COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00039608 Ilk Kiiiiii ■■1 5^ SS SSSS5SS8 XGr^ ^8 S JJ*%( kru Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/onuseabuseofpessOObant ON THE USE AND ABUSE PESSARIES BY GEORGE GRANVILLE BANTOCK M.D.. F.R.C.S. Edin. SURGEON TO THE SAMARITAN FREE HOSPITAL WITH ILLUSTRATIONS SECOND EDITION— ENTIRELY RE-WRITTEN LONDON H. K. LEWIS, 136, GOWER STREET, W.C. 1884 PRINTED BY II. K. LEWIS, 136, GOWER STREET, LONDON, W.C. PREFACE TO THE SECOND EDITION. The pamphlet on which this work is based first appeared as an ephemeral paper in the pages of The Lancet, and it was afterwards published in a separate form. It was intended as a mere sketch, and was written hastily in answer to a sort of chal- lenge " defying all the doctors in Christendom to put right " a displaced uterus. The reception which it has met with, the voluntary testimony of nume- rous impartial practitioners, both special and general, as to the results obtained from a practical test of the principles and practice inculcated, and the numerous inquiries after the pamphlet since it has been out of print, have induced me to bestow a con- siderable amount of labour upon this edition. I have not aimed at a systematic treatment of the subject, but have preferred to handle it from a practical point of view. In this form I trust it will be more acceptable to the busy general practitioner, while the gynaecologist will find it more easy to com- pare the opinions and practice with his own experi- ence. I am not unconscious of the feeling that iv Preface. some of the views here advanced will meet with strenuous opposition from a section of the latter class. Some of the doctrines are now common to a great many eminent gynaecologists, and therefore are not new ; others are novel and must run the gauntlet of criticism. In this I believe they will stand their ground. From a practical test, which alone is of value, I am confident they will emerge triumphant. It only remains for me to express my thanks to Mr. Alban Doran for his valuable assistance as these pages were passing through the press, and to Dr. Junker for several of the illustrations. TABLE OF CASES, CASE I. PAGE Retroversion of many years' standing ; prolapsus of left ovary ; Hodge's pessary. Cure 10 CASE II. Retroversion with menorrhagia ; Hodge's pessary. Cure of menorrhagia . . . . . . . .12 CASE III. Retroversion ; severe menorrhagia ; Hodge's pessary ; subse- quent pregnancy . . . . . , , 13 CASE IV. Frequent abortions, due to retroversion ; menorrhagia ; Hodge's pessary ; subsequent pregnancy . . . . 1 5 CASE V. Retroversion with attendant symptoms ; pessary ; pregnancy. Cure . . . 16 CASE VI. Retroversion ; repeated miscarriages ; severe bearing-down, &c. ; pessary ; birth of a double monster. Cure . . 17 CASE VII. Retroversion with sub-involution ; pessary; pregnancy . . 18 vi Table of Cases. CASE VIII. I'AGE Retroversion ; sub-involution ; menorrhagia ; Hodge's pessary for two years. Cure 19 CASE IX. Vaginismus ; retroversion ; Hodge's pessary. Cure of Vaginis- mus ; pregnancy ......... 22 CASE X. Retroversion ; Hodge's pessary ; subsequent pregnancy in a recently married woman . . .... 23 CASE XI. Retroversion, &c ; Hodge's pessary. Cure ; subsequent preg- 24 CASE XII. Acute retroversion with symptoms simulating pregnancy ; Hodge's pessary. Cure. Death four years later from malignant disease of left ovary 25 CASE XIII. Acute retroversion from falling on the face ; Hodge's pessary. Cure 31 CASE XIV. Retroversion with sub-involution ; Hodge's pessary ; subse- quent pregnancy and return of the Retroversion . . 55 CASE XV Retroversion of uterus with flexion ; severe dysmenorrhea ; menorrhagia intercurrent ; adhesions of uterus ; removal of ovaries and tubes by abdominal section ; division of adhesions. Cure. ........ 80 Table of Cases. vii CASE XVI. PAGE Retroversion ; Ring pessary for nine months ; failure ; Hodge's pessary followed by pregnancy, &c. ..... 87 CASE XVII. RetroFLEXION ; vaginitis ; Hodge's pessary after the cure ot the vagnitis ; failure ; Meadows' compound stem. Cure : subsequent marriage and pregnancy . . . . 92 CASE XVIII. Retroflexion with hypertrophy ; severe menorrhagia ; Hodge's pessary ; failure ; Meadows' compound stem. Apparent Cure ........... 96 CASE XIX. Retroflexion with some version, the result of a fall on the face ; dysmenorrhea ; failure of Hodge's pessary ; compound stem ; relief ........... 99 CASE XX. Retroversion of gravid uterus ; failure of the genu-pectoral pos- ture ; replacement by means of the volsella ; Hodge's pessary 106 CASE XXI. Retroversion of gravid uterus with retention of urine, &c. . 106 CASE XXII. Retroversion of three and a half months' gravid uterus ; reten- tion of urine, &c. ........ 107 CASE XXIII. Very acute anteflexion ; severe dysmenorrhea ; failure of Stem and Hodge ; Meadows' compound stem. Cure . . .138 viii Table of Cases. CASE xxiv. PAGE Anteflexion, with posterior rotation ; congestion ; dysmenor- rhcea ; failure of combined uterine and vaginal pessaries ; Meadows' compound stem. Cure ; pregnancy . . . H4 CASE XXV. Anteflexion with retroversion (posterior rotation) ; dysmenor- rhea ; Meadows' stem. Cure ; subsequent marriage and pregnancy .......... \t CASE XXVI. Acute anteflexion ; constriction of internal os ; dysmenorrhcea ; sterility ; " division of cervix." Cure of dysmenorrhcea and sterility . . . . . . . • . • J 5 : CASE XXVII. Acute Anteflexion with stricture of the internal os ; dysmenor- rhcea ; epileptiform convulsions ; division of cervix, fol- lowed by uterine stem. Cure 155 ON THE USE AND ABUSE OF PESSARIES. There is probably no subject in the whole range of gynaecology on which so much difference of opinion exists, on which opinions are so much opposed, as that of uterine displacements. Not only do opinions differ as to the nature of these displacements, but they also differ as to the symptoms which they produce. So varied also are the views as to the value of mechanical appliances in the treatment of uterine deviations, that, while on the one hand many eminent gynaecologists regard pessaries with great favour, as very efficient means in the treatment of displacements, and the morbid conditions so fre- quently associated with, if not actually dependent on them, others equally eminent, but in smaller number, are as much opposed to them, and attribute to their use untold mischief. In illustration of this conflict of opinion a few quotations will not be out of place. Some years ago Dr. Atlee stated that he had had no experience in the introduction of pessaries, but a B 2 Use and Abuse of Pessaries. large experience in their withdrawal, and that he had been able to remove the symptoms in most of his patients without the use of pessaries ; and when that could not be done he was satisfied without their their use. And he went on to declare, that with the uterus and pelvic organs in a healthy state, he was of opinion that a change in the position of the uterus was of no significance whatever, and there was no need of an instrument to keep it in a certain position. Dr. Henry Bennet says, his whole experience is antagonistic to the doctrines taught, and the treat- ment pursued, by those who employ mechanical means.* Dr. Matthews Duncan, believes, there is " a fashion in these matters ; " that " years ago every woman suffering from uterine disease was said to have a dislocated uterus ; at a later period no one had any affection of that sort ; and now again every woman was orettina- her uterus dislocated ; " and he added this strong challenge : " I defy all the Doctors in Christendom to put it right."* Again, he considers "the morbid importance of displace- ment as very much exaggerate 1. It would be nearer the truth to say it has little or no import- ance, "f Of pessaries all he has to say is, that he thinks "the support by a Hodge or similar vaginal pessary, of a large, tender uterus, a plan of treat- ment well worthy of trial. "| He divides displace- * British Medical Association Journal. Aug. 25, 1877, p. 259. t Transactions Obst. Soc. of London, 1881, p. 206. X Letter to Lancet, Feb. 2, 1878. Use and Abuse of Pessaries. 3 ments into two classes, viz : "displacement without descent, and displacement with descent." He believes " displacement without descent is, so far at least, an uncomplicated affection, introduces no new- kind of disease, but a changed set of conditions not so simple as those of displacement with descent."* Scanzoni says, that " Flexions (under which head he also includes Versions) do not acquire any importance, nor are followed by any serious dangers save when they are complicated with an alteration in the texture of the organ." He then goes on to discuss the question " How and why flexion eventually almost necessarily induces alterations in the structure of the organ, "f Bernutz writes thus : — " It has been my aim to prove that deviations of the uterus when simple, with the exception of prolapsus and procidentia do not cause any functional disturbance, but when complicated with old pelvi-peritonitis, or uterine catarrh, or congestion, the faulty position and the abnormal mobility of the uterus are a source of pain, and demand treatment"! On the other hand Barnes, Graily Hewitt, the two Simpsons, Edis, Atthill, Angus Macdonald, Hart and Barbour, and others in this country; Sims, Thomas, Emmet, Albert Smith, Goodell, Lusk, Munde and a host of others in America ; * Obst. Soc. Trans., loc. cit. t On the Diseases of Females, by Scanzoni. Gardner's transl. p. 115. % Diseases of Women, Bernutz and Goupil. Syd. Soc. transl. p. 231. 