Vaginal Tamponnement in the Treatment of Prolapsed Ovaries. BY WALTER P. MANTON, M.D., DETROIT, MICHIGAN. REPRINT FROM TRANSACTIONS, VOL. I, 1888. VAGINAL TAMPONNEMENT IN THE TREATMENT OF PROLAPSED OVARIES. BY WALTER P. MANTON, M.D., DETROIT, MICHIGAN. REPRINTED FROM TRANSACTIONS OF AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS, SEPTEMBER, 1888. PHILADELPHIA: WM. J. DORNAN, PRINTER. 1889. VAGINAL TAMPONNEMENT IN THE TREATMENT OF PROLAPSED OVARIES. By WALTER P. MANTON, M.D., DETROIT, MICHIGAN. In these days when laparatomy has become a cross-road opera- tion, and every practitioner who can boast a scalpel and a threaded needle, rushes unhesitatingly into abdominal surgery, it is not ultra conservatism that bids us pause for a moment and look into a past, when these bolder methods were deemed, as that old worthy Richard Bright puts it, hazardous enterprises which we should not be tempted to adopt as a rule of practice; for, as the skilful angler stretches the tinselled bait behind him in order that it may be cast further along the stream in advance, so the retrospection of methods more or less fallen into disuse tends only to place present and future advancement on a surer, sounder basis. I would not, however, be thought as blind to the great service rendered humanity by a long list of distinguished operators, who, from McDowell down, have remedied conditions which but little more than half a century ago were considered incurable; nor would I, by any word of mine, seek to stem the current of progress which is sweeping omvard in its life-saving course. But, let me put the question squarely, Are we not, in this country at least, given to accepting boldness for knowledge, and the glitter of surgical instruments for skill? Let me ask you, Who has brought these operations to be considered legitimate, the experienced, or the inexperienced, and if the former, was skill acquired by foolhardy daring, or by years of careful study and preparation? Oophorectomy for whatever condition performed, is, and must always be, looked upon as a dangerous operation, which reason dic- tates should not be attempted, except under the most favorable con- ditions, and by those well competent to cope with the multitude of 2 MANTON, emergencies liable to arise, even in those cases which at the begin- ning appear to be most simple. Surgery is not infallible, neither is the surgeon, and until the latter has had that training which gives him the knowledge of methods, it is the height of folly for him to open up the abdominal cavity. With the successes of distinguished men before us, and the apparent ease and simplicity of acquiring results, the temptation to ignore possibilities is great, and we are apt to forget that less dan- gerous methods may be rewarded with as satisfactory and praise- worthy termination. It was not until 1864 that Holst1 and Shultze2 called attention to the fact that the ovaries could be palpated by means of the biman- ual touch. As the result of this announcement, the literature of ovarian diseases was soon flooded with accounts of the various dis- ordered conditions which could be diagnosed in this simple manner. In point of fact, however, as is well known, ovarian palpation is not so easy and requires much practice and nicety of touch; and the experiments of Meyer3 go to show that even in the simple con- gestion and enlargement of the ovaries during menstruation, it is often impossible to distinguish any increase in size. When we con- sider, too, that even with the ovaries on a plate before us, or in sec- tion under the microscope, it frequently becomes a matter of dispute as to which is the healthy and which the diseased portion, the absurdity, in the majority of cases, of positive diagnosis with the little organ in situ becomes apparent. Coe4 has well expressed what all who are familiar with micro- scopical diagnosis will endorse, when he says; "The microscopist who succeeds in determining to what extent an ovary may contain cysts without being 'cystic,' and just how much fibrous tissue must exist in its stroma before the diagnosis of 'cirrhosis' is justifiable, will deserve no little praise." With ovarian pathology in so unsettled a state, then, is the sur- geon justified in gratifying his ambition for fame by removing the ovaries for discernible or obscure pelvic pain, before a careful trial 1 Die Klinik fiir Frauenkrankheiten zu Dorpat, 1860 bie 1862. Rega, 1864. 2 Jenaisclie: Zeitsehrift fiir Mediein und Naturwissensehaften, 1864. 3 Arch, fiir Gynakologie, Bd. 22, p. 54. 4 A System of Gynecology by American Authors, vol. i. p. 170 TREATMENT OF PROLAPSED OVARIES. 3 of all local and general treatments has been made; and, even in this instance, is it not a matter of supreme importance to determine carefully, as far as it is possible, whether such removal will accom- plish the desired results? Perhaps the most frequent condition which the specialist is called upon to treat in connection, or not, with uterine disease, is ovarian prolapse. It would appear no difficult task to determine whether or not an ovary is displaced from its position an inch to the side of the uterus, but in reality it is not always easy, for, occa- sionally, one or both of these organs may be found so low that a diagnosis of prolapse would seem called for, excepting that there are no symptoms pointing to this condition. The ovary, like the uterus, being a comparatively free organ, undoubtedly changes its position as the result of conditions which also favor uterine displacements. Barnes has pointed out the fact that the left ovary is more liable to downward displacement than the right, because the left side of Douglas's cul-de-sac is deeper than the opposite, and the right ovarian ligaments are shorter