TILE USE OF UTERINE SUPPORTERS. 
Bv CLIFTON E. WING, M.D., Boston. THE USE OF UTERINE SUFrORTERS.1 
Clifton E. Wing, M.D., of Boston. 
It often happens that patients coining to the specialist for treat- 
ment, when told that it will be necessary or best for them to wear a 
pessary for a while, at once reply with much positiveness that they 
do not wish to do so, and on inquiring the reason one not unfre- 
quently learns that the physician who has previously had the patient 
under treatment has warned her against ever allowing anything of 
the kind to he introduced, called.them "unnatural things,” perhaps 
termed them "inventions of the very d—1,” and told of Mrs. B or 
Mrs. C who had one inserted by Dr. , and "was nearly killed 
by it.” Perhaps the doctor, if conscientious, has told of cases in his 
own practice where the results of attempts to make use of uterine 
supporters were disastrous, although he "used the greatest possible 
care,” in consequence of which experience he has resolved never to 
use another. It may be the patient says she has tried a pessary and 
found she could not wear one. Inquiry here usually elicits the fact 
that the physician who used it had but two or three to choose from, 
often, indeed, procuring a single one at the instrument-dealer’s, for 
the particular patient, choosing a size which he thinks will pass into 
the vagina without giving him trouble in its introduction, which he 
fears might shake her confidence in his special skill in such cases ; 
and, having inserted it, that he instructed her to wear it, and if it 
hurt, not to mind hut to "get used to it”; that she did wear it as 
directed until increasing pain caused her to to have it taken out, and 
finding herself much more comfortable without it than with it she 
made up her mind not to have the experiment tried again, or 
that, "determined to get well,” she wore it until forced to go to bed 
with all the symptoms of pelvic inflammation ; she sent for her doc- 
tor, who made an examination, removed the supporter, told her she 
had inflammation (which was probably the fact), or said there was 
"fever,” kept her in bed until the acute trouble disappeared, and, 
when she was again up and about and anxious for relief from her old 
symptoms, told her " it was probably now as plain to her as it was to 
him that she could never tolerate a uterine supporter.” 
Not unfrequently in such cases it results that the fears and doubts 
of the patient having been overcome by explanations and arguments 
induced in favor of the supporter, she experiences so much comfort 
and relief of symptoms when it is once properly fitted that she 
strenuously objects to parting with it when its object having been 
accomplished the time for its removal comes, and new arguments 
1 Read before the Norfolk District Medical Society, February 14, 1877. 2 
must be brought to bear before she will allow it to be taken away. 
That this is no exaggeration every specialist having experience in 
the proper fitting of Uterine supporters can testify. There can be 
no question that they have done and are still doing an immense 
amount of harm. Instances continually come to our notice where 
patients have been sadly injured by them ; but the fault lies not in 
the pessaries per se but in the ignorant and unskilful way in which 
they are used. But a limited proportion of uterine troubles can be 
benefited by them, yet they are found introduced in all manner of 
cases, as a matter of course, often only to prove complete failures. 
The fact that vagina? and pelves vary infinitely in size and shape, 
although known to all, seems to be ignored by the majority of 
physicians who attempt to use pessaries, yet with a case requiring 
a supporter it can do nothing but harm unless perfectly fitted 
to the given vagina. 
Let us take a homely illustration : suppose that wanting a pair of 
shoes, we should enter a shoe store where the proprietor kept but 
three or four different varieties or sizes ; that he should select a pair 
which slipped on to the feet readily and say all was right; that the 
shoes might hurt after a while, but we need not mind that; we must 
get used to them. Suppose we accepted what he said and wore 
them. There is a bare possibility that we might escape trouble. 
The shoes might be just the peculiar size to fit us perfectly, but the 
probability is that they would not, and that they would soon begin 
to hurt. But we have been told we must bear the pain and get used 
to the shoes, so we try it for a time, but before long they are thrown 
aside with imprecations on them and the man who sold them, while 
we suffer with tender feet for a few days as a result of the attempt. 
Were we to have as much confidence in our shoe dealer as many a 
patient has in the physician to whom she has applied, and were we 
as determined to wear the shoes as the patient, in her anxiety to get 
well, often is to wear her pessary, we should surely be laid up with 
inflamed feet just as the patient who persists in wearing a badly-fitted 
supporter suffers with acute pelvic inflammation. Now were we 
on account of such an experience as that supposed to entirely discard 
foot covering, and break out in a tirade against boots and shoes 
wdienever the words were heard, wre should be putting ourselves in 
much the same position as many who denounce all uterine support- 
ers, and the statement we often hear that they are of little or no use 
can come only from those who are ignorant of their correct applica- 
tion and the brilliant results to be obtained by their proper use. 
The circulatory system of the uterus is adapted for supplying that 
organ with the proper amount of blood when in its usual position, 3 
but it may be accepted as a rule that any change in the position of 
the womb from the normal tends to interfere with the circulation, and 
usually the greater the displacement the more the congestion. Con- 
gestion of an organ as richly supplied with blood-vessels as is the 
womb means a material increase in its weight, which of course tends 
to perpetuate and increase the displacement. 
Patients suffering with these troubles often say they have been told 
the womb never gets out of place unless previously diseased, and 
that their physicians, on examination, found that organ congested 
and enlarged, which condition was the cause of the displacement. It 
is true that uterine trouble generally precedes the displacement and 
is its chief cause, but in certain cases the reverse is true, and the 
physician who holds steadfastly to the one view or the other must 
sometimes be at fault. Certain cases of uterine displacement take 
place suddenly as the result of violence, such as the strain from lift- 
ing a heavy weight, or a fall. 
Let us, to illustrate our point, take a case of tho latter kind where 
the displacement is the result of a fall, and apply in a common-sense 
way the law of mechanics that “the impetus of a falling body is the 
product of its weight and its velocity,” in other words, the momen- 
tum of a heavy mass moving slowly may be equaled by that of a 
lighter mass moving swiftly. Now if we agree as we all must, that 
a heavy enlarged womb may be thrown out of place by the impetus 
acquired in a comparatively slight fall, keeping in view the above 
law, we must allow that the lighter, normal-sized womb may be dis- 
placed by a severer fall, and cases proving the truth of our assump- 
tion are frequent enough. A woman previously in excellent health 
and without a single symptom of uterine trouble is thrown from a 
carriage or from a horse, makes a misstep on the sidewalk, or in some 
other way has a fall (in one case the patient slipped on the waxed 
door of a ball-room while dancing) and dislocates the womb, we will 
say, backwards. Immediately or soon after she begins to suffer with 
backache and pelvic pains. The true nature of the accident not 
being suspected, the pain in the back often leads to the idea that the 
spine has been injured, which seems to be confirmed by the fact that 
the pain there is much increased by walking. The patient, it may 
be by the advice of her physician, keeps her bed for weeks in the 
hope that rest will cure the injury. After a longer or shorter time 
excessive pain at the monthly periods, pain with every movement of 
the bowels, dysuria or some other troublesome symptom, or the fact 
that the patient gets no better, leads to a uterine examination. The 
physician, finding the fundus backward upon the rectum, extremely 
tender to the touch, larger than normal, a discharge pouring from 4 
the uterine canal, what he considers “ulceration” at the os uteri,— 
the true nature of which I have endeavored to make clear in a previ- 
ous paper,1—and that the use of the sound shows the inside of the 
womb to be tender to the touch, is apt to conclude at once that the 
patient must have had for a long time latent uterine trouble which 
has now culminated in the present state of acute suffering and dis- 
placement. Imagine that one of us, sitting in an arm-chair, should 
bend his head down over the arm of the chair as far as possible, and 
keep it in that inverted position for days and weeks, and we can 
easily understand that congestion, oedema, and increased sensibility 
would follow, and with the congestion of the mucous membrane an 
abundant secretion of mucus. Suppose we should be called to 
relieve such a patient. The first thing we should advise would be 
that the head be restored to its natural position. In case of sudden 
uterine displacement where this common-sense course has been 
pursued, and the uterus has been restored to its normal place and kept 
there by a pessary until its natural supports regained their tone, I 
have seen the congestion and sensibility of the womb rapidly dimin- 
ish while it grew less in size, the uterine discharge stop, the pain in 
the back cease, constipation, painful defecation, and trouble with the 
bladder disappear, dysmenorrhoea, due to the congested hypertesthe- 
tic state of the womb or perhaps to obstruction caused by a flexion, 
give place to perfectly painless menstruation, that curious feeling in 
the back of the neck and top of the head, which patients often think 
“will drive them crazy,” and which we recognize so often as the result 
of uterine troubles without being able to explain the connection, 
vanish, and recovery take place, when no other treatment whatever 
was employed. But cases where such complete success follows the 
use of the pessary without further treatment are rare. There is 
generally trouble which precedes the displacement and is its cause, 
which will not be cured by simply restoring the womb to its place, 
and in the comparatively rare cases of sudden displacement, where 
no previous condition of disease existed, so much time is usually lost 
before the diagnosis is made and the patient comes under treatment 
that the condition of engorgement and its sequences have become 
chronic, so to speak, and further treatment appropriate to the given 
case is necessary to restore the parts to a healthy condition. 
If displacement produces in a previously healthy womb the con- 
gestion and the other conditions we have enumerated, we can easily 
understand that with a womb not in a state of health it aggravates 
the pathological states present, and adds new complications, and he 
who undertakes to treat a displaced womb for congestion, tenderness, 
endometritis, "ulcerations,” dysmenorrhoea, and the like, making 
‘On the So-Called “Ulcerations” of the Os Uteri. Boston Medical and Surgical 
Journal, March 16, 1876. 5 
no attempt to restore it to its normal position and to retain it there, 
as we so often see done, commits an error. 
There is a wide-spread impression among patients and even with 
many of the profession that if a woman once wear a supporter she will 
never he able to do without it, and that "supporters weaken the liga- 
ments,” as it is often expressed. Nothing can be further from the truth, 
provided a proper pessary be properly applied. There can be no dis- 
placement of the womb without some of the tissues which are intended 
to support it in its normal position being extended and overstretched. 
Without entering into a discussion here as to whether it is this lnja- 
ment or that which is particularly concerned, it cannot be questioned 
that, in a case of displacement backward, for instance, the tissues 
which, in the normal condition, act to prevent the womb from falling 
backward, when that organ is once dislocated in that direction and 
remains out of place, arc put in a state of abnormal tension, and 
that their elasticity will sooner or later be overcome and destroyed 
by such continued extension. The same is true of a displacement 
in any direction. The opposing ligaments and tissues are overcome 
and kept extended as long as the displacement continues, and our 
main hope of a cure in such cases lies in restoring the womb to its 
place before its proper supports become permanently overstrained, 
and in retaining it in position until they regain their tone. We have 
in a well-fitted supporter an agent which will often answer our pur- 
pose perfectly, and in many other cases where from the condition of 
the parts other measures, perhaps operative, are necessary before the 
womb can be restored to its place and kept there, the pessary is an 
aid in the treatment, which cannot be dispensed with. 
Owing to the ease with which they can be introduced and to the 
idea which seems rational to those not familiar with the subject, that 
the softer and more elastic the supporter is the less likely it will be 
to cause trouble, certain kinds of uterine supporters are in general 
use which do in fact often leave the pelvic supports weaker than 
before they were used. I refer to the various kinds of elastic-ring 
and globe pessaries and to those made of soft rubber and inflated in 
the vagina. We are all familiar with the effect produced by the steady 
pressure of the elastic ligature which has come into use as a substi- 
tute for the knife in many cases since Professor Dittel, of Vienna, 
brought it into notice after seeing its surprising action in the well- 
known case of the child who died in the Allgemeine Krankenhaus of 
that city from brain trouble caused by the elastic of a common net, 
worn continuously for several weeks, cutting through both tables of 
the skull down to the membranes of the brain. With an elastic- 
ring pessary, which is introduced while compressed and allowed to expand in the vagina, we have a condition of things somewhat simi- 
lar, only the force is from the centre instead of towards it. From 
the elasticity of the ring the pressure is continued until it cuts its 
way into the tissues to the extent of its dilatability, unless the vagina 
dilates to that extent. One or both of these things must hap- 
pen when an elastic-ring pessary, large enough to support the womb 
properly, is used. The cases where the vaginae become dilated by 
pessaries, although they do not show at first so strikingly the injury 
done, frequently have worse final results. There is a tendency at 
the present day to undervalue the influence of the vagina in support- 
ing the womb and in keeping it in place, particularly since the ex- 
periments of Dr. Savage, of London, upon the cadaver, which 
showed that when the womb was seized and pulled forcibly down- 
ward the utero-sacral ligaments offered the first serious resistance to 
its descent. No one would suppose that the vagina and the soft 
tissues about it would resist such traction, but it is plain that the 
walls of the vagina, when in apposition and of normal tone, and 
supported by the surrounding tissues, must act as a column of 
support to the womb of considerable strength, and that when its 
walls become lax or distended their power in this direction is dimin- 
ished, the womb has a greater freedom of movement in the pelvis, 
and greater strain is put upon the uterine ligaments. In this way 
sueh supporters do in fact weaken the ligaments. Soft rubber is, 
moreover, one of the worst of materials for a supporter. It ab- 
sorbs more or less of the secretions, becomes in a short time very 
foul and irritating, and gives rise often to excessive leucorrhoea. 
Now and then even the softest inflated pessary, which seems incapa- 
ble of injuring the parts, will cause an astonishing amount of ulcer- 
ation in a very short time. 
The supporters which have a stem attached to a belt or other con- 
trivance on the outside of the body are, as a class, perhaps the 
worst of all. Having a fixed support, they cannot accommodate 
themselves to the mobility of the womb, which moves up and down 
with every breath taken by the woman, and although at first sight 
they would seem to avoid distending the vagina, yet they often dis- 
tort the parts very much, for the direction of their pressure and 
their correct position can be more easily indicated on the wood-cut 
than controlled in actual practice. But for the ease with which 
they can be introduced into the vagina, which with many is the 
main test of the value of a supporter, they would be little used. 
Of all the materials which have as yet been brought into use hard 
rubber is by far the best, and the various modifications of the closed 
level pessary of Ilodge, made of this substance, will be found to 7 
supplant the other varieties of pessaries in proportion to the experi- 
ence of the physician in their application. 
Put the secret of success with pessaries lies not so much in the 
kind which is employed, for a variety which is proper for a given 
case may he improper for the next, hut in accurately fitting the sup- 
porter to the patient, and herein is the explanation of the fact that 
so many of the profession as well as the laity denounce their use. 
It is the exception, however many different pessaries are kept on 
hand, that one can he found which without some alteration in shape 
will properly fit a patient. Unfortunately, the applying of a sup- 
porter is an art only to be acquired by practice rather than a 
science which can he learned from rules. I do not hesitate to affirm 
that there is more special knowledge, skill, and experience 
required to properly fit a supporter in many cases which present, 
than in performing the majority of the operations of uterine surgery ; 
yet practitioners who are unwilling even to pass the sound to learn 
the direction of the uterine canal have no hesitation in inserting 
pessaries at hap-hazard, having anything hut a clear idea of how 
they support the womb or how they should lie in the vagina, and 
after a few trials of this kind they consider themselves experts, and 
think they have proven by experience that pessaries are worse than 
useless, and conscientiously warn patients against them. I have 
known such men to dispute as to which was the upper end of a com- 
mon Hedge’s pe66ary, neither knowing enough of the subject to be 
sure that he was right or convince the other that he was wron"1. 
Indeed the number of physicians whose knowledge of gynaecology 
is limited to some such experience as the above, who consider them- 
selves especially fitted to treat uterine cases, is astonishing. It is 
the exception rather than the rule not to learn from the patient that 
her physician has given special attention to female complaints. 
Could the result of treatment be as apparent here as with some 
other specialties, that of the eye, for instance, there would speedily 
be a revolution in the practice. 
Physicians at the present day do not attempt to provide their pa- 
tients with false teeth, but refer them to the dentist whose constant 
practice in his specialty renders him expert; yet it is an easier mat- 
ter to fit the plate to the mouth than to apply the uterine supporter, 
for in the first case the operator can take a perfect cast of the parts 
and work from that. Put it is not alone necessary that whoever 
attempts to use a pessary possess the mechanical skill and tact to fit it 
nicely, lie must be able to judge when its use is proper and neces- 
sary, and when it is not. For example, an attempt to use a pessary 
if cellutitis or pelvic peritonitis be present (and it requires an edu- catert touch to discover a localized subacute inflammation in the 
pelvis) may result in the death of the patient. On the other hand 
I have seen instances in which the tenderness of the womb and 
adjacent parts, due entirely to congestion caused by displacement, 
has been mistaken for inflammation, and patients have been uselessly 
kept in bed and told they could not wear a pessary, when this was 
exactly what was needed, as the result showed. I have known a 
lady to be considered hysterical, dosed with valerian and similar 
drugs, showered with cold water, and treated with anything but 
consideration by her friends, when suffering agony from an ovary 
jammed between the sacrum and the upper end of a pessary, and 
bruised with every movement of the body, an accident which the 
physician had never once suspected. 
One of the most distinguished and able of living specialists has 
expressed his idea of the benefit to be obtained from supporters by 
saying he who did not believe in their use was not fitted to treat 
uterine troubles. Their successful employment necessitates such a 
thorough acquaintance with the whole subject of gynaecology that the 
results which a physician obtains with them is a fair criterion by 
which to judge of his ability in the specialty. The objection often 
made that supporters are " unnatural ” is hardly worthy of discus- 
sion. The same may be said of any appliance known to surgery. 
There is nothing natural about the surgeon’s splint, yet it holds the 
dislocated elbow in its natural position until it will stay there un- 
assisted, as the pessary does the dislocated womb. A woman suffer- 
ing from uterine displacement once asked me why the womb was 
ever made top-heavy. It was a question hard to answer, yet the 
fact remains, and we must be prepared to combat the results. It 
is to be deplored that so many varieties of pessaries were ever in- 
vented. Physicians failing with a supporter through not fitting it 
properly are apt to conclude that their want of success arises from 
not having used the proper kind, and so they uselessly try one sort 
after another. Many of them are the inventions of instrument 
dealers and makers who know nothing of their practical application, 
but there is too much anxiety on the part of certain members of the 
profession to hand their names down to posterity as inventors of 
pessaries which are far superior to anything before conceived of, and 
which are claimed to be perfect. After a short trial these almost 
invariably disappoint their originators and are too often followed by 
some newer invention of the same mind, heralded as a great advance 
beyond the last, in short, perfection improved upon, which soon 
proves useless, and is thrown aside like its predecessor.