11 2 4 Use and Abuse of Pessaries. and in Germany, Hegar and Kaltenbach, Fritsch (Halle), Schultze, Winckel (Dresden), Amann (Munich), and others, all maintain the import- ance of uterine displacements, and the necessity for their treatment by mechanical appliances. A distinguished American recently said to me in discussing this question, "In my country this question is now settled, and no one worthy of con- sideration thinks of disputing the value of properly adapted pessaries." This paragraph would be incomplete without mention of the case of Dr. Angus Macdonald, to whom I referred a few years ago, in a speech delivered before the Obstetrical Society of London, in these words : — " Not long ago Dr. Angus Macdonald related a most instructive case, in which, after exhausting all the modes of constitutional and topical medication, on which Scanzoni and others would have relied, in vain efforts to relieve his patient, he was obliged to have recourse to a pessary. The result was a complete success. At the same time he took occasion to confess, with a courage which all must admire, that, though he had begun practice strongly disposed to disregard uterine displacements, this case convinced him that he was bound to reconsider his position, and to recognise not only the importance of displacements as a cause of suffering, but also the value of the pessary as a means of relief." I have reason to know that Dr. Macdonald is now a firm believer in the necessity for, and the value of, the pessary. An attempt to reconcile these conflicting views, Use and Abuse of Pessaries. 5 or to explain them away would be a hopeless task, but it will not be without use if I pass in review the statements and opinions of those who take the negative side. When Dr. Atlee admits that he has had no experience in the introduction of pessaries, he cannot fairly discuss their use and abuse ; and when he says that with the uterus and pelvic organs in a healthy condition (and I would add, as a necessary corollary, with the patient free from symptoms) a change in the position of the organ is of no signifi- cance whatever, he states a self-evident proposition. Many discussions have taken place on this subject, but I am unable to recall a single instance of any one contesting this point. For : What is the object of all treatment ? It is to relieve symptoms, and the relief of symptoms is the measure of the efficacy of all treatment. A man with a dislocated shoulder, which did not interfere with the full use of his arm would not trouble himself about reduction, any more than a woman with a dislocated uterus, which pro- duced no symptoms, would apply for relief. But experience shows that a man with a dislocated shoulder does suffer great inconvenience ; and it also shows that a woman with a dislocated uterus is no more exempt. How is it that women with well marked anteflexion so frequently complain of dysmenorrhea, that they are so often barren (if married), that the use of a stem pessary relieves the dysmenorrhea and so often brings about fertility ? How is it that in a case of anteflexion with con- 6 Use and Abuse of Pessaries. striction of the internal os, severe dysmenorrhoea, and barrenness, the division of the cervix without any other treatment produces the same results ? How is it that retroversion is so often found associated with barrenness, and more often is the cause of repeated abortions ? How is it that a woman who complains of a tolerably definite and regular train of symptoms is found to be the subject of a retroversion of the uterus, and that the rectification of the uterus removes the symptoms, renders her fertile, and enables her to go to her full time ? How is it that a woman, who has been the subject of menorrhagia, after bearing one or more children, gets rid of her menorrhagia by no other treatment than the introduction of a properly-fitting pessary ? Are all these facts, which will be illustrated in the course of this work, consistent with the idea that displacement of the uterus is of no importance ? Is it only an effort of the imagination when we describe a case of this kind ; namely, that a woman who walks or hobbles into our consulting room, or lives a life of chronic invalidism, complaining of pain in the sacral region, and an indefinable feeling of " bearing" down " in the pelvis, which interferes with her walking, is aggravated by a faecal evacuation, and renders irksome, if it does not prohibit, sexual relations, in a few minutes after the application of a pessary walks with comfort, tells us she is now free from pain, and subsequently finds that she can discharge all her duties with satisfaction? Surely, Use mid Abuse of Pessaries. 7 we have not been living in a fool's paradise all this time ! Dr. Henry Bennet's statements are of too general a character to analyse, and amount only to assertion. More definite are those of Dr. Matthews Duncan, who recognises two forms of displacement — viz., " displacement with descent, and displacement with- out descent," the latter of which he regards as " of no importance whatever." Whatever importance is to be attached to this descent in the case of back- ward displacement, it can have none in that of, say anteflexion, in which there is no descent of an appre- ciable amount, in the great majority of cases ; and yet these cases of anteflexion are the most produc- tive of symptoms and disabilities. Dr. Duncan believes that in displacement with descent the symptoms are due to the dragging on the broad ligaments. In anteflexion there can be none of this dragging. On the other hand, in the case of retro- version and retroflexion, as Dr. Graily Hewitt* pointed out, this descent " forms an essential part of the disorder." This has been demonstrated in the most exact manner by Dr. Berry Hart. In the case of retroversion we find not only a descent of the cervix in the vagina, but also a descent of the body into Douglas's pouch. Hence the dragging pains in the sacral and lumbar regions, together with dislocation of the ovaries, accompanied by inevitable discomfort under various circumstances, such as faecal evacuation, sexual relations, &c. This descent * Trans. Obst. Soc, loc. cit. 8 Use and Abuse of Pessaries. is very pointedly noticed in the recently published work of Hart and Barbour, in these words : " On vaginal examination the cervix is low down in the pelvis ; "* and again, " we observe clinically that it (the cervix) is much more easily reached. This is partly due to the alteration in its direction and posi- tion (being nearer the symphysis pubis, it is more within reach), partly to the sinking down of the uterus as a whole in the pelvis. "f Of the correctness of this description any one may satisfy himself by direct measurement in a case of retroversion by first measuring the distance of the os uteri from the vaginal outlet in the retroverted state, and then after replacement of the organ into its natural position, and especially after the adaptation of a pessary. Dr. Duncan's treatment of retroversion or retro- flexion is probably in accordance with his views of the pathology ; yet he admits that he thinks " the support by a Hodge or similar vaginal pessary, of a large, tender uterus, a plan of treatment well worthy of trial."! When Scanzoni affirms that flexions (and versions) do not acquire any importance, nor are followed by any serious dangers (symptoms ?) except when they are complicated with an alteration in the texture of the organ, he fails to be consistent with himself when he goes on to discuss the question " How and why flexion eventually almost necessarily induces alterations in the structure of the organ." After * Manual of Gynecology. Chapter — Retroversion, p. 332. t Op. tit. Chapter— Retroflexion, p. 334. J See p. 2. Use and Abuse of Pessaries. 9 such an implied admission it seems needless to pursue this part of the subject further. Bernutz says, "It has been my aim to prove that deviations of the uterus, when simple, with the exception of prolapsus and procidentia, do not cause any functional disturbance." How far M. Bernutz has proved his case I leave to the reader to deter- mine. It is a remarkable fact that women who are the subjects of prolapsus or procidentia complain more of the discomfort arising from the inability to micturate freely, or from the presence of the pro- lapsed organ between the thighs, and the consequent irritation of the exposed parts, than anything else. He admits that when the organ is "the seat of chronic catarrh or congestion, the faulty position and abnormal mobility of the uterus are a source of pain, and demand treatment." He ignores the effect of the displacement in the causation of these morbid conditions. In this he may be left to the refutation of Scanzoni. In a recent number of the Zeitschrift fur Geburtshillfe und Gyndkologie, and in an article on the subject of vomiting in pregnancy by Dr. M. Horwitz, of St. Petersburg, the following sentences occur : — " The epoch in gynaecology in which versions and flexions of the uterus were regarded as in themselves something very serious and pathological is long gone by : the gynaecologist of the present day looks upon the question from quite a different standpoint. Every version or flexion of the uterus is only pathological when it is io Use and Abuse of Pessaries. the result of decided alteration in the parenchyma of the organ."* The author must have been ignorant of the views of all the leading gynaecologists of America, and of not a few in this country, who maintain the importance of displacements as such. Does he ignore the very serious nature of retrover- sion of the gravid uterus, and maintain that the displacement in this case is not pathological ? According to his view also an acute or traumatic retroversion is not pathological. By parity of reasoning, a hernia of intestine is not pathological. It will now be convenient to present a few cases illustrating the foregoing comments. Case I. — Retroversion of many years standing ; prolapsus of left ovary ; Hodge s pessary. Cure. Some years ago I was asked by a medical friend to see his wife, who for months had been almost confined to her bed. She had had two children, and had never been well since her last confinement. I was told that she had been for several months, without any benefit, under the care of a distinguished gynaecologist, who neither believes in the importance of displacement nor in the value of the pessary, and it will readily be accepted that the suggestion of a pessary was made in. vain. On examination I found the uterus very large, mea- * Ueber das unstillbare Erbrechen dcr Schwangeren. Von Prof. Dr. M. Horwitz, St. Petersburg. Zeitschrift fur Gcburtshiilfc und Gynakologic, IX. Band, I. Heft, 1883. p. 138. Use and Abuse of Pessaries. 