than those of the left side. The contiguity of the - often - overloaded rectum also undoubtedly exerts a strong influence in producing left ovarian descent. The great amount of suffering to which these prolapsed organs may give rise, sooner or later leads the patient to consult a physi- cian, who, perhaps, after a few local applications to the uterus, and without really discovering the true seat of the trouble, advises removal of the ovaries. Now the treatment, other than surgical, of these much-abused organs when displaced, meets with but scant discussion in most of our text-books on gynecology, and the practitioner who would know something of the manner of handling these cases must search the periodical literature of the day for instruction. For a method, the results of which are so pronounced and so gratifying, vaginal tamponnement is hardly mentioned in the books, and the indications pro and con for its employment rarely alluded to; yet I venture to say that, where the packing is properly applied, there is nothing which will afford the patient more relief and grati- fication. The first to advocate the vaginal tampon in this class of cases was the late Dr. Taliaferro, of Atlanta, Georgia, who, in 1878, in a 4 MANTON, paper before the Medical Society of that State, advocated putting the patient in the knee-chest position, retracting the perineum with the Sims's speculum, and packing the vagina, more or less, accord- ing to the requirements of the case, with pledgets of cotton, the upper ones of which had been soaked in glycerine.1 Other papers on the same subject appeared from Dr. Taliaferro's pen in 1882 and 1883. Since that time various substances have been advocated for the tampon instead of cotton, but those who have had much experience in this method of treatment have come to the conclusion that, although not fulfilling all the requirements, cotton is as yet the best substance at hand for the purpose. The tampon which I have found most effective, consists of a thin strip of absorbent cotton about six inches long, by one-half inch wide. This is saturated in equal parts of pure glycerine and water, and squeezed dry between the palms of the hands; the strip is then folded upon itself from both ends until a quadrate is formed in shape much resembling a caramel. A large number of these tam- pons must be prepared at a time, for the capacity of the vagina is sometimes astonishing. Before using the tampons, I am accustomed to sprinkle them liberally with boracic acid. To use the tampons the patient is put upon her left side, Sims's speculum introduced, the vagina cleaned with an antiseptic lotion, and the cotton wads packed around the cervix, until the vagina is from one to two-thirds full, when I am in the habit of finishing off with a roll of cotton or sheep's wool, the edges of which have been kneeded in and the roll compressed to about one-half its original size. This holds the packing in place for a longer time, but is not absolutely essential. The degree of firmness with which the tam- pons are crowded into the vagina depends on the sensitiveness of the patient. The more compactly they are placed, the more effectual are they in their working. Before beginning the process I usually paint the vaginal-vault with Churchill's iodine, and then saturate the first two or three tampons with plain glycerine, iodide of potassium, iodoform, or other substance, in glycerine. 1 1, The Application of Pressure in Diseases of the Uterus, 1878. 2. The Applica- tion of Pressure in Diseases of the Uterus, Ovaries, and Peri-uterine Structures, 1882- 3. Precautionary Measures and Contra-indications to the Use of Pressure by the Tam- pon in Diseases of the Pelvic Organs, 1883. TREATMENT OF PROLAPSED OVARIES. 5 Dr. Taliaferro advocated the knee-chest position in packing, but I have found the left lateral decubitus as satisfactory, and much less disagreeable and fatiguing to the patient. In certain cases, notably where there are subinvolution and sagging of the vaginal walls, the knee-chest position may be assumed until the organs have been forced up into position, either by atmospheric pressure, or by the cotton-stick, or fingers in the vagina, and then, as advised by Dr. Emmet1 in a recent paper, the patient is allowed carefully to lower her body onto the left side, the speculum is introduced, and the packing inserted. I have tried this in but very few cases, having found that, as a rule, it is quite unnecessary. When the dislocated ovary is non-adherent, there is usually no difficulty in replacing it by the finger or cotton-stick; but the pressure of the tampons is sure to force it upward with less dis- comfort to the patient. It may be asked, why, if the ovary is free, it is not as well to insert at once a cushion pessary which will hold it in place? The reason is obvious ; in most of these cases there are present more or less congestion and a high degree of sensitiveness, not only of the ovary itself, but also of the surrounding structures, so that the presence of a pessary of any kind instead of affording relief, which tamponnement is sure to do, only increases the pain and discomfort, with, perhaps, the chance of lighting up an active inflammation. A few packings will, however, usually do away with these conditions, and a suitable support may then be placed. The cases, however, in which the value of vaginal tamponnement is best observed, are those where the ovary, having become pro- lapsed into Douglas's pouch, is tied down and fixed by inflammatory deposits. Here the results of careful, systematic packing are often truly brilliant. That the favorable effects produced by the tampon are due almost wholly to mechanical pressure, aided probably by the various medi- caments with which the cotton is impregnated, especially where adhesions are present, is well illustrated by the following cases: Case I.