leverage it could act 
upon the vaginal cervix alone, and, by displacing it, the 
cervix alone responded to the movement, the position of 
the fundus remaining unchanged, thus relatively increas- 
ing the retroversion, or the organ rotated upon its long 
axis, depressing the fundus, and actually increasing the 
retroversion. It seems almost self-evident that, upon this 
theory, the Hodge instrument could not replace a retro- 
verted uterus. 
Fig. 31. ELY VAN DE WARNER. 
31 
The diagram, Fig. 31, is an attempt to demonstrate the 
theory of action of this class of pessaries. Conceive of an 
elastic tube defined by the lines B, I} /, and that a force 
within it is acting in the direction of A C; if this force is 
prolonged in the direction of C it will deflect the line B, as 
represented by the dotted line at C, and thus draw toward 
it any point upon the line B between this point and C. 
Obeying this movement, the line D L will assume the 
position of E, turning upon its axis of rotation at F. Com- 
pensation for the movement of L toward C is gained by the 
movement of the line / in the direction of G. This seems 
to my mind the only way in which pessaries of this class 
can operate beyond the limits of the vagina. It is equally 
evident to me that these instruments are useful only in ver- 
sions. In case of flexions, the axis of the uterus, expressed 
J)y the line D L, will respond to the movement of the vagi- 
nal cervix, but remain in its distorted condition. The mere 
rotation of the organ will not straighten it. 
First in point of interest are Hodge’s instruments in 
their original form. PI. XIII., Figs. 1, 2, 3. The instru- 
ment represented by Fig. 1 is now but little used. It is 
more particularly indicated in urethral and bas fond irrita- 
tion of the bladder. Of all instruments of the class, the 
Albert Smith modification of Hodge is the most univer- 
sally in use. The form of this modification of Hodge va- 
ries very greatly according to the ideas of the author who 
refers to it, or the instrument makers. Figs. 5 and 6, PI. 
Fig. 32. 
Fig. 33- 
XIII., and Figs. 32 and 33, showing Thomas’s modification 
of the Smith-Hodge, give a good idea of these changes 32 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC* 
of form. Eight other alterations in curve and lateral out- 
line are named and sold, but they do not deserve place 
here. Chamberlain’s pessary, Figs. 34, 35, is the most radical 
change which the Hodge form of in- 
strument has undergone. It can be 
worn with considerable comfort, but 
shows a marked tendency to drop 
down from its place, owing to the 
slight grasp of the vagina upon its 
lower limb. Carroll’s instrument, 
Fig. 36, is a spring pessary, and its 
central constriction, being firmly 
grasped by the vagina, gives it great 
Fig. 34- 
Fig. 35. 
supporting power. It cannot, in my view of its action, cor- 
rect a flexion. Woodward’s pessary, Fig. 37, must be classed 
among the modifications of Hodge- 
Smith. It is simply furnished with 
a “cross-bar” to give additional 
support to the uterus. Scattergood’s 
Fig. 36. 
Fig. 37. 
pessary, PL XIII, Fig. 8, has a spring concealed in its 
lower limbs Aside from the error of its construction, it 
easily gets out of order, and becomes foul. ELY VAN DE WARNER. 
33 
One word as to the general principle of construction of 
pessaries of this class. A pessary upon the Hodge plan 
retains its position in proportion to its amount of reversed 
curve. The Hewitt form (PI. XIII., Fig. 4), while it cor- 
rects the uterine position perfectly, is constantly getting 
out of place, owing to the slight amount of curve. The 
same may be said of the Schultze instrument (PI. XIII., 
Fig. 10); although the inventor endeavored to secure vagi- 
nal grasp by twisting the pessary twice upon itself in its 
long diameter, yet the general contour is straight, and the 
pessary easily drops out of place from supra-pelvic pres- 
sure. If, however, the curve is too great, it interferes with 
the traction exerted by the vaginal vault upon the cervix, 
and puts such a strain upon the walls of the passage that 
it cannot be borne. 