1 1 suring about three inches-and-a-half in its cavity, and so retroverted that the os uteri pointed to the upper part of the vaginal outlet (as the patient lay- in the dorsal position). The left ovary could be felt very distinctly prolapsed into the left side of the utero-rectal sac, and was very tender to the touch. The riorht could also be felt on bimanual examina- tion scarcely lower than its normal position. For many months the patient had done little more than pass from her bedroom, usually in the evening, to the couch in the sitting-room, as the erect position or the act of walking caused her so much pain. There was no leucorrhcea nor excoriation, nor could I find any cause for the symptoms other than the retroversion of the uterus and the consequent pro- lapsus of the left ovary. I at once replaced the uterus by means of the sound, the ovary at the same time resuming its normal position, and, while it was thus kept in position, introduced a Hodge's pessary. The sound indicated, by its falling to one side, that the pessary was not efficient. I therefore withdrew it and introduced a larger instrument, with a satis- factory result. The ovary was no longer prolapsed. I asked her to get out of bed while we left the room, and try the effect. This she did with a sense of great relief, and I bade her good-bye, recommending her not to exert herself much for a few days. I remained a short time in conversation with her husband, and before leaving the house had the satis- faction of seeing her walk into the room, when she expressed her delight at the prompt success of the 12 Use and Abuse of Pessaries. treatment. Beyond this, nothing was done except the administration of an occasional dose of a saline chalybeate aperient. The patient came to my house (a distance of four miles) in order that I might be satisfied as to her condition. After about a year the instrument was removed, and the uterus and ovary were left in normal position. The patient has continued quite well to this day. The question naturally arises, why did her former medical attendant, a man of great fame and expe- rience, afford this patient no relief ? The answer comes that he both failed to recognise the import- ance of the displacement, and was not aware of the value of the pessary. Case II. — Retroversion with menorrhagia ; Hodges pessary. Cure of menorrhagia. In 1 87 1, Mrs. B came under my care suffer- ing from severe menorrhagia and dysmenorrhea, for which she had been under medical treatment for several months. She complained of constant pain, more or less severe, which so interfered with her walking, that it was with great difficulty she made her way to the out-patient department of the Sama- ritan Free Hospital. Menstruation was excessive in quantity and duration. I found the uterus very much retroverted, its body enlarged and the cavity measuring 3f inches. The organ was readily re- placed by means of the sound, but at once fell back on removing the support. There was tenderness Use and Abuse of Pessaries. 13 of the body on bimanual pressure, great tenderness on pressing the sound against the fundus, and a little blood followed the use of this instrument. I at once adjusted a Hodge's pessary with my usual precautions, and the patient went home in great comfort, with a prescription for tincture of the muriate of iron and liquid extract of ergot in ten mimim doses three times daily. She wore the instrument for about nine months, during which time she was able to attend to her household duties : the periods gradually assumed the normal character, assisted, as I believe, by the use of two sponge tents, and I removed the instrument. When last seen she was quite well. Case III. — Retroversion; severe menorrhagia ; Hodge 's pessary ; subsequent pregnancy. Mrs. D , aged thirty-three, came under my care at the Samaritan Free Hospital, in the summer of 1875, the subject of severe menorrhagia, which told its tale in her anxious appearance, and from which she had suffered since her last (sixth) con- finement, a year and a half previously. She also complained of a constant bearing-down, and stated that the loss of blood was very great, and that she was scarcely a week free from a hsemorrhagic dis- charge. I prescribed iron and ergot. A few days afterwards I was requested to visit her at her own home, and so great was the loss that I at first 14 Use and Abuse of Pessaries. thought I had to do with a case of abortion. I then found the uterus very much retroverted, and prescribed 10 grains of gallic acid every two hours. As soon as possible she was admitted into the Hospital, and on the same day I adjusted a Hodge's pessary. This gave immediate relief to the bear- ing-down. I kept her in bed for about a fortnight, administering iron and ergot three times a-day, with the result of procuring her an interval of nearly three weeks, and a moderate flow. I then dis- missed her. She returned on November 9th, stating that the menses were regular and not excessive in quantity, the flow lasting eight days " off and on." She complained of some discomfort in the left groin. The uterus was in good position, well sup- ported by the pessary ; the bowels were constipated, and she had frequent headaches. I prescribed quinine and iron, and a mild aperient at bedtime. On December 7th I substituted for this a saline chalybeate, with such effect that by January 25th, 1876, she was free from symptoms. The last period continued for seven days and was moderate in quantity. After an interval of three weeks, namely, on February nth, she again returned, complaining of aching in the pelvic region, and bearing-down, and stated that she had "gone over her time." I kept her under observation till May 2nd, when I was satisfied that she was pregnant, and on the 23rd I removed the instrument. She was confined on September 25th. No return of the retroversion or monorrhagia. Use and Abuse of Pessaries. 15 Case IV. — Frequent aboi'tions, due to retroversion; menorrhagia ; Hodge s pessary ; subsequent pregnancy. Mrs. H , aged twenty-four, married eighteen months, consulted me on October 9th, 1872, on account of menorrhagia and frequent miscarriages, of which she had had three — the first at three months, the second at four months, and the third at two months. She complained of a feeling of weight in the sacrum and hypogastrium, increased by exer- tion. The menses were very free, lasting eight days, and were much more abundant than before marriage. The patient, moreover, was anxious in appearance. I found the uterus retroverted ; os open; uterine tissues generally flabby; slight leucor- rhcea. A Hodge's pessary was adjusted and kept the uterus in excellent position : iron and ergot were prescribed. Nov. 9th. Uterus in good position, admitting sound readily in normal direction. I recommended her to continue the treatment, and to let me know should she miss a period. January 8th, 1873. Stated that she had last menstruated in the last week of November, and for the last few days had been sick in the morning, and had felt some bearing-down on standing. I found the pessary lying across the vagina, but the uterus still in position. I withdrew the instrument, and while the patient was in the knee-shoulder posi- tion I replaced it. It will suffice to say that on 1 6 Use and Abuse of Pessaries. January 26th she had a slight haemorrhagic dis- charge ; that on February 10th I substituted (with immediate relief to pain in the sacral region on standing), a larger instrument, as the uterus was rather low in the pelvis : that from the 24th to the 27th she was again threatened with abortion : that I removed the instrument on May 22nd, and that the patient was confined on September 3rd, under the care of Dr. Baxter Forman, of Stoke Newington. She made a good recovery. 1884. This patient has now a numerous family and has had no return of the retroversion. Case V. — Reti'oversion with attendant symptoms; pessary ; pregnancy. Cure. Mrs. S , aged twenty-seven, the mother of six children, of which the last was born on Sep- tember 20th, 1875, came under my care on April 3rd, 1876, stating that since her last confinement she had suffered from severe bearing-down and pain in the hypogastrium, for which she had been continuously under treatment, but without relief. The bowels were costive, evacuations painful, and sexual relations intolerable. I found the uterus retroverted, the fundus and body tender on pressure (in the act of elevating with the ringer), and the os open so as to admit the tip of the finger ; no exco- riation and very little leucorrhcea. A Hodge's pessary gave immediate relief, and the patient walked home in comfort. I prescribed also a saline Use and Abuse of Pessaries. 