-Mrs. L., age thirty-eight, referred to me by Dr. Bigg, of Detroit, entered my private hospital May 30th, of the present year. She had borne one child at term sixteen years previously, and had aborted twice at about 1 On the Use of the Vaginal Tampon in the Treatment of Certain Effects following Pelvic Inflammation. Reprint. New York Medical Journal, February 13, 1888. 6 MANTON, the third month. Menstruation began at fourteen ; was always regular, and associated with more or less pain and general malaise, for a week previous to the flow. Five years ago she suffered from ovaritis, possibly of a gonor- rheal nature, for which she had been treated, and had remained compara- tively well until two years ago, when, after a long exposure and thorough wetting she was again attacked by ovarian trouble. At this time, (May, 1888) she suffered greatly from a sensation of constant " weight and pulling " in the left side, with pain running down to both knees, the condition on the right side having existed but two months though increasing in severity. Walking is difficult and causes her much suffering. The appetite is fair, but digestion is impaired. Physicial examination revealed a retroflexed uterus, somewhat enlarged but quite movable. The right ovary, the size of a walnut, was prolapsed deep behind the uterus: left ovary the same, but slightly higher up. Parts exquisitely sensitive, and examination caused great pain and discomfort. During a period of ten weeks this patient was packed some twenty-one times. On two occasions during the treatment, a soft rubber- cushion pessary was inserted instead of packing, but it failed to afford relief. At the end of five weeks the patient was sent to her home in the country, but continued to visit my office weekly for treatment for another five. At the end of this period the ovaries had diminished fully one-half in size, were movable, but slightly below their normal position, and the local sensitiveness had entirely disappeared. At this date-two months since cessation of treatment-the ovaries still continue in position, the pain has constantly diminished, that in the legs has entirely disappeared, and the patient sleeps, eats, and digests well, and is able to walk a mile without much discomfort. In conjunction with the tamponnement, tonics and the iodide of potassium were given. At present she is taking small doses oi corrosive sublimate, and the hot vaginal douche is employed. The results in this case are better appreciated from the patient's gratitude than from anything that can be written. Case II.-Mrs. J., referred to me by Dr. George P. Andrews, of Detroit, a widow, forty-three years old, mother of four children, the last of -which was born eleven years previously ; had suffered since the birth of her third child with severe and constant pain in the small of the back, for which she had been treated by several well-known physicians. Examination revealed a retroflexed uterus bound down by adhesions, and a mass to the right, which proved to be the ovary surrounded by effused lymph. I began packing this patient on the twenty-eighth day of July. On the thirteenth day of October, after thirteen packings, the uterus could be placed in ante- version, and a soft ring support was adjusted. She wore this for a time; and I then resorted to the packing to force up the ovary. After seven packings the ovary became quite movable, and could be pushed well up in the pelvis. December 24th, the patient left town, and I did not see her until the fourth of the March following. She was much improved in general health and had had no attack of local inflammation. A Smith- TREATMENT OF PROLAPSED OVARIES. 7 Hodge pessary was inserted to keep up the womb, which was inclined to fall backward. A week after placing, the support came out. April thirteenth, the patient returned with the womb tipped back into the old position, and the ovary bound down almost as firmly as at first. There had, how- ever, been no inflammatory attack to account for this. To shorten a long story, the packing was resumed, and the ovary liberated from its adhesions. After a time it again became adherent, and was again released. Subse- quently I lost sight of the case. Now, as there was in this case no inflammatory condition to account for the repeated tying down of the ovary, I can only account for the results obtained from the packing and the subsequent return of the condition, by supposing that the adhesions were not all absorbed, but were greatly stretched, and that after stopping the packing they gradually contracted and drew the ovary down to its former position. Such cases as the above might be multiplied, but the two given will serve to illustrate the very efficient action of the tampon when correctly used. The only contra-indication to the employment of this method of treatment is active inflammation. When there is a high degree of sensitiveness only, or where the parts are engorged with blood, great relief is afforded by the support furnished by the tampons. In all such cases the vaginal vault should be painted with iodine, the upper tampons well soaked in medicated glycerine, and the packing placed as lightly as possible, until tolerance is established. In the above remarks I have attempted to show : 1. That the indiscriminate removal of ovaries for pelvic pain is to be discountenanced on every ground. 2. That vaginal tamponnement properly applied and persisted in will result in a satisfactory percentage of cures in cases of prolapsed ovaries; and, 3. That in cases where cure is impossible, it will afford immense relief without risk to the patient, and render her life worth living.