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The subsequent granulations appeared healthy, and in two weeks the patient left the city, since which time I have not seen her.

This last application produced more than a local effect, viz., a more severe ptyalism than that which affected this patient it would be difficult to imagine, and this was attended by an intensely jaundiced appearance of the entire surface of the body.

The following extracts are from a letter received, a few weeks ago, from the husband:

"MY DEAR DOCTOR:-I received your letter a few days ago; must acknowledge my carelessness in not writing to you; have often thought I ought to write to you in reference to my wife's condition and state of health since her last treatment. The current of time has borne us along on smooth waters; all enjoy reasonable health, peace, and prosperity. Mrs. R., during the past four years, with the assistance of my daughter, has performed the duties of a housewife, with all the cares and work, except when she has been laid up for a day or two with sick headache. She has it to-day the second time in eight weeks; am giving her a new remedy which has increased the intervals between the attacks two weeks. I do not think the ulceration has ever appeared since the last treatment; have not examined her with speculum for several years. The uterus rests upon the perineum and seems heavier than it ought to be, and of late has been the cause of much disturbance of the rectum, requiring its replacement. She suffers some pain occasionally, and the menses are sometimes very profuse. There has not been any discharge of water since you applied the nitrate of mercury. It was heroic treatment, but I believe it saved her life, and I shall ever feel grateful to you and Dr. Jackson for your kindness towards Mrs. R. and myself."

TRANSACTIONS OF THE OBSTETRICAL
AND GYNECOLOGICAL SOCIETY
OF ST. LOUIS.

Stated Meeting, March 18th, 1886.

DR. W. M. MCPHEETERS, President, in the Chair.

ENCYSTED PESSARY.

DR. T. L. PAPIN exhibited to the Society a Hodge's hard-rubber pessary, which by boiling had been made to assume a circular form, and had thus been used for the purpose of relieving procidentia. The doctor found the pessary imbedded deeply in the tissues of the cul-de-sac of Douglas. After its introduction, cellu

litis had supervened, with subsequent hypertrophy of the tissue, so that the ring had become completely imbedded. The doctor cut down upon, but could not remove it, then with a long handled saw he cut out a segment, and was thus enabled to slip it out as a lady would remove an earring from the ear. The proliferation of tissue had completely cured the procidentia, and as this cicatricial tissue was left intact, the removal of the pessary did not in the least interfere with the result. Although this pessary had been introduced seven years previous, Dr. P. said that it was by no means true that so long a period is necessary to complete the imbedding of a pessary, as he has seen a case in his own practice in which a pessary in the course of two months had become thoroughly imbedded, so that an operation was necessary for its removal.

DR. L. CH. BOISLINIERE considered the imbedding of the pessary, in the case related by Dr. Papin, an admonition to the gynecologist of the necessity of carefully observing a pessary after its introduction, in order to anticipate any tendency to cut into the tissues. If this does not take place within a week after the introduction of the instrument, however, he concludes that no such effect will occur. He deprecates the haste of some gynecologists who introduce the pessary before the uterus has been replaced, and considers it a very grave mistake. For effecting a reposition, he makes use of an instrument devised by himself, or of a Sims' repositor. The latter he considers the most valuable instrument invented by Dr. Sims. Dr. B. admits a limitation of cases in which reposition must be attempted, but he does not consider adhesions, where there is an absence of pelvic cellulitis or peritonitis, as contra-indicating the use of the repositor and reposition of the uterus. He has never met with a case of adhesions such as he refers to, which could not be easily broken up without causing injury. Of course, he would consider any attempt at reposition, where cellulitis or peritonitis exists, as extremely injudicious. Hodge's pessary he looks upon as a very valuable instrument: an ordinary rubber teething ring also answers an admirable purpose in the virgin uterus; it is easily bent and soon assumes the shape of the sacrum, transforming itself into a Hodge's pessary. The instrument devised by Dr. Gehrung is an admirable anteversion pessary, and is so recognized by Dr. Mundé and other writers; it offers no impediment to coition, but must be carefully watched, as it tends to turn. Dr. B. considers that it answers an admirable purpose in anteversion, especially in cases of cystocele and prolapsus of the uterus in the first degree, and in prolapsus of the anterior wall of the vagina. He has never seen a case in which Gehrung's pessary had done any harm by causing erosion or by cutting. Dr. B. had removed a gold-globe pessary with the forceps, which had been imbedded for years, causing a purulent discharge, and resembled a tumor. He considers the ordinary softrubber ball a good pessary for clinical cases on account of its extreme cheapness; he makes use of it frequently at his clinics. By expressing the air it is readily introduced, and then, becoming inflated, serves to support the uterus very nicely. Of course, it is necessary to remove such ball pessaries frequently for purposes of cleanliness, but the patient can be taught to do this. Another

method of treatment, which to some extent dispenses with the pessary, is the dry treatment, the use of cotton, jute, and oakum tampons, which was so admirably explained to the Society by Dr. Engelmann at a recent meeting.

DR. T. L. PAPIN related the case of a German lady whom he had seen some years ago, who had worn a wooden ball pessary for four years. When she presented herself to him and begged him to remove it, she was in a pitiable condition. On removing the pessary with a pair of forceps, the fenestra was found to be completely filled with thick, cheesy mucus secreted by the vagina. After cleansing the parts thoroughly, he directed the use of a weak solution of perchlorate of potash, and within a few weeks she improved beyond recognition.

DR. GEO. J. ENGELMANN thought the subject upon which the preceding speakers had touched, i. e., the evils resulting from the use of pessaries, should be elaborated. He said it was time that the profession at large should know something of the abuse of the pessary; the instrument had been too freely used by ignorant and inexperienced persons, physicians who have no idea of the anotomical relations of parts, and even by midwives. The pessary was a valuable and necessary instrument, and one which could not be replaced for the particular object for which it was intended, in proper cases; but it by no means subserved all the purposes for which it had been used. Like intrauterine applications of the tincture of iodine, it had been used too frequently and indiscriminately. The pessary should be used only in a healthy pelvis, to support healthy organs, displaced by reason of the relaxation of the tissues; it should be inserted only to aid an organ which is healthy, or nearly so, to replace or to strengthen the weakened supports. If we have displacements which are the result of disease, we should direct our efforts toward the relief of the disease which causes them, and if, after curing the disease, the displacement still persists, we should use the pessary to correct that.

A great many practitioners use the pessary because they have read the glowing accounts which have been written of the benefits derived from its use, and it is high time that the evil results are recorded, as well as successes. A great many very sad cases result from the improper use of pessaries; the class of cases of which Dr. Papin spoke, in which the pessary is imbedded in the tissues, is perhaps the most striking, but least frequent and least serious. He has frequently seen cases in which cellulitis has been caused or aggravated by the use of the pessary; he now has under treatment a patient, the wife of a physician, who came to this city some two years ago for the treatment of some uterine disorder, and her condition was then somewhat improved. She returned last year for further treatment and a pessary was used, but not giving satisfaction, one after another was tried, the patient being exhorted to bear the pain caused thereby, as the result would be satisfactory in the end, until at last she was forced to her bed and compelled to return home, where she spent the better part of six months on her back. She was now under his treatment for chronic cellulitis. It is true that the uterus is displaced, but no attempt can be made to replace it. Cellulitis probably existed in a mild form before pessaries were used, but her present pitiable condition is due to the ill-advised and improper use of these instruments. This case is by no means an isolated instance; the gynecologists meet with many such cases, where thoughtless and

inexperienced practitioners have used pessaries under circumstances which do not warrant their use, and, in consequence, inflammatory conditions are excited in the adjacent tissues, uterus, ovaries, or ligaments. We readily see what anteversion and anteflexion pessaries amount to, when we remember that Dr. Thomas has invented no less than thirteen or fourteen, and himself admits that he is not satisfied even with the last.

There are hundreds of different forms of pessaries, every shop is stocked, and immense numbers of them are sold. It is true that a vast amount of good can be done by judicious use, but they must be inserted only if the surrounding tissues are healthy, after the disease which caused the displacement has been relieved, if not overcome, or when the uterus is low down in the pelvis by reason of a lack of vigor in the pelvic tissues which support it; and even in those cases Dr. E. prefers to inaugurate a curative treatment, deeming the pessary curative only in isolated cases.

DR. W. L. BARRETT thought the pessary, when properly fitted, in suitable cases, a curative instrument. It rectifies the position of the uterus, helps to restore the circulation to the normal, and takes off pressure, and consequently betters cellular troubles. Any instrument which causes pain or irritation is pernicious. If the practitioner has the requisite skill to adapt the pessary to the requirements of the case, it will be a curative instrument, but if the instrument is imperfectly fitted, or if it be a case which is not suitable for wearing a pessary, it will do harm. All pessaries should be made of malleable material. Every case requires a different shaped pessary, and he does not consider a pessary of any value except Hodge's. Dr. B. believes that no instrument was ever invented which would do good in anteversion; that no woman will tolerate the pressure on the bladder which is produced by the anteversion pessary. The only benefit derived from the anteversion pessary is by way of lifting the uterus, anteverting it a little more, and freeing the ligaments from pressure in that way. He considers the pessary valuable in diseased conditions of the uterus; and not made solely to correct malpositions; that few malpositions can be corrected by the pessary-none except the backward displacement. Dr. B. calls attention to Dr. Emmet's health line in fitting pessaries, when cellular inflammation exists about the uterus, the patient is placed in the erect position, the uterus is slowly elevated on the inserted finger, when the point is reached at which a sense of relief from the dragging down and pain is obtained, it indicates the point at which the uterus should be held. Dr. Emmet contends very properly that there is no normal position of the uterus; that the position of the uterus varies in different women, and perhaps in the same woman at different times. Of course, in order to derive benefit from the use of the pessary, the uterus must be placed in the normal position. Any instrument which holds the uterus too high, puts the tissues on the stretch and does as much harm as if no pessary were used, and the uterus dropped down below the normal. A great deal of skill is required to adjust the instrument to the individual case, and but few know how to fit the pessary, but when properly fitted, in suitable cases, it is an invaluable instrument.

DR. T. L. PAPIN considers the pessary to be to the uterus what the suspensory bandage is to the testicle, or the splint to a broken leg. He certainly would not use the pessary in acute vaginitis, acute peritonitis, if the uterus were immovable, held by old adhe

sions, or in cases of cancer; but these are exceptional, and in other cases the pessary answers an admirable purpose. The womb is not fixed in any given position in the pelvis; its very purpose precludes this idea; it is attached by broad and round ligaments very loosely, and depends upon the surrounding parts for its support. If the woman stands on her feet, it dips down; if she lies on her back, it dips backward; if she leans forward, it dips towards the bladder; if she becomes pregnant, in the first few weeks, it falls down, because its ligaments are unable to support the very slight additional weight of its body, so that the uterus has really no stationary normal position; but for ordinary purposes and for the purpose of making ourselves intelligent, not only to the student but to the practitioner, we have accepted a normal position. In cases of posterior prolapse, no one remedy has done so much good in his hands as the pessary, modified to suit the individual case; but, as a rule, he finds that, by simply selecting the different sizes of pessaries which are to be obtained, he has succeeded in making his patients very comfortable. He would feel unable to continue the practice of gynecology if deprived of the use of the pessary.

TRANSACTIONS OF THE OBSTETRICAL SOCIETY OF LONDON.

Meeting of Wednesday, April 7th.

DR. BLACK, Vice-President, in the Chair.

The following specimens were shown:

1. Naegele Pelvis, by Dr. W. S. A. Griffith.

2. Infant one month old with Fusion of the Phalanges of the Right Index and Middle Fingers (living specimen), by Dr. John Phillips.

3. Hemato-salpinx with Ovarian Cyst, by Dr. John Phillips for Dr. Playfair.

4. Meningocele in a new-born Child, by Dr. Benington.

The following papers were read:

ON CONTRACTION, INHIBITION, AND EXPANSION OF THE UTERUS.

By J. MATTHEWS DUNCAN, M.D.-The uterus proper, or its body, is chiefly considered, but not to the entire exclusion of the cervix uteri and vagina. Contraction is temporary, and followed by relaxation and return to original dimensions. It may be morbid in force, in duration, in rhythm, in extent. Contractions in childhood are believed to be present, and in the whole of menstrual life and especially in menstruation. They are morbid in dysmenorrhea spasmodica, and may be tetanic. The rate may be six

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