The third class of this group is quite a modern and use- 
ful one. The distinguishing trait is the mechanical fixation 
of the vaginal cervix, so as to limit its lateral and antero- 
posterior rotations. This class has considerable reputation 
among those who have a prejudice against the intra-uterine 
stem of replacing a flexed uterus, and certainly, from their 
ability to firmly fix the cervix, they come nearer to this re- 
sult than any other class of vaginal pessary. Many of 
these instruments combine other mechanical principles, but 
it is doubtful if these complications add any efficacy to the 
pessary. 
Hoffman’s pessary (Fig. 38) would accomplish consid- 
erable uterine rectification if it could be retained in proper 
adjustment. When small it is crowded too far back in 
the posterior cul-de-sac, and when of full size is not worn 
with comfort. The uterine neck, even when the central 
opening is of sufficient size, is pressed down with force 
enough to retard the circulation, and the discharges of 
the part add to danger of erosion. Soft rubber is always a 
bad material for a pessary. Hurd’s instrument (PI. XII., 
Fig. 6) carries out the same idea in a better way. It is 
polished and vulcanized, and more easily kept clean, but its 
effect upon the inclosed vaginal cervix is the same as 34 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
the Hoffman. Unlike the latter it is very easily introduced 
and removed, while the Hoffman is, after being worn some 
Fig. 38. 
Fig. 39. 
Fig. 40. 
time, held with a vice-like grasp, owing to atmospheric 
pressure. Woodward’s instrument (Fig. 39) is a modified 
Hodge, with an arched bar in front of the posterior curve 
which impinges upon the anterior vaginal wall. In very 
sensitive parts it cannot be borne. Fowler’s (Fig. 40) has 
great reputation, and is a very useful instrument. The bow 
form is the one represented, and in my own experience is 
not an improvement. Fitch (Fig. 41) and Studley’s (PI. XIV. 
Fig. 6) are instances of the endless combinations which 
may be made on the Hodge form. The fixation in this 
combination is too great to be used with either comfort or 
Fig. 41. 
Fig. 42. 
safety in the majority of cases. Thomas’s anteversion (Fig. 
42) is another variation of the principle of the Hodge, but 
fixation is very much less than in the two last examples, on 
account of the shorter projection into the grasp of the va- 
gina. Schroeder’s eccentric ring (PI. XII., Fig. 7) combines ELY VAN DE WARNER. 
35 
displacement with fixation, and is given for the purpose of 
showing the way in which the various groups merge into 
each other. All the instruments of this class might be 
used in cases where sensibility and engorgement of the 
parts are removed, and the case has settled down into hope- 
less displacement. Even here they are. attended with one 
great drawback. In cases selected as above, the patient 
ought to be able to remove and adjust her support at her 
own option. I have found it very difficult to instruct the 
average woman to do this with this class of pessary. 
Group III.—This group includes all those instruments 
known as intra-uterine stems. They are almost exclusively 
used for the correction of flexions of the uterus. Within 
their sphere they are theoretically the most perfect, practi- 
cally the most useful. It is one of the oldest forms for the 
correction of versions or flexions of the uterus. In 1843 
Simpson showed to the Medico-Chirurgical Society of Edin- 
burgh both forms of the intra-uterine stem ; while it was 
not until 1846 that Kilian introduced his elytromochlion. 
Both these instruments were followed by a numerous 
progeny. Gynecologists have been loath to abandon the 
mechanical theory of the intra-uterine stem. They have 
Fig. 43* 
Fig. 44. 
thus thought to evade supposed dangers by giving the in- 
strument a great variety of forms. No advance has been 
made upon the first form of Simpson. To him we owe 36 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
the instrument, and to him also we owe its most dangerous 
variation. 
Class i in this Group III. is that form of the intra-uterine 
which is secured in place by support external to the body. 
Fig. 43, known as Cutter’s, is one of its modern forms. By 
comparing it with Fig. 44, Simpson’s “ third form,” it will 
be seen that the variation is not material. 
