TRANSACTIONS OF THE OBSTETRICAL SOCIETY OF NEW YORK.

REPORTED BY THE SECRETARY, DR. H. C. COE.

Stated Meeting, April 6th, 1886.

The President, DR. P. F. MUNDE, in the Chair.

A NEW RETROVERSION STEM-PESSARY.

DR. H. M. SIMS exhibited a hard-rubber pessary of his own devising, adapted to cases of retroversion in which the cervix uteri is very short. It consisted of a straight stem, to the base of which was attached a ring having the shape of the posterior half of a Hodge-pessary. At the points where the ends of the ring joined

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the base of the stem were two peculiar bends, or shoulders, of such a shape that when a downward pressure was exerted upon the stem, the ring was tilted upwards.

The instrument was adjusted by exposing the cervix through a Sims' speculum, pulling the anterior lip downwards and forwards, and at the same time slipping the end of the stem into the os. As soon as the weight of the uterus rested upon the disc forming the base of the stem, the ring was thrown forwards against the symphysis, where it took its point d'appui, pressing the cervix backwards, and thus anteverting the uterus.

Dr. Sims explained that the instrument known as the uterine elevator had suggested to him the principle adopted in the pessary. He had invented the latter a year and a half before, but wished to test it thoroughly before offering it to the profession; he had used it in a number of cases, and always to his perfect satisfaction.

THE PRESIDENT asked if he did not understand Dr. Sims to say that the instrument was to a certain extent self-replacing, and that it differed from other retroversion pessaries in not distending the posterior vaginal fornix.

DR. SIMS said that there was no distention of the vagina whatever; the uterus was anteverted by its own weight. It was rarely necessary to bend the ring.

DR. JANVRIN did not understand exactly where the ring rested when the pessary was in position.

DR. SIMS replied that it pressed directly against the symphysis. In reply to a question, he said that the instrument could be worn with comfort for several months, provided that it was occasionally removed and cleansed.

DR. CLEVELAND asked to what particular class of cases it was adapted.

DR. SIMS said that he had used it in those cases in which no other pessary could be retained, i. e., when the cervix was very short.

DR. CLEVELAND inquired if its use was restricted to married

women.

DR. SIMS answered that he had two unmarried patients who were wearing the instrument with comfort; in virgins it was, of course, necessary to have small rings.

THE PRESIDENT asked the speaker if he had ever tried the pessary in a case in which the uterus was retroposed, while, at the same time, there was anteflexion of the cervix and body.

DR. SIMS replied in the negative, adding that he generally employed the galvanic stem under these circumstances.

THE PRESIDENT said that he had found it almost impossible to obtain sufficient leverage to raise such a uterus; he had used the Thomas-Cutter instrument in such cases, but had rarely been satisfied with the result. He thought that if Dr. Sims' pessary could overcome such a displacement its efficiency would be established beyond doubt. He regarded the principle upon which the instrument was made as an exceedingly ingenious one; it was, as far as he knew, unique in its construction.

DR. SIMS said that Dr. Chadwick, of Boston, had invented a pessary similar in appearance to the one exhibited, but the principle of its action was different.

DR. CLEVELAND did not see why the pressure of the vaginal walls upon the ring was not an element in the support afforded to the uterus.

DR. JANVRIN agreed with Dr. Cleveland that it was the pressure of the vaginal walls against the ring that tended to force the cervix backwards and thus to throw the fundus forwards.

DR. SIMS differed with both gentlemen. He did not think that the ring was sufficiently large to support any pressure from the vaginal folds. He added that when the perineal body was destroyed it was necessary to make the ring both longer and broader than when the latter was intact.

DR. PERRY remarked that he never used stem-pessaries unless there was subinvolution, as well as displacement, of the uterus. He regarded the instrument under consideration as an excellent one; he had often thought of devising a similar one for anteverting the uterus.

A SPECIMEN OF DOUBLE PYO-SALPINX.

DR. SIMS presented two specimens of pyo-salpinx of unusual size, one of which was intact, while in the other the contents of the sac had been evacuated. He related the following history: The pa

tient was a young girl who had had typhoid fever ten years before. Her menstruation, previously normal, was subsequently attended with severe pain, which at first was confined to the time of the flow, but latterly appeared from two to six days before the periods. Within the past six months she had lost flesh and strength rapidly, and complained of constant shooting-pains. Four weeks before she had been brought to Dr. Sims by her physician. On examination, a tumor was felt on the right side of the uterus, which displaced that organ to the left; another mass could be felt in Douglas' pouch. The latter moved slightly with the uterus. The tumor upon the right side was supposed to be a small ovarian cyst, and an operation was advised; it was performed during the following week. On opening the abdomen, a mass was found which filled the right iliac fossa, and was firmly

adherent both to the uterus and to the bottom of the pelvis. On account of the size of the cyst, it was necessary to evacuate its contents, which proved to be odorless pus. On separating the pelvic adhesions, the hemorrhage was considerable; it was controlled by the application of the cautery, it being impossible to tie the vessels, as they were inaccessible by reason of their position near the floor of the pelvis. The growth within the posterior cul-de-sac proved to be the left tube, which was distended with pus to the size of a large pear. A double-current drainage-tube (devised by Dr. Sims) was introduced, and continuous irrigation with carbolic-acid solution was maintained for three days, in order to control the temperature. The tube was removed on the seventh day, from which date the convalescence was uninterrupted. The patient was then sitting up.

The PRESIDENT asked if the pus evacuated from the first tumor was offensive.

DR. SIMS replied that it had the appearance of pea-soup, and was without odor. In reply to a question, he stated that the patient was a virgin.

The PRESIDENT said that the latter statement was of importance, because, during a recent discussion on the subject of pyo-salpinx, Dr. T. Addis Emmet had expressed the opinion that this condition could only result as a sequela of gonorrhea, or acute endometritis. He thought that the use of the drainage-tube in connection with the case was of considerable interest.

B

DR. SIMS stated that the patient would undoubtedly have died had it not been for the introduction of the tube. He described his apparatus in detail. It consisted of two hard-rubber tubes, one within the other. The tube was left in situ, and it was not-necessary to disturb the dressings while washing out the pelvic cavity. A piece of rubber tubing was attached to one branch (A) of the drainage-tube, and led

A

into a vessel placed between the patient's thighs; carbolized water was pumped in through the other branch (B), and was siphoned out into the vessel. The irrigation was continued until the water came away clear. Dr. Sims said that he had frequently seen the temperature fall rapidly immediately after irrigation.

DR. CLEVELAND asked concerning the indications for drainage.

DR. SIMS replied that he rarely introduced the tube except when there were extensive adhesions; when there was any doubt, however, he always gave the patient the benefit of it and used drainage, and he had never had occasion to regret it.

The PRESIDENT remarked that he had recently had a case of double ovariotomy in which the adhesions were numerous, although there was no oozing; after some hesitation he thought he would introduce a drainage-tube as it would at least do no harm. The next morning he removed from ten to twelve ounces of bloody serum from the tube, thus proving the wisdom of this decision. He thought that the patient would have died if drainage had not been maintained.

DR. CLEVELAND recalled a successful case of ovariotomy in a very fat patient with an adherent cyst; although drainage seemed to be indicated, he did not use it, yet the patient made a normal

recovery.

DR. B. M. EMMET protested against the use of a drainage-tube in every case in which there were adhesions, unless, at the same time, there was considerable oozing. He had seen more harm than good results from drainage.

DR. SIMS replied that he could recall many instances in which the patients would have been saved had drainage-tubes been used.

DR. CLEVELAND moved that this subject-the indications for drainage after laparotomy-be made the topic for discussion at the ensuing meeting. The motion was seconded and carried.

SPONTANEOUS EXTRUSION OF A SUBMUCOUS FIBROID, CAUSING PARTIAL INVERSION OF THE UTERUS.

THE PRESIDENT stated that he had been called, a few weeks before, to see in consultation a lady who had come from Boston on the same day. She was a widow, forty-nine years of age, who had had one child twenty-eight years before; she had been complaining for several weeks of "falling of the womb." On the day in ques

tion, while making a sudden movement when standing, she felt something protrude from the vulva; at the same time there was a pain in the abdomen and an escape of blood from the vagina. Her attendant, Dr. Weber, on examining her hastily, thought that an inversion of the uterus had occurred. The President examined the patient under ether and found, protruding from the vulva, the tumor of the size of two fists, which was exhibited. It measured ten inches in length, and weighed two pounds. No trace of the