SOME HINTS REGARDING UTERINE SUPPORTERS. 
CLIFTON E. WING, M.D., Boston. Press of David Clapp & Son. SOME HINTS REGARDING UTERINE SUPPORTERS.1 
Ci-ifton E. Wino, M.D., Boston. 
In an article entitled "The Use of Uterine Supporters,” read 
before one of our medical societies a short time ago and since pub- 
lished in pamphlet form, I called attention to the fact that to obtain 
success in the use of uterine supporters the physician must be 
thoroughly acquainted with uterine disease, that he may know 
when they should be used and when they should be avoided; and, 
moreover, must be experienced in their application and have greater 
facilities at hand for properly fitting them than the general practi- 
tioner possesses. 
The adjusting of a pessary which shall be worn for an indefinite 
time until its objects have been attained, is not always a matter to 
be accomplished by once or twice seeing the patient, although some 
simpler cases require but little more attention, but often a process 
which must extend over weeks and perhaps months, and which re- 
quires the closest attention on the part of the operator to avoid 
injuring instead of benefiting the woman. 
That this fact is not appreciated by the profession at large is evi- 
dent from the number of patients sent to the specialist, who come 
expecting to have a supporter applied, leave the office in a few min- 
utes, and have no further trouble about the matter. Occasionally 
this can be done, but such cases are exceptions to the rule. 
When a uterus has been out of its proper position for a length of 
time, the tissues and parts about it accommodate themselves to the 
new position it has taken. 
We all know how easily a recent uncomplicated dislocation of the 
shoulder or hip-joint can be reduced by proper manipulation, and 
1 Read before the Suffolk District Medical Society, Sept. 29, 1877. 4 
how difficult may be the process of reduction when the dislocation 
has become of long standing and the surrounding tissues have 
become habituated, so to speak, to the malposition. 
It is exactly the same with a uterine displacement. When the 
womb has been but recently thrown out of position it can often be 
easily replaced and retained where it belongs. When the displace- 
ment is of long standing, frequently the process of reduction is a 
very difficult matter. Hence the importance of early recognizing 
and treating these conditions. A complete replacement, in many 
instances which present, cannot be accomplished at once; the parts 
can only be carried back where they belong gradually. Oftentimes 
continued pressure must be used to do this, and must be kept up 
afterward to hold them in place until they acquire, once more, the 
tendency to stay in the normal position. 
While with the surgery of the external parts of the body, as in a 
case of club-foot for instance, for the gradual bringing into position 
of the tissues, appliances having screws, pulleys and springs can be 
brought into use, and thus the steady pressure which is needed be 
readily applied and regulated, with a uterine displacement such 
appliances are impracticable, and we are obliged to depend upon the 
skill and ingenuity of the surgeon in applying pessaries of different 
sizes and shapes to keep up the pressure which is needed, and at the 
same time avoid serious injury to the tender tissues. 
In many cases of displacement of the womb the vagina, from being 
kept in an abnormal position, acquires a form very different from its 
normal one, and when the uterus is being carried back where it 
belongs the vagina, " pari passu,” gradually regains its natural shape. 
So it follows that a pessary which will to-day fit the parts perfectly 
and perform its duty of supporting the womb, will perhaps be found, 
on examination a fortnight, more or less, hence, to fail in keeping 
the womb up as it should, and now will not fit the vagina at all. 
Before the final pessary (the one which the patient can wear indefi- 
nitely) is reached, she may have to wear quite a number of different 
ones, each of which will do nicely for a time and then be useless, 
or worse than useless, for a badly fitting instrument is always likely 
to do harm. Thus, for the successful treatment of even a single 
case, the physician may need quite a full asssortment of pessaries, 
and, moreover, he must know from experience when and how to 
change them.. 5 
The two cases to which I ask attention are not in any way excep- 
tional or remarkable. They are only examples of such as are fre- 
quently met with in the routine of daily practice, and on that account 
will 6ervc all the better to illustrate these points. 