Another slightly modified form of Simpson’s instrument, 
copied from Winckel, is shown in Figs. 2, 3, 4, PI. I. This 
author is in error in assigning the instrument of Kiwisch 
five years priority over Simpson’s pessary.1 Kiwisch’s in- 
strument (1847) is shown in Fig. 1, PI. I.; Valleix (1850), 
P'igs. 1, 2, PI. II., has an inflatable rubber ring attachment, 
but it does not act as a guard against the dangerous pene- 
tration of the intra-uterine part of the instrument. Kilian 
(1849), Fig. 1, PL HI., is of the same dangerous character. 
Beigel has invented the most inoffensive instrument of the 
class. It consists of an intra-uterine stem attached to an 
inflated rubber ball, and the tube through which the ball is 
inflated is caught up in a belt around the waist (PI. III., 
Fig. 2.) 
These instruments are figured in the interest of history 
rather than as being of any practical value. They vio- 
late every law governing the use of the intra-uterine stem. 
This group of pessaries owes its ill-repute to one of this 
class,— that of Valleix. I know of no good author who 
recommends their employment. There will probably never 
be a revival of this form. 
Class 2. — Intra-uterine stems combined with various 
forms of vaginal pessary : — 
Fig. 4S- 
Fig. 46. 
1 Selected Obstet. and Gynecol. Works of Sir J. Y. Simpson, p. 
706. New York. 1871. ELY VAN DE WARKER. 
37 
Fig. 48. 
Fig. 47. 
Fig. 51. 
Fig. 49. 
Fig. 52. 
Fig. 50. 
FiC. 4 
Fig. 53. 
Fig. 54 38 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
This combination is made 
for the purpose of correcting 
the tendency of a corrected 
flexion to result in a version. 
A simple intra-uterine stem 
may straighten a flexed organ, 
but of itself has no power to 
lift the depressed fundus. Al- 
most any simple vaginal pes- 
sary that will correct a version 
— especially a retroversior^— 
may serve for the vaginal at- 
tachment. Two rules must 
govern us in the selection of the combined instrument: 
That the vaginal pessary does not produce undue uterine 
fixation ; and that the intra-uterine stem be not too rigidly 
attached to the pessary. 
Kinloch’s instruments (Figs. 45, 46) are good examples 
of what a pessary of this kind should be. Fig. 47 is very 
liable to produce undue uterine fixation, but it will be ob- 
served that the stem has no fixed attachment, but plays in 
a cup-shaped depression between the limbs of the pessary. 
The pessary is by Dr. Thomas, and is, I suppose, aban- 
doned by him, as it has no place in the later editions of his 
book. As it is offered to the trade, however, it is worth a 
notice. Thomas’s other forms of anteflexion stem pessa- 
ries (Figs. 48, 49) are theoretically perfect. A lateroflexion 
stem pessary by the same author (Fig. 55) meets all the 
limitations which govern the use of these instruments. 
Mossman’s pessary (Fig. 54), notwithstanding its novel pro- 
file, is a modified Hodge; its improvement consists in a 
jointed stem, and by the freedom of movement to the stem 
by its attachment to the pessary. It strikes me, however, 
that less tension would be exerted upon the os externum if 
the stem was planted in the centre of its disk instead of 
posterior to it, and if the lower part of the pessary was 
curved the reverse of the upper part the bladder and ure- 
thra might be saved possible pressure. The instrument 
Fig. 55. ELY VAN DE WARNER. 
39 
deserves trial. Bad examples of this form are seen in Figs, 
i, 2, PI. IX.—the Hodge-Simpson form. In this instance 
intra-uterine stem and pessary must move together, and the 
uterus be constantly subjected to a double strain. The 
Barnes pessary shows a similar instrument with this error 
corrected (Fig. 3, PI. IX). The Williams (Fig. 4, PL IX.) and 
Winckel’s (Fig. 2, PI. VIII.) have the stem resting upon a 
perforated elastic diaphragm. Winckel’s pessary, notwith- 
standing the great size of the ring, can conserve no other 
purpose than the simple one of sustaining the ring. Stud- 
ley’s pessaries (Figs. 6, 7, PI. VIII.) have the stems sup- 
ported by elastic bands crossing from limb to limb of the 
Hodge-Smith instrument, and are nearly ideally perfect. 
Schultze’s (P'ig. 5, PI. VIII.) for anteflexion, must be an ex- 
ceeding difficult pessary to adjust, while the larger part of 
the figure of eight must exert an undue tension on the an- 
terior vaginal wall. Winckel’s modification of Valleix’s pes- 
sary (Fig. 1, PI. VIII.) must, from the size of the ring to 
which the stem is tied by strings, rather tend to increase 
the tendency to retroversion. Chadwick’s form (Fig. 3, PI. 
VIII.), would evidently serve a very useful purpose when 
the tendency to retroversion is not strong. Winckel’s orig- 
inal form (Fig. 3, PI. VII.), the Simpson-Martin (Fig. 1), 
and Hewitt (Fig. 2, PI. VII.) possess the common error of 
drawing the vaginal cervix forward, and thus tend to re- 
trovert the uterus, instead of carrying the vaginal portion 
backward, a movement opposite to that of retroversion. 
Schultze’s form (Fig. 5, PI. VI.) has the stem attached in 
too rigid a manner, as well as having the error in construc- 
tion of those last mentioned. Another form by the same au- 
thor (Fig. 7, PI. VI.) for anteflexion has the stem rotating 
upon a shaft between the limbs of a Hodge pessary, and 
its movement controlled by an extension of the stem at 
nearly right angles to it from the under side. Detschy’s, 
of which two forms are given (Fig. 1, PI. IV., Fig. 6, PI. VI.), 
is an exceedingly dangerous form, and too strong language 
cannot be used in its condemnation. Strong language is 
happily not required ; the instrument is obsolete. Cutter’s 40 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
pessary (Fig. 4, PI. VIII.) is a most unfortunate combination, 
every law governing the proper use of a pessary is violated 
in its construction. Another form of stem of this class 
consists of such a vaginal extension of the stem itself that 
the version is corrected by the same means which removes 
the flexion. Amann’s intra-uterine stem (Fig. 2, a and b, 
PI. VI.) for anteflexion has the stem terminate in a flattened 
disk extending into the vagina parallel to the axis of the 
stem. After the stem is introduced the vaginal part is 
wedged backward by cotton, and the uterus maintained in 
an erect position. The instrument is very perfect in theory, 
but requires constant attention from the physician to keep 
the cotton in place. Taken altogether, grouped and clas- 
sified, it is a stem pessary belonging to Group II., Class 
1, acting by displacement. My own form of pessary of 
this class is shown in Figs. 50, 51, 52, 53. A light stem 
rests before a shelf turned at right angles to a broad disk, 
b. The tendency to anteversion of the uterus after the 
stem is in position forces the disk b against the posterior 
vaginal wall, thus holding the uterus at about a normal in- 
clination, while the posterior vaginal surfaces give an elas- 
tic and yielding support to the disk. The stem has great 
freedom of movement upon the vaginal attachment. As 
shown in the cuts, the disk may be given various forms to 
meet the requirements of different cases. Introduction is 
very simple ; a wire is inserted into the part D of the stem 
(Fig. 50), and the stem is introduced as though it were a 
sound ; after introduction the vaginal attachment is run on 
the wire as a guide, the end D is inserted into the opening 
of the disk, and the wire removed. The stem is worn with 
great comfort, especially in irritable bladder. The instru- 
ment was published in 1876. 
Class 3, Group III. The self-retaining form has but few 
varieties. These instruments are designed for flexion of 
the uterine cervix, and especially of the vaginal portion. 
Methods of simple self-retention are out of the question in 
flexion located at the os internum, or of the uterine body ; 
for, when situated at these points, uterine expulsive effort ELY VAN DE WARNER. 
41 
is, at times, so strong that every form of intra-uterine stem 
may be expelled. When the flexed point is at the lower 
neck, the relative position of the organ above 
may be normal. This normal, forward inclina- 
tion permits the os externum to rest lightly 
against the posterior vaginal wall in such a 
manner that a light intra-uterine stem may be 
prevented dropping out. An instrument such 
as is shown in Fig. 56 is very useful for this 
Fig. 56. 
purpose, and is worn with the greatest ease and 
comfort by young girls, who are sometimes the 
greatest sufferers from flexion of the vaginal 
neck. Fig. 57 represents a form of my own 
which I occasionally use. The upper part of 
the stem is perforated, through which passes 
a short piece of pure gum tubing. It works 
very well in cases in which an intra-uterine 
stem has been worn for some time, and the ex- 
pulsive irritability of the organ diminished. As flexions 
at the os internum or uterine body are those forms of dis- 
tortion in which we simply correct a flexion that we may 
contend afterward with a version, this, or any other form of 
self-retaining stem, is contra-indicated. Squarey’s instru- 
ment is represented by Figs. 5, 6, PI. IX. The pessary is 
flexible, and is introduced stretched out as in Fig. 6 ; by 
withdrawing the extending force the upper part of the tube 
expands, as shown in Fig. 5. The pessary has given excel- 
lent results in the hands of the inventor. 
Class 4. — The Spring, or Divcrticnlating Intra-uterine 
Stem. This class is also a self-retaining form, but it differs so 
widely from Class 3 that it deserves separate study. While 
upon the subject of the displacement pessary with spring 
Fig. 57. 42 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
action (Group II., Class i), I referred to the difficulty of 
estimating the force of a confined spring, and the injury 
that elastic pressure was prone to inflict upon the soft parts. 
These objections hold good with double force when this 
elastic pressure is confined within the comparatively un- 
yielding uterine cavity, and acts upon tissues disposed to 
resent continuous pressure. How slight this force may be, 
and yet excite uterine expulsive effort, the elasticity of the 
small cross-section of tubing in my own self-retaining form 
has convinced me. I generally found that these were not 
well borne unless previous tolerance had been gained by 
the use of the sound, or simple intra-uterine stem. 
The idea of holding the instrument in place by elastic 
separating intra-uterine branches of the stem is an old one. 
In 1850 Kiwisch invented one of this class, which, regarded 
across the great space covered by achievement rather than 
by time, and which divides the present from the past in the 
history of gynecology, seems an impossible thing to apply 
to the uterus. Figs. 1, 2, 3, PI. XI., give a fair idea of the 
instrument. The dividing branches a are drawn together 
by the cord k, operated by a screw at m, in the handle e e. 
Fig. 3 shows the handle as removed from the canula i c, 
and Fig. 2 represents the intra-uterine branches spread 
apart in situ. Figs. 4, 5, PI. XI., exhibits Carl Mayer’s im- 
provement, which consists in guiding the cord over the 
convexity of the branches, instead of the concavity as shown 
at k, a, Fig. 1. The instrument is given here for its his- 
torical importance. It is an interesting fact in the history 
of these two instruments, that their descriptions appear as 
consecutive articles in the same number of the “Verhand- 
lungen.” 
Fig. 1, PI. X., exhibits Simpson’s pessary; the springs 
are compressed for introduction by a ring, and released 
by drawing upon cords attached to the ring and passing 
through its vaginal bulb. It is figured full size, and is a pow- 
erful instrument. Fig. 2, PI. X., represents Wright’s, and 
is a much less objectionable pessary than that of Simpson. 
It is introduced by means of a handle that compresses the EL Y VAN DE WARNER. 
43 
blades, which is figured at A. Fig. 3 shows the instrument 
in position. Fig. 4 of the same plate is Chambers’s modi- 
fication of the last inventor’s pessary, still further modified 
and figured by Biegel. It is difficult to understand the im- 
provement over the original form of Wright’s. Fig. 5, PI. 
X., is the form of Chambers’s. It is introduced by means 
of the handle A, which draws down the flange C as the 
handle is removed. It is well tolerated, and its field of use- 
fulness, like that of all this class, except its Kiwisch and 
Mayer forms, is in flexions of the lower portions of the 
uterine neck, where the tendency to version is slight or 
wanting. Fig. 6 represents Aveling’s pessary. The blades 
are confined by passing through a short canula, and are 
released by forcing the spring forward by means of the 
handle B. The action of the canula is well shown at A. 