1 7 chalybeate aperient. On the 5th she returned, saying she was perfectly free from pain in walking, and had no bearing-down. On July 1st I removed the pessary as an experiment, and though the time was in my opinion too short, the uterus remained in good position. She returned on the 8th with the uterus aeain retroverted and a recurrence of the old symptoms. I re-introduced the pessary with the same result as before. On September 18th the sound entered readily in the normal direction, and there were no symptoms. On November 14th she stated that she had missed her period by four days, and for several days had had morning sickness. On March 19th, 1876, I removed the pessary, and on July 20th I attended the patient in her confine- ment. She made an excellent recovery. The retroversion has not returned. Case VI. — Retroversion ; repeated miscarriages ; severe bearing-down, &c. ; pessary ; birth of a double monster. Cure. Mrs. S , the subject of repeated miscarriages, was sent to me by a neighbouring practitioner, by whom she was supposed (from her symptoms) to be suffering from prolapsus. The case was one of retroversion, and was at once relieved by a Hodge's pessary. About a month afterwards, through violent exertion in lifting, the instrument was expelled and her old symptoms returned. I re- 18 Use and Abuse of Pessaries. introduced the pessary. She became pregnant some months after. The instrument was worn till she entered the fifth month, and the patient was somewhat prematurely delivered of a double monster, which is now in the Museum of the Obstetrical Society, Case VI I. — Retroversion with sub -involution ; pes- sary ; pregnancy. Mrs. C , aged twenty-one, was sent to me on August 17th, 1882, by Dr. Playfair, of Bromley. She had had two children at full time, and a five months' abortion (on June 23rd, 1881). Ever since last confinement she had complained of bearing- down, and felt on sitting as if something were being " pushed up " her "body." Menstruation had only once occurred since she weaned her baby eight weeks previously. It was then very free, and she had great pain for several days before, and during the flow. The uterus was retroverted, very tender ; lips everted, red, excoriated. The appetite was very bad, and the bowels were irritable (chiefly rectal irritation). I ordered her at once to use the hot douche, and prescribed Ammon. Chloridi gr. 10, Extr. Ergots Liq. \\\ 20, three times a-day, and complete rest. October \\tJi. — Since visit has been "unwell" every fortnight, for four or five days, flow very free, nu- merous clots, great pain, increasing towards the end. Still complains of the bearing-down in the intervals. Use and Abttse of Pessaries. 19 No leucorrhcea to speak of. Bowels still irritable. Uterus still retroverted, large and tender. It was now evident that the uterus wanted support, and I accordingly adjusted a (No. 7) Hodge's pessary and ordered her to continue the douche. I also in- creased the dose of Ammonium Chloride to gr. 15. 2dfth. The instrument got displaced about four days ago, and the patient withdrew it and replaced it up-side down. The uterus is now almost ante- verted. Introduced a No. 6, so as not to push the cervix too far back. Uterus still tender. Bowels constipated. To continue the treatment, with the addition of a dose of Hunyadi Janos when required. January $\st, 1883. — About a month ago patient removed the instrument as she thought it was some- what displaced. Last menstruation, which ceased a week ago, continued over a fortnight with a great deal of pain. Uterus in very good position and smaller, but still tender. Ordered a more complete observance of instructions as to rest. May 2\th. — Has not menstruated for three months. Uterus pregnant, in good position. Case VIII. — Retroversion; subinvolution; Menor- rhagia; Hodge s pessary for two years. Cure. On January 28th, 1882, I was consulted by Mrs. G , aged thirty-one, mother of four children, the last four-and-a-half months old. She complained of great pain in the pelvic region, excessive men- c 2 20 Use and Abuse of Pessaries. struation, debility and dyspnoea, and an irritable condition of the bowels. Menstruation irregular, interval varying from two to three weeks ; flow lasting for eight to ten days, and requiring from twenty to thirty napkins : pain worst at the beginning. More or less constant discharge, usually yellowish-white, somewhat brownish. Appetite variable, tongue clean, frequent calls to stool but no diarrhoea. Patient looked anxious, there was a slight hsemic murmur, and she complained of short- ness of breath on exertion. On examination the uterus was found very much retroverted, os large and open, pointing in the axis of the vagina ; the sound entered very readily with the concavity backwards, and having gone just over three inches without touching the fundus I hastily withdrew it, fearing she might have been pregnant, as she was getting near the time of her next period. The uterus being very firm I was able to replace it by backward pressure on the cervix, and adjusted a No. 8 Hodge's pessary without using the sound. Prescribed Tr. Fer. Mur. P. E. nji 10, Tr. Nucis Vom. iiji 5, three times a day. February \\th. — Menstruation came on the day after her visit and continued for a week, not quite so free as before, only about a dozen napkins ; a few small clots ; paroxysmal pains, but missed the pain at commencement of flow, os admitting the tip of index finger, feels granular, uterus in very good position. A little milky-looking discharge in vagina. Some irritability of rectum still. To take Fer. Sulph. Use and Abuse of Pessaries. 2 1 gr. 2, Magn. Sulph. gr. 30, Acid. Sulph. Dil. nji 5, three times a day, and to use the hot douche. July 191/1. — Feeling altogether better, has no discomfort of any kind. Menses regular, fair quantity — 4 to 5 days' duration. Has not been taking the medicine at all regularly. Bowels regular. November 2nd. — Thinks she is "quite right;" no pain, no discharge ; feels nothing of instrument ; uterus somewhat anteverted, menstruation regular, normal. March 13IA, 1883. — Condition so satisfactory that I removed the pessary. April 27th. — As the position of the uterus was such that I feared it might again become retro- verted, I re-applied the same pessary, after slightly shortening it. June 2nd. — Has nothing particular to complain of: feels quite comfortable as regards the instru- ment. January 22nd, 1884. — Has not been feeling well for six weeks or so, complains of loss of appetite, debility, and some dyspepsia. Menses quite regular, nothing to complain of in that respect ; uterus some- what antevered, os normal size, uterine cavity measures 2 J inches. Removed the pessary and the uterus appeared to be firmly set in its position, exhibiting no tendency to retroversion. Instrument quite clean : no vaginal discharge. 22 Use and Abuse of Pessaries. Case IX. — Vaginismus ; retroversion ; Hodges pes- sary. Cure of Vaginismus ; pregnancy. Mrs. C , aged twenty-four, consulted me on September 27th, 1881. Suffered from vaginismus when first married, yet became pregnant within two months, and was confined on April 24th. On resump- tion of marital relations experienced the same diffi- culty. The husband now also complains. Menses regular, with a great deal of pain the first two days. The rectum was loaded with hard faeces, and the uterus was retroverted. I had to be contented with simply dilating the vagina, forcibly with the fingers, and prescribing an aperient. October <\th. — Complaining of backache ; the rec- tum being now clear, I introduced a No. 6 Hodge's pessary. October lit/). — Feeling very comfortable, "would not know the instrument was in." October 25th. — No backache nor bearing-down. Sound enters the uterus in normal direction. Very little vaginismus now. November 7.2nd. — Feels quite well, but at times intercourse is not absolutely free from discomfort. She says, " It is nothing to speak of now." January iot/1, 1882. — Vaginismus has completely disappeared. Uterus and instrument in excellent position. Menstruated a few days ago, and had no pain to speak of. Husband has accompanied her, to express his gratitude for the relief given to him- self and his wife. Use and Abuse of Pessaries. 23 March 2 1st. — Has no discomfort or inconvenience of any kind. Has not menstruated since January 8th. Evidently pregnant. Case X. — Retroversion; Hodges pessary; subse- quent pregnancy in a recently married woman. Mrs. B , aged thirty-nine, came under my care at the Samaritan Free Hospital in February, 1873. Had been only recently married, and was com- plaining of bearing-down, which had come on since her marriage. I found that this was due to a Retro- version, and I introduced a pessary, which at once gave her relief. After a few weeks I dismissed her, and had forgotten her case. About twelve months afterwards she returned, wishing to know why she had missed her period. I was careful not to use the sound, and merely satisfied myself by slight examination as to the position of the pessary. The patient had no complaint to make of pain or discomfort, and the instrument did not interfere with her in any way. It turned out she was preg- nant. In the course of the fifth month I removed the instrument, which was — after about eighteen months — as clean as if she had worn it for only a day or two. In due course she was delivered of a living child, which, however, survived only a short time. 24 Use and Abuse of Pessaries. Case XI. — Retroversion, &c. ; Hodge s pessary. Cure. Subsequent pregnancies. Mrs. W , consulted me on December 4th, 1877. She stated that she had had three chil- dren, the last a year ago, and a miscarriage at about fifth week in August last. Menses irregular — every three to five weeks — with pain in the bottom of the back. Complains of a constant bearing- down, aggravated by exertion. On examination I found the uterus retroverted, os low down, and pointing to the vaginal orifice. The uterus was easily replaced, and a Hodge's pessary supported it well, giving the patient much relief. jth. — Instrument threatens to come out on straining. Now, however, in good position, and sound enters in normal direction. Removed instru- ment, widened it anteriorly to meet the enlargement of vaginal orifice, and replaced it. ) \th. — No discomfort of any kind, and is not aware of the presence of the instrument. Bowels very costive. To take Mixture Fer. Sulph. and Magnesia. (Formula p. 21.) July 2>ist, 1878. — Instrument was removed a month ago, and the uterus now retains its normal position. Menstruated last on June 18th. It would be easy, were it not tedious, to multiply these cases. I think I have sufficiently proved my Use and Abuse of Pessaries. 25 case so far, and I now proceed to develop the sub- ject further. Retroversion in the virgin or unmarried woman is very uncommon. Its successful treatment is also difficult ; yet if uncomplicated by pelvic peritonitis resulting in adhesions, I believe it to be well within the means of cure. Whatever may be the etiology of some of these cases — whether due to error in development, or morbid conditions within the pelvis or vagina — it is certain that some are due to direct violence, such as falling on the buttocks, or (as in the cases to be recorded) from falling on the face. Such cases are attended with well-marked symptoms at the occurrence of the displacement; while the others resemble the more common in- stances occurring in the fertile woman, in often pre- senting no symptoms until congestion or disturb- ance of function has been set up. The following cases illustrate the acute or trau- matic form : — ■ Case XII. — Acute retroversion with symptoms simulating pregnancy ; Hodges pessary. Cure. Death four years later from malignant disease of left ovary. Mrs. O — — , aged thirty-three, was under my care during her first pregnancy. She suffered during the whole period from very distressing sickness and heartburn, for which the usual remedies, such as bismuth, soda, hydrocyanic acid, bromide of potass- 26 Use and Abuse of Pessaries. ium, &c, were tried in vain. I delivered her (by forceps) at full time of a very large and well- nourished male child in August, 1877. The sick- ness ceased with the birth of the child, but the heart- burn continued for a few days. She made a very good recovery, regained her normal health, and suckled the baby for the usual period. Soon after weaning her baby the menses re-ap- peared and recurred with regularity, though rather more abundantly than formerly. She menstruated from October 8th to 12th, 1876, as usual. On the 14th she carried a rather heavy child, five years and a half old, very hurriedly up two flights of stairs, but felt nothing more than what might be expected from such severe and unusual exertion. The next day she felt sick on getting up in the morning, and shortly afterwards the sickness assumed the same form as in her pregnancy of the preceding year. I saw her on the 16th, but for another object, and she omitted to say anything about the sickness. She then went to the seaside, and on her return I saw her aeain on November 2nd. The sickness and heartburn had then assumed their old proportions, and I aeain tried some of the usual remedies. She had menstruated at the usual period, but she thought there was a difference, inasmuch as for two or three days the flow ceased during the night and returned in the morning after getting up. Finding the medical treatment of no avail, the patient affirming with confidence that she was preg- nant, I got her consent to try the effect of local Use and Abuse of Pessaries. 27 treatment. At that time two methods were before the profession, the application of nitrate of silver to the os, as practised by Dr. Jones of Chicago ; and the dilatation of the os and cervix, introduced by Dr. Copeman. The high recommendation of the former by so distinguished an authority as Dr. Marion Sims determined the choice of this method. Through the speculum the cervix was seen to be very congested, the os was patent, and the mucous membrane turgid, and a glairy discharge issued from it. I applied the fused nitrate, by means of my probe, to the circle of the os and a portion of the cervix. Up to this time of the day the sickness and heartburn had been very distressing. Next day she told me the effect had been almost instantaneous, for on getting up again about an hour after the application, she felt perfectly well, and she had had no return. For three days this immunity continued, but on the fourth day the sickness returned, though in dimi- nished intensity. For a day or two there was a slight hemorrhagic discharge. The application was repeated on the 25th, and again on December 5th, but with less effect. After these two applications there was no haemorrhage discharge. The menses re-appeared after the usual interval ; but the flow was of the same "dodging" character as on the last occasion. On digital examination I found the uterus enlarged, os patulous, and body en- larged, but I could not satisfy myself at this early period as to the existence of pregnancy or not. I now thought the vomiting, &c, might be kept 28 Use and Abuse of Pessaries. up by the version, and accordingly adjusted a Hodge's pessary, placing the patient, for this pur- pose, in the knee-shoulder position. In this way I was able, by pressing the cervix backwards, to rectify the position of the uterus. On placing the patient on her back, after the introduction of the pessary, I found that the cervix maintained its normal position. The result of this was that the sickness was much relieved at once, and soon after- wards entirely ceased. I now saw the patient only at long intervals, and she appeared to be advancing in pregnancy. She was conscious of progressive increase in size, and felt convinced of her pregnancy. Nor did her friends fail to notice her condition. I told her at the last mentioned date that the pessary would have to be worn for about three months. Meeting her about the middle of March, I was told that she had removed the pessary, and had continued regular, and that she was entirely free from sickness or heart- burn. My suspicions were now aroused, though her appearance did not support this feeling, and I asked her to call upon me. This she did on April i st, expressing the hope that I was not going to make an "April fool" of her. It was my duty, after examination, to tell her that she was not preg- nant. The uterus was again retroverted, though not so much as before ; the os had contracted to a more normal size, and the body was decidedly smaller, the cavity measuring about 2 J inches. There was certainly no foetus there, nor was there Use and Afoise of Pessaries. 29 any question of extra-uterine foetation. There was nothing to be discovered in the abdomen or pelvis of an abnormal character, and the mammary areolae confirmed the diagnosis. The impact of the sound on the fundus caused her some pain. The uterus was replaced with the sound ; a Hodge's pessary was introduced and ascertained to be efficient. On April 7th she told me that two days after her visit she was sick in the morning, that she had had sen- sations in her breast similar to the " draught ;" that, moreover, she had been able to squeeze a drop or two of milk out of the nipples ; that she was as large as ever, and that her friends and several monthly nurses were convinced (!) the doctor was in error ; one of the latter in her superior wisdom, and, after calling attention to her peculiarities of shape, affirm- ing that if ever she saw a pregnant woman my patient was that one. The result of wearing the pessary for some months more was that the patient got rid of the distension, as well as all gastric disturbance. The uterus retained its normal position, as proved by the use of the sound, and menstruation went on regularly and well. The instrument was removed in September, 1880. On March 1st, 1881, the patient was complaining of pain in the left groin, and discomfort generally in the pelvis. The uterus was in a very good position and direction, the left ovary was as large as a hen's egg, tender to the touch. No menstrual trouble to speak of. 30 Use and Abuse of Pessaries. On April 22nd, she reported that two days after her last visit she was seized with an attack of sick- ness, with severe epigastric pain and vomiting of a greenish fluid for three days. She complained of pain in the left hip, thigh, and leg, aggravated by walking. The left ovary was still large and tender. I did not see the patient again till September 3rd, when the pelvic examination revealed a very serious state of things. The uterus was depressed, the os was open, and the whole organ was pushed forward and fixed ; behind the cervix a small round hard knob bulged into the vagina, and was con- nected intimately with a confused mass which filled up Douglas's pouch, spreading to each side of the pelvis and immovable. There was considerable tenderness on pressure. She complained of a constant feeling of pressure, and desire to go to stool, shooting pains in both groins and in the vagina, and frequent micturition. It was now only too evident that the disease was of a malignant nature, and this opinion was sub- sequently confirmed by the appearance of dissemi- nated nodules in the abdomen — probably in the omentum. Constipation became very troublesome, emaciation rapidly set in, and in a few months the poor patient's sufferings terminated in death. That this was a case of acute retroversion there can, I think, be no doubt. Up to October 14th the patient was, as far as she knew, perfectly well. She rushes up two flights of stairs with a heavy Use and Abuse of Pessaries. 31 screaming child hanging on her neck, and within twenty-four hours begins to have sickness. What further evidence do we require to establish the relation of cause and effect ? I confess I am satis- fied. On the other hand we have also the evidence that the replacement of the organ was followed by a cessation of the sickness. Case XIII. — Acute retroversion from falling on the face ; Hodge s pessary. Cure. Miss S , aged fifteen-and-a-half, came under my care on March 17th, 1879. Menstruation began in July, 1877, and continued regular and without pain, except the first time. On January 28th, 1879, while stooping down to pick something off the floor she was seized with a fit of sneezing in which she fell prone on the floor. As she fell, she felt as " if something had given way in the bottom of the back," in the region of the coccyx. She was unable to rise without assistance, and when she got up, so great was the pain that she was obliged to lie down. This pain gradually passed off with rest. At her next period, in the first and second weeks of February she was obliged to keep her bed on account of the pain. This pain was abdominal and hypogastric. After that period she could not sit upright without discomfort, and on rising from her chair she had to assist herself with her hands. The pain was now referred to the coccyx. A careful 2)2 Use and Abuse of Pessaries. examination of this part failed to detect anything wrong ; there was no tenderness even when roughly handled. I therefore made a vaginal examina- tion and found the uterus retroverted, and I could not but attribute the symptoms to this. After replacing the organ by means of the sound I introduced a No. 4 Hodge's pessary, with the result that the uterus retained its position, supporting the weight of the sound. After sitting down for a few minutes she found she could rise with much less discomfort, and without the help of her arms. The replacing of the uterus caused an aching sensation in the hypogastrium for a few minutes. On March 2 1 st she reached for something over head, and suddenly felt a pain in the bottom of the back. Up to this time she had been quite comfortable, and had almost forgotten that she had had anything wrong — and, certainly, she had forgotten my instructions, or deemed she was no longer under the necessity of observing them. Since then she had had more or less discomfort — though much less than formerly, and she could rise from her chair in the ordinary way. She had none on sitting down. On exami- nation, the pessary was found too loose in the vagina, and I substituted a No. 5. This gave her so much relief, that on rising from her chair she was just conscious of " something not quite right," as she expressed it. The last period was from the 6th to 10th and was quite painless. November \th. — Patient feeling quite well. I re- moved the instrument to find that the uterus was in Use and Abuse of Pessaries. 