The shorter of the two pessaries which I will first pass around 
was worn for thirteen months by a patient who applied for relief 
from menorrhagia and the pain in the region of the spine, bad feel- 
ings in the head, etc., which so often accompany uterine displace- 
ments. She had had several children. Examination showed a 
retroverted uterus low down in the pelvis, and the vagina shortened 
by its long malposition. The free bleeding which followed the care- 
ful use of the uterine sound showed that there was something more 
than the simple displacement at the bottom of her haemorrhages, and 
under ether the uterus was curetted and many large granulations 
removed. No bad symptoms followed, and at the end of about ten 
days the uterus was put forward with the sound and pessaries were 
applied. She was unable to remain in the city as long as I wished, 
but before she went home I inserted the pessary (the shorter of the 
two shown) which was longer than any used before, and the longest 
she could then tolerate ; indeed pressed so far down toward the 
pubic bones that I told her it was doubtful if she could continue to 
wear it. She however got along pretty well until about two 
months before her return (which was thirteen months after her first 
coming to me), when she had a return of her old symptoms of back- 
ache, pain in head, etc. Upon examination I found that the vagina 
had lengthened out to something like its proper shape, and the pes- 
sary was now so much too short that it allowed the body of the 
womb to fall backward over its upper end. I adjusted another, of 
the size of the other pessary shown, which now fitted the parts and 
she went away wearing it with comfort. The differences in the 
length and shape of the two supporters, which show how the vagina 
had altered, are noticeable. Had the patient lived near at hand so 
that her case could have been followed up and the uterus kept 
properly in place during the thirteen months, it is quite likely that 
she might be able to dispense with the supporters by this time. 
The other two pessaries which I will pass around were used 
in the case of a young lady suffering with a retroflexion, which, 
from the history of the case, had probably existed a number of 
years. Here also the vagina, as often happens in such cases, was much shortened. The uterus was put forward with the sound, and 
the various pessaries required successively used until the parts were 
in fair position. When they were finally carried up where they 
belonged, the womb would at once spring backward as soon as the 
supporter was removed, with a return of all the old symptoms, and 
it became necessary to continue the pressure of the pessary until the 
resiliency of the tissues was overcome. Keeping the uterus in 
position for a few days and then taking the pessary out and letting 
it fall back and repeating the process, would be like pulling a dislo- 
cated elbow into place and then letting it slip out again and repeat- 
ing, in the hope that it would finally catch in place and stay 
there. It might eventually do so, but the ligaments and tissues 
would be stretched and loosened by the process, provided inflamma- 
tion did not follow the repeated manipulations, as would be quite 
probable. The tissue of the vagina in this case was unusually 
tender, and the cul-de-sac readily cut by the pressure of the pessaries. 
Here then was the difficulty, to continue the pessary and not cut into 
the cul-de-sac. By alternately using first one and then the other of 
the two pessaries shown, one of which you will perceive is so 
shaped at its upper part as to press upon the centre of the cul-de- 
sac of the vagina and not upon its side, and the other so bent that 
the pressure comes on the sides of the cul-de-sac and avoids its cen- 
tre, the constant pressure desired was kept up until the tendency on 
the part of the uterus to bend backward was overcome, and at the 
same time all injury to the vagina was avoided. This once accom- 
plished, a shorter pessary, not long enough to cause any pressure but 
still sufficient to keep the uterus from being thrown out of place by 
any jar or sudden movement, was substituted and worn with 
comfort. 
Such cases show how much attention must be given to the minutiae 
where pessaries are used. The aim of the doctor should not be to 
merely temporarily relieve the patient by the use of supporters, but, 
as the surgeon uses the splint, to so use them that when they arc 
removed the parts will continue in place. This can be accomplished 
in a fair proportion of cases if the operator understand his business— 
of course not in all—but the number of such successes will be small 
if he is satisfied when, by using a pessary, he has stopped the back- 
ache and other symptoms, and does not assure himself that the parts 
are in their normal position. The patient may be relieved of her symptoms when the uterus is lifted but slightly from the position 
into which it lias fallen, and then a pessary may keep it there; but 
unless it be thoroughly carried back where it belongs, which process 
may even cause greater discomfort to the patient than she has experi- 
enced from the displacement itself, the malposition will almost 
inevitably return when the pessary is removed. 
Occasionally it will happen that a pessary which is inserted, without 
much attention being given as to whether it fits or not, will luckily 
prove to be just the proper one for the patient; but these happy hits 
rarely occur, and then with the simpler cases. As the rule, a Sims 
speculum (the only one which allows the operator to see exactly how 
the pessary lies in the vagina), and the services of an experienced 
assistant to properly hold it, are indispensable to the proper fitting of 
the supporter; and in all cases they greatly simplify the process. 
Pessaries are not instruments to be resorted to when everything 
else has failed, in the vague hope that possibly they may in some 
way, not distinctly understood, benefit the patient, but the cases 
where they are proper are to be selected with knowledge and 
judgment. 
It is only since it has been recognized that those suffering with 
short- or far-sightedness must apply to the skilled oculist to be 
properly fitted with glasses, that such persons have derived the full 
benefit to be obtained by their use. It is much the same with uterine 
supporters. They should be used scientifically or not at all. It is 
their abuse, not their use, which has brought them into ill-repute.