Wright’s and Chambers’s instruments have been exten- 
sively used in England, and are quite well borne. The cer- 
tainty of retention, especially in cases of dysmenorrhea due 
to flexion of the lower neck, has tended to make them pop- 
ular. Other forms of self-retaining stems, or with simple 
vaginal attachments for retention (Class 5), not rarely be- 
come displaced just at the moment when they are most 
needed. My own experience of these pessaries shows that 
menstruation, while the instrument is worn, is more pro- 
fuse and lasts longer than when the simple stem is em- 
ployed. Careful supervision must be had over the patient 
while wearing instruments of this class. 
Class 5.—Intra-uterine Stems with Simple Vaginal At- 
tachment necessary for Retention. This class includes the 
ideally perfect intra-uterine stem. In all those cases in 
which a corrected flexion does not result in a version of 
such a degree that its replacement is required, this form of 
instrument is indicated. The vaginal part is added to the 
intra-uterine for the purpose of retaining the latter in posi- 
tion, nothing more. The greatest confusion has prevailed 
as to the size of the vaginal attachment necessary to ac- 
complish this purpose. The illustrations of this class 
exhibit the great diversity in size. As a rule, the vaginal 44 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
attachment should be no larger than is necessary to retain 
the stem in position ; that is, to resist the force of gravity 
and the uterine expulsive force. If there is any excess in 
size over this, normal uterine mobility is restricted, the 
function of the near parts may be disturbed, or the vaginal 
part may become displaced by expulsive efforts in defe- 
cation. 
The form which I have used for many years, and after 
numerous trials of other instruments, is shown in Figs. 
58 and 59. 
The stem in Fig. 58 is actual size. I have the 
stems made after measurements of the uterine 
cavity. Sometimes, but rarely, the stem is made 
one fourth or three eighths of an inch longer, but 
never of greater diameter than in 
the cut. A wire is run into the 
end a, the cervix is exposed by a 
Sims’ speculum, and firmly held by 
a tenaculum, and the stem intro- 
duced in the same manner as a 
sound. The flange, also actual size, 
is slid over the wire through its central opening a 
until it is placed upon a of the stem (Fig. 58). At 
times difficulty is met in passing the flexed point; in 
this case a sound with proper curve is first passed 
and the uterus straightened, and held in that position for a 
minute or two, when, on the next trial, the stem will prob- 
ably pass easily into the uterine cavity. If, however, it 
should not, use the sound a second time. Patience and 
gentleness of manipulation must be cultivated as an art by 
the physician who aspires to treat uterine flexions success- 
fully. I have, on very few occasions, used a flange larger 
than that shown in Fig. 59. It will happen now and then 
that the flange and stem will get displaced. The remedy 
is a simple one: replace them, remembering that if a stem 
is so securely held in place by vaginal attachment that it 
cannot become displaced it is probably too good a fit, and 
the patient cannot wear it. 
Fig. 59. 
Fig. 58. EL Y VAN DE WARNER. 
45 
Fig. 6o represents Dr. Sims’ intra-uterine stem. I have 
never used it, and am not aware that Dr. Sims has ever 
formally brought it before the profession; but the instru- 
ment has too many merits to neglect giving it a place in a 
monograph of this description. It deserves attention for 
the free motion of the stem upon the retaining portion, 
certainty of retention furnished by a ring over a solid vagi- 
nal part, and is evidently easy to introduce. 
Fig. 6o. 
Fig. 61 represents Donaldson’s pessary. It is a very 
recent invention, and deserves notice on account of the 
ingenious attachment of the 
intra-uterine stem to the 
retaining portion. The 
stem is fixed in the centre 
of a rubber diaphragm, 
which allows free movement 
in any direction. Another 
advantage has been noticed 
with reference to several 
other instruments, namely, 
the superior retaining power 
of an open or horse-shoe 
form over a disk or solid retaining part. One disadvantage 
it possesses in common with all forms of intra-uterine 
stems in which the stem is a permanent attachment to 
the retaining part. It is difficult to introduce the latter 
into the vagina while the former is being introduced into 
the uterine cavity. In some cases it is difficult to in- 
Fig. 6i. 46 
MECHANICAL THERAPEUTICS OF VERSIONS, ETC. 
troduce even a sound, and in cases in which the vagina is 
narrow, as in virgins, who are very frequent subjects for 
intra-uterine stems, there is no room for the retaining por- 
tion, which ought, on this account, to be a separate part 
of the instrument. 
Simpson’s forms of pessaries of this class are shown in 
Figs, i, 2, 3, 4, 5, PI. V. They are among the oldest forms 
of the instrument. Indeed, to Simpson we owe the first 
practical use of the intra-uterine stem; that he abandoned 
the idea later in life is evidence of his too indiscriminate 
use of it, rather than of any fault in the method itself. 
Fig. 4, PI. I., shows another form of Simpson’s pessary. 
Cazarewitch’s pessaries are exhibited in Figs. 6, 7, PI. V. 
Fig. 6 is made of glass, and shows a twisted form, the ad- 
vantage of which is doubtful. The pessary represented by 
Fig. 7 is hollow, which, I think, is the result of a mistaken 
idea of the office of the stem. Shroeder’s form (Fig. 8, PI. 
V.) is closely after the model of Simpson. Fig. 9, PI. V., 
expresses Peaslee’s pessary. It also follows the model of 
Simpson (Fig. 3, PI. V). The second bulb is attached for 
the purpose of retention. It is a very useful pessary, and 
holds its place securely. The hinge attachment for reten- 
tion purposes is useless. The vaginal part is sure to col- 
lapse from the pressure of the passage. Conant’s (Fig. 
3, PI. VI.) and Edwards’s (Fig. 4, PI. VI.) are examples. 
Tait’s pessary, another model after the design of Simpson, 
is, from the structure of its bulb, held in place very imper- 
fectly. It is shown in Fig. 1, PI. VI. C. Braun’s stem 
(Figs. 4, 5, PI. VII.) has the retaining part in the form of 
a small globe detached from the stem, and perforated so 
that it may be attached to the stem. Its distinctive feature 
is the extreme curve of the stem. Curved stems are worn 
with great comfort. In very acute and strong flexures it is 
necessary. The normal uterus is not a straight organ, and 
the perfectly adapted stem ought to conform to this normal 
curve. E. Martin’s pessary, shown in Fig.! 6, PI. VII., 
closely follows the model of Braun. In both these pes- 
saries there is evidently no advantage to be gained in the 
globe form of the retaining part. PI, I. 
ViS-1- 
Pl3.z. 
fij.3 
fiS-4- PI. II. 
Fiji 
Fiy.Z. pirn 
n3.i. 
Fy*~ PL IV. 
Fitj.l. 
fy- *■ PI .V 
Tig.1 
FJf.2 
Fiv J 
Fiy 4- 
Tig. 5 
Fig. 8 
Fiy.8 
Fig 6 
Fig 7 PLVl 
FI o.3 
Fig.t 
FiS.l. 
(j Ctm/. 
Fig. 4 
Fiy.S 
Fjf. 6 
Fig.7 PI.VII 
Tig.i 
Fig. Z 
Fig. 6 
Fig. 4 
Flg.3 
Fig. S pi.viir 
Fig.l 
Fig 3, 
Fig 4 
Fig 6 
Fig.F 
Fig.S. 
ru.r FI. IX 
Tig. l 
Fief' Z 
Fi3. 3 
Fig. 4 
Tig-5 
Fig. 6 Pl.X 
Fig-1 
Fig 2 
Fig. 3 
FigA 
Fig. 6 
Tig. 5 P i XI 
Fig-1 
Fig. * 
Fig. Z 
Fig.3 
Fig -5 pi. XII 
Fig.l 
Tigz 
Fig. 3 
Fig.4- 
Fig 6 
Fig. 7 
Fig 5 
Fig. 8 pi xm 
Fig.1 
Tig Z 
Fig 3 
Tig. 5 
Tig. 6 
rif.7 
Fig8 
Fif.9 
Fie. 10 
Fjg.ii Pi.jav 
Fig.4- 
Vigl 
Fig Z 
Fig.t 
Fif 6 
I’jyJ 
Had 
FiS' 9 
fjyT