3 3 its normal position. Since last visit the periods have been quite regular, and without anything more than a little aching, such as she used to experience before the accident. Before the case recorded on p. 92 came under my notice I had come to recognise the essential differ- ence, and the importance of distinguishing, between Retroversion and Retroflexion, not only from an anatomical point of view, but also in respect of treat- ment. Yet I was anxious again to test the correctness of my views, and the value of the vaginal pessary ; and I had the less hesitation in doing so, as the cer- vical canal was very open, and there was consequently no dysmenorrhcea. What I have so long held was here illustrated most unmistakably, for the body of the uterus was so bent over the posterior bar that I could not pass the sound while the pessary was in situ. With the view of keeping the cervix as high and as far back in the vagina as possible, I bent the instrument into a short S shape ; but the result was the same. We are told by some gynaecologists that if the cervix be kept well back, the intra-abdominal pressure of the intestines will carry the body forwards. I venture to affirm that it will not do so in a case of well-marked flexion. In this case we have a well-marked flexion, with some version added, and we see a practical refutation of the argument. The substitution of a Meadows' com- pound stem, however, brought about the desired result. This was worn for twelve months uninter- ruptedly. Within three weeks of its removal it D 34 Use and Abuse of Pessaries. was evident that the uterus was falling back again, and I re-introduced the instrument for another period of seven to eight months, when it got dis- placed and the patient removed it. By this accident it is probable that the uterus was forcibly displaced, for thus I found it on examination. But there was this difference, that the displacement was now a pure version, and the left ovary was also brought down. The stem was now set at an acute angle to the frame, with the view of keeping the uterus somewhat anteverted, so as to assist in the restora- tion of the ovary. This was completed in a short time, and at the end of five months I felt confidence in entrusting the support of the uterus to a Hodge's pessary. Now it is of great importance to recognize the difference between ^^Xxoversion and Retroflexion, and cases will be given to illustrate this importance in view of treatment. The lines of demarcation overlap one another, so that it is often difficult to say, of a particular case, whether it is essentially a version or a flexion. Thus the uterus may, in the first instance, have been simply retroverted, but in consequence of the cervix meeting with more resist- ance in its forward and upward movement, than the body in its downward, an amount of flexion has been superadded, whose intensity will bear a direct relation to the difference between the degrees of resistance. How is this question to be settled ? I am in the habit of regarding the position and direction of the Use and Abuse of Pessaries. 35 cervix as the chief test. For instance, if the os point towards the coccyx, and the fundus can be felt in Douglas's pouch, close behind the cervix, with the usual sulcus between the body and cervix, the case is a true Retroflexion. If, on the other hand, the cervix be found behind the pubes, with the os pointing more or less towards it, or even above it, the case is one of Retroversion. Under the last- named circumstances the uterus is almost completely inverted. There is no difficulty in distinguishing between these two conditions. But there are all shades of gradation between these two extremes, and the nearer the case approaches the intermediate position the greater is the difficulty. Let me take one of these. The uterine body is down in Douglas's pouch and the os points to the vaginal outlet, so that the finger as it passes up the vagina goes straight into the os. Such a case, not- withstanding that there is a distinct bend at the junction of the body and cervix, whose concavity looks backwards, is essentially a 'Retroversion. If, in such a case, the cervix be pressed back- wards, the body will be found to recede from the finger in a corresponding degree, until it can be made to attain its normal position. To take another instance. The body is in the same posi- tion, but the cervix is not so far forward, that is, so low in the vagina, yet distinctly in advance of its natural position, and the os points towards the anus or thereabouts ; but there is a much closer approxi- mation of the body to the cervix, and the sulcus is d 2 36 Use and Abuse of Pessaries. deeper. Such a case is essentially a Retroflexion ; and it will be found that on pressing the cervix backwards, the uterus is doubled upon itself, and the body does not rise correspondingly out of its un- natural position. Considerable difference of opinion exists as to the relative frequency of these two conditions. Scarcely two authors agree. This difference of opinion arises, in great measure, from the differ- ence of the views held as to what constitutes version and what flexion. A few quotations will make this clear. Dr. Graily Hewitt says, in his third edition — " Changes in the form of the uterus are described under the term ' flexion and version,' the two being often confounded. Flexion of the uterus is generally associated with some degree of version, but there may be version without flexion." In the 4th edition he expresses himself thus : "It is very generally the case that version of the uterus is conjoined zvitk flexion of the organ, though in some cases the axis of the uterus is actually undisturbed, and there is version pure and simple."* While in the 3rd edition he so confounded the two conditions, that from the beginning to the end of the chapter the term Retroversion occurs only twice, and then only, as it were, by haphazard, he makes a much clearer distinction between the two in the 4th, and I quote with satisfaction the following paragraph on the Degrees of Version. He says : * American Ed. by Harry Marion-Sims, M.D., p. 174. Use and Abuse of Pessaries. 37 "If the uterus were perfectly rigid, and if its axis of suspension (a horizontal line drawn trans- versely across the pelvis at the centre of the uterus), were also fixed, the descent of the fundus backwards would imply necessarily a corresponding elevation of the os uteri. The motion would be a see-saw motion ; as the fundus descended the os uteri would be elevated, there would be true retroversion. But the uterus is not absolutely rigid, and when the fundus descends backwards, it usually becomes bent above the axis of suspension, and below it also. The attachments of the cervix uteri prevent the elevation of the os, so the whole canal becomes flexed. The os uteri has different degrees of eleva- tion in different cases."* While he thus describes the two conditions of flexion and version — the latter with great accuracy — he does not adhere to this division in his further treatment of the subject. Nor does he make any attempt to state their relative frequency. Dr. Barnes ostensibly observes the distinction between the two forms of backward displacement, and while he describes them under different heads, and in separate chapters, he yet confounds them. In proof of what I say, I would refer to his illus- tration under the head of Retroversion, showing the mode of applying Hodge's pessary, for what ? — for Retroversion ? — No, for Retroflexion. Hence it will not surprise us that he affirms that Retroversion is not nearly so frequent as Retroflexion. * Op. cit. American Ed. pp. 251-2. 38 Use and Abuse of Pessaries. Drs. West and Duncan say that " there seems reason for believing that the different varieties of flexions of the womb, as its retroflexion and ante- flexion, are of more frequent occurrence than the corresponding alteration in position of the whole of the organ which is known as Retroversion or Ante- version. In this they are totally at variance with Emmet, who tells us that " Retroversion is the most common form of uterine displacement," * a statement in which I wholly concur. While the late Sir J. Y. Simpson f treated of back- ward displacement under the head of Retroversion, his successor in the professorial chair adopts the term Retroflexion. In the recent work of Messrs. Hart and Barbour my views are strongly supported. In the opening paragraph, under the head of Retroflexion, they say " for convenience' sake this condition is usually called Retroflexion to distinguish it from Retrover- sion strictly speaking, the condition is Retroversion + Retroflexion." % This seems to imply that, in their opinion, there is no such thing as pure Retroflexion — a statement with which I can- not agree, but which I accept in so far as it tends to confirm my experience as to its very great rarity. But for this definition I would have sa*d they com- mitted the same mistake as Dr. Barnes in the ac- * Principles ;ind Practice of Gynaecology, 2nd Ed. p. 294. t Selected Obstetrical and Gynaecological Works, Edited by J. Watt Black, 1 87 1 , p. 683. X Manual of Gynecology, p. 334. Use and Abuse of Pessaries. 39 companying figure, in which is shown the " diagnosis of retroflexion by bimanual examination." I call the position an essential version with only slight flexion superadded. The same may be said of Fritsch's drawing, Fig. 2. In this illustration the uterus is represented as very moderately flexed, but so much retroverted that the Fig. 1. — Diagnosis of Retroflexion by bimanual Examination (Hart and Barbour). axis pretty nearly corresponds with the axis of the vagina. Gaillard Thomas observes closely the distinctive character of the two forms of displacement as I have described them. He defines retroversion as con- sisting " in a particular inclination of the uterus, so that the fundus approaches the sacrum and the cervix advances towards the symphysis pubis," and 4-0 Use and Abuse of Pessaries. retroflexion as existing " when the body of the uterus is bent towards the sacrum so as to create an angle on the posterior wall. Retroversion may exist in slight degree, the uterine axis inclining so as to make with that of the superior strait an angle Fig. 2.— Retroverteu and Flected Uterus (Fritsch). of 45 , or it may incline to 90 , thus lying across the pelvis ; or the cervix may be thrown up, and the fundus descend so as to form an angle of 135 . These varieties constitute the first, second and third decrees of retroversion." Use and Abuse of Pessaries. 41 " Retroflexion also has been divided into varieties dependent upon the degree of intensity, but they are so entirely arbitrary that they may as well be ignored." * This precision of definition and description in the case of retroversion may be proper in a systematic work, but it is scarcely reducible to practice. I readily subscribe to his statement with regard to the varieties of retroflexion. Thomas makes no attempt to state the relative frequency of these two conditions, from his own ob- servations. Of such statistics as he has been able to collect from others, viz., Meadows, Nonat, and Scanzoni, he says " nothing but discrepancy and doubt result from the comparison of the figures of these three conscientious observers," and " after a comparison of such statistical evidence," he feels in- clined to agree with Sydney Smith who says " there is nothing so unreliable as figures except facts." f Edis is of opinion that Retroflexion is more often met with than Retroversion independently of pro- lapsus. J Munde, on the other hand says, " while pure ante- flexion is frequently met with, retroflexion without accompanying (usually preceding) retroversion, is, in my experience, rare. I have seen many cases of retro-displacement of the uterus, and I should be false to my experience if I admitted that flexion was * On the Diseases of Women, 5th Ed. p. 432. f Op. cit. p. 432. X Manual of Diseases of Women, 1st Ed. p. 92. 42 Use and Abuse of Pessaries. the most frequent variety, or the common conse- quence of retroversion." * This statement of view was called forth in opposition to that of Fritsch who maintains that " retroversion is almost exclusively a passing displacement," in other words that "retroversion precedes almost every retroflexion, and that retroflexion is undoubtedly the most fre- quent pathological position of the uterus." f Schroeder holds the same view as Fritsch. Goodell after defining retroversion and retroflexion as I have done, in common with Thomas, says "It is rare to meet with a pure case of retroversion, that is, one without some degree of flexion, and so rare to meet with a case of retroflexion without being com- plicated with more or less of version that both of these displacements can be treated in pretty much the same manner." \ How few recognize the essential difference be- tween a version and a flexion ! In determining the question of version or flexion the important points to bear in mind are these, viz., that in retroversion the cervix may be displaced, as Thomas says, " until the uterine axis forms with that of the superior strait an angle of even 135 " or until the os points to the top of the symphysis pubis ; that a certain amount of flexion may be superadded, that the amount of flexion will depend on the vary- ing degrees of resistance offered on the one hand to * On the Curability of Uterine Displacements. American Journal of Obstetrics, Oct. 1881, p. 797. f Fritsch. Die Lageveranderungcn der Gebarmutter, p. 76. X Lessons in Gynecology, 2nd Ed. pp. 134-5. Use and Abuse of Pessaries. 43 the descent of the body, and on the other hand to the ascent of the cervix, and that the more the cervix is displaced the more certainly is the case one of essential retroversion. In the case of true retro- flexion the cervix is little, if at all, displaced, or in- clined from the axis of the superior strait. Guided in my observations by these distinguishing characteristics, it results from my own experience that retroversion is, in the words of Emmet, " the most common form of uterine displacement," and that the order in which they occur is this, viz., retroversion, anteflexion, anteversion, retroflexion. Thus of two thousand women who came under my notice in the out-patient department of the Samaritan Free Hos- pital, during the three years 1872 to 1875, of which I have tolerably accurate notes, 149 were the subject of uterine displacement, accompanied by symptoms which directed attention to the pelvic organs. That this is only an approximation I am free to admit, and for this reason among others, that many women who complained of pelvic pain or discomfort would not submit to examination. Of this number seventy-two had retroversion, fifty-one had anteflexion, twenty- one had anteversion, and only five had retroflexion. Thus there were seventy-seven cases of backward, and seventy-two of forward displacement, a state- ment of results, in this form, closely approaching those of Valleix and Mayer. The former gives the proportions as thirty-five deviations of the uterus forward and thirty-three backward, and the latter 44 Use and Abuse of Pessaries. sixty-five cases of the former and sixty-four of the latter.* The mode of action of the pessary has given rise to great difference of opinion ; for while some maintain that the instrument supports the fundus directly, others affirm that the support is indirect, and that the force is exerted only through the cervix. Graily Hewitt tells us that the " Hodge's pessary pushes up the fundus and draws the cervix backwards," and Thomas seems to hold the same view. Instruments have even been constructed with the posterior transverse bar made concave on the uterine aspect, under the belief that the uterus might rest in this hollow (Gervis). Indeed, I my- self at one time had mine thus formed. I maintain, on the other hand, that the support is indirect, and I have frequently demonstrated the fact that back- ward pressure on the cervix brings the uterine body forwards, even to a state of anteversion ; while, with a suitable position, such as the knee-shoulder position, I have, in cases of retroversion with preg- nancy, repeatedly taken advantage of this fact in adjusting or re-adjusting a pessary. That the direction of the uterus can be altered by backward traction on the cervix through the vaginal wall alone, is readily demonstrated by using Neuge- bauer's speculum in a case of well-marked antever- sion. Every one knows how difficult it is to get the os fully into view when using a Ferguson's speculum, and that it is necesssry to fix and hold * West and Duncan, p. 189. Use and Abuse of Pessaries. 45 the uterus by means of a tenaculum or volsella. In using Neugebauer's speculum in such a case, separation of the two blades, by approximation of the handles and with the posterior blade longer than the anterior, brings the os fully into view, as thoroughly as if held by the volsella. It can also be shown that the same manoeuvre will retrovert the uterus from its normal position. This results from the fact that the uterus is a more or less rigid body. Moreover, a consideration of the anatomical Fro. 3. — Retroflexion of Uterus. Peritoneo-vaginal septum at a. (After Savage. ) relations of the parts leads us to the same conclu- sion. Here is a diagram illustrating the condition of retroflexion from which it will at once be seen, how impossible it is, in any ordinary circumstances, to bring pressure to bear on the fundus. Indeed I may add that it would not be desirable, even if it were possible, to construct an instrument, to do so, as it could be done only at the expense of the utero-sacral ligaments, on the integrity of which the position of the uterus so much depends. As will be 46 Use and Abuse of Pessaries. seen by the diagram a pessary acting by its trans- verse bar on the peritoneo-vaginal septum at a forces it backwards and upwards until by a great deal of stretching it, perhaps, touches the back of the body. At the same time it drags the cervix in the same direction, with the effect of still further doubling the uterus upon itself, except in so far as it is obviated by a rotatory movement of the latter. But this is not all ; for experience tells us that the posterior transverse bar, taking the diagonal of the opposing forces, slips into the sulcus between the body of the uterus and the cervix, and the condition is only aggravated. Hence I take it as a most valuable indication of the inefficiency of the pessary when, with the instrument in situ, I cannot re-intro- duce the sound. As an illustration of this I would refer to the cases which are reported. The next figure, for which I am indebted to Hart and Barbour, shows how untenable is the idea of direct support of the fundus, and that the support is indirect, in the manner I have just explained. This is the view supported by Herman, when he says, " It is certain that it (the pessary) cannot by direct pressure upon the body push a retroverted or a re- troflexed uterus into the axis of the pelvic inlet."* On the other hand Edis holds the view that the pessary supports the fundus directly. He says, " Instead of inserting an ordinary Hodge's pessary, which presses unduly upon the fundus uteri, and often causes much discomfort, an elastic ring is * Medical Times and Gazette, Nov. 17, 1883. Use and Abuse of Pessaries. 47 much more likely to be tolerated ; and by its uniform distension of the posterior cul-de-sac is less likely to press unduly upon the tender fundus uteri than the posterior limb of a Hodge's pessary."* Fig. 4. — Hodge's Pessary in situ. (Hart and Barbour.) Hence the uselessness, as I have so long main- tained, of the vaginal pessary in a case of true retroflexion. I would even go so far as to say that it is positively injurious. On this point Fritsch * The Treatment of Chronic Metritis associated with Retroflexion (? Retroversion). British Medical Journal, Sep. 22, 1883, p. 573. 48 Use and Abuse of Pessaries. admits that " a vaginal pessary has not been con- ceived, which can convert a retroflexion into an anteversion by its own action."* Several views have been advanced in explanation of the mechanical principles involved in the action of the so-called lever-pessary. Thus Hodge says, " The pessary operates as a lever in elevating the fundus from its real position against the sacrum to its normal position behind the bladder ; that portion of the pessary which is posterior to the neck of the organ being the ' short arm,' while all anterior to the neck is the ' long arm ' ; and the fulcrum or support is the posterior surface of the vagina. As the long arm or horn is depressed by the finger of the prac- titioner, the short arm rises and carries with it the body and fundus of the uterus, "f Schultze, followed by John Williams, maintains that the uterus itself is the lever, the body of it is the weight, the fulcrum is the attachment of the uterus near the internal os, and the power is applied through the vagina to the cervix. Galabin holds that the pessary is the lever, " the fulcrum a transverse axis nearly through its centre, upon which it is capable of oscillating as it is grasped by the vaginal walls ; the power is the pressure of the anterior vaginal wall upon its anterior limb, greatly increased during expulsive efforts ; the weight, or resistance, is the fundus uteri which is pushed up by the posterior limb. "J * Op. at. p. 117. f Diseases peculiar to Women, 2nd Ed. 1868, p. 417. J Diseases of Women, 1st Ed. p. 68. Use and Abuse of Pessaries. 49 Goodell says, "this pessary acts on the principle of a lever, but the mechanism of its action is two- fold. By stretching the vagina upward and back- wa d, it draws the cervix in the same direction. The womb then turns on its central point of liga- mentous attachment, as on a fixed point, and the fundus is consequently tilted forward. The womb itself then becomes a lever, of which its point of attachment to the bladder is the fulcrum. The power is applied to the cervix, and the fundus becomes the weight or resistance .... Then again the pessary itself acts as a lever. The anterior vaginal wall, with the visceral pressure above it, now becomes the power applied to the lower limb, or ' long arm,' of the lever, the posterior vaginal wall is the fulcrum, or support, and the upper limb, or ' short arm,' lying behind the cervix directly pushes up the weight, or fundus uteri."* Such, then, are some of the explanations of the mechanical principles involved, and I shall not render " confusion worse confounded " by offering another. Choose which you will. It has been asserted that Hodge's pessary, while it may and does relieve symptoms, never cures a retroversion. This subject has, of recent years, occupied the attention of several authors, amongst whom Fritsch has treated it at great length. He says, "It may happen that the uterus retains its position after its first replacement. In recent cases, therefore, the * Lessons in Gynecology, 2nd Ed. pp. 156-7. E 5 adjusted, the apparatus is ready for use. 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Willi. University, and Surgeon-in-Chief of the Syphilitic Wards and Skin Disease ]Vards of the Charite Hospital, Berlin. THE TREATMENT OP SYPHILIS WITH SUBCUTA- NEOUS SUBLIMATE INJECTIONS. Translated by Dr. Carl Prceole, and Dr. E. H. Gale, late Surgeon United States Army, Small 8vo, 7s. LEWIS'S PRACTICAL SERIES. Under this title Mr. Lewis purposes publishing a complete Series of Monographs, embracing the various branches of Medicine and Surgery. The volumes, written by well-known Hospital Physicians and Surgeons recognized as authorities in the subjects of which they treat, are in active preparation. The works are intended to be of a thoroughly practical nature, calculated to meet the requirements of the general practitioner, and to present the most recent information in a compact and readable form ; the volumes will be handsomely got up, and issued at low prices, varying with the size of the works. Several volumes are nearly ready, and further particulars will be shortly announced. LEWIS'S POCKET MEDICAL VOCABULARY. [In the P/css. J. S. LOMBARD, m.d. Formerly Assistant Professor of Physiology in Harvard College. I. EXPERIMENTAL RESEARCHES ON THE REGIONAL TEMPERATURE OF THE HEAD, under Conditions of Rest, In- tellectual Activity and Emotion. With Illustrations, Svo, 8s. II. ON THE NORMAL TEMPERATURE OF THE HEAD. 8vo, 5s. WILLIAM THOMPSON LUSK, a.m., m.d. Professor of Obstetrics and Diseases of Women in the Bellevue Hospital Medical College, &c. THE SCIENCE AND ART OF MIDWIFERY. Second Edition, with numerous Illustrations, Svo, 18s. Catalogue of Works Published by H. K. Lewis. JOHN MACPHERSON, m.d. Inspector-General of Hospitals H.M. Bengal Army (Retired). A uthor of " Cholera in its Home" &c. ANNALS OP CHOLERA FROM THE EARLIEST PERIODS TO THE YEAR 1817. With a map. Demy Svo, 7s. 6d. DR. V. MAGNAN. Physician to St. Anne Asylum, Paris ; Laureate of the Institute. ON ALCOHOLISM, the Various Forms of Alcoholic Delirium and their Treatment. Translated by W. S. Greenfield, M.D., M.R.C.P. 8vo, 7s. 6d. A. COWLEY MALLEY, b.a., m.b., e.ch. t.c.d. MICRO-PHOTOGRAPHY; including a description of the Wet Collodion and Gelatino-Bromide Processes, together with the best methods of Mounting and Preparing Microscopic Objects for Micro- Photography. With Illustrations and photograph, crown Svo, 5s. PATRICK MANSON, m.d., cm. Amoy, China. THE FIL ARIA SANGUINIS HOMINIS ; AND CER- TAIN NEW FORMS OF PARASITIC DISEASE IN INDIA, CHINA, AND WARM COUNTRIES. Illustrated with Plates and Charts. Svo, 10s. 6d. PROFESSOR MARTIN. MARTIN'S ATLAS OF OBSTETRICS AND GYNECO- LOGY. Edited by A. Martin, Docent in the University of Berlin. Translated and edited with additions by Fancourt Barnes, M.D., M.R.C.P., Physician to the Chelsea Hospital for Women ; Obstetric Physician to the Great Northern Hospital ; and to the Royal Maternity Charity of London, &c. Medium 4to, Morocco half bound, 31s. 6d. net. WILLIAM MARTINDALE, f.c.s. Late Examiner of the Pharmaceutical Society, and late Teacher of Pharmacy and Demon- strator of Materia Medica at University College. AND W. WYNN WESTCOTT, m.b. lond. Deputy Coroner for Centra! Middlesex. THE EXTRA PHARMACOPOEIA of Unofficial Drugs and Chemical and Pharmaceutical Preparations, with References to their Use abstracted from the Medical Journals and a Therapeutic Index of Diseases and Symptoms. Third Edition, revised with numerous ad- ditions, limp roan, med. 241T10, 7s., and an edition in fcap. Svo, with room for marginal notes, cloth, 7s. [Now ready. 10 Catalogue of Works Published by H. K. Lewis. J. F. MEIGS, m.d. Consulting Physician to the Children's Hospital, Philadelphia. AND W. PEPPER, m.d. Lecturer on Clinical Medicine in the University of Pennsylvania. A PRACTICAL TREATISE ON THE DISEASES OP CHILDREN. Seventh Edition, revised and enlarged, roy. 8vo, 28s. DR. MORITZ MEYER. Royal Counsellor of Health, &c. ELECTRICITY IN ITS RELATION TO PRACTICAL MEDICINE. Translated from the Third German Edition, with notes and additions by William A. Hammond, M.D. With Illustrations, large 8vo, 18s. Wm. JULIUS MICKLE, m.d., m.r.c.p. lond. Member of the Medico-Psychological Association of Great Britain and Ireland ; Member of the Clinical Society, London ; Medical Superintendent, Grove Hall Asylum, London. GENERAL PARALYSIS OP THE INSANE. 8vo, 10s. KENNETH W. MILLICAN, b.a. cantab., m.r.c.s. THE EVOLUTION OP MORBID GERMS : A Contribu- bution to Transcendental Pathology. Cr. 8vo, 3s. 6d. , E. A. MORSHEAD, m.r.c.s., l.r.c.p. Assistant to the Professor of Medicine in University College, London. TABLES OP THE PHYSIOLOGICAL ACTION OP DRUGS. Fcap. 8vo, is. A. STANFORD MORTON, m.b., f.r.c.s. ed. Senior Assistant Surgeon, Royal South London Ophthalmic Hospital. REFRACTION OP THE EYE: Its Diagnosis, and the Correction of its Errors, with Chapter on Keratoscopy. Second edit., with Illustrations, small 8vo, 2s. 6d. WILLIAM MURRELL, m.d., m.r.c.p., m.r.c.s. Lecturer on Materia Medica and Therapeutics at Westminster Hospital ; Senior Assistant Physician, Royal Hospital for Diseases of the Chest. WHAT TO DO IN CASES OP POISONING. Fourth Edition, revised and enlarged, royal 321110. [In the press. NITRO-GLYCERINE AS A REMEDY POR ANGINA PECTORIS. Crown 8vo, 3s. 6d. Catalogue of Works Published by H. K. Lewis. 1 1 WILLIAM NEWMAN, m.d. lond., f.r.c.s. Surgeon to the Stamford Infirmary. SURGICAL CASES: Mainly from the Wards of the Stamford, Rutland, and General Infirmary, 8vo, paper boards, 4s. 6d. DR. FELIX von NIEMEYER. Late Professor of Pathology and Therapeutics ; Director of the Medical Clinic of the University of Tubingen, TEXT-BOOK OF PRACTICAL MEDICINE, WITH PARTICULAR REFERENCE TO PHYSIOLOGY AND PATHO- LOGICAL ANATOMY. Translated from the Eighth German Edition, by special permission of the Author, by George H. Humphrey, M.D., and Charles E. Hackley, M.D., Revised Edition, 2 vols., large 8vo, 36s. C. F. OLDHAM, m.r.c.s., l.r.c.p. Surgeon H.M. Indian Forces ; late in Medical charge of the Dalhousie Sanitarium. WHAT IS MALARIA ? and why is it most intense in hot climates ? An explanation of the Nature and Cause of the so- called Marsh Poison, with the Principles to be observed for the Preser- vation of Health in Tropical Climates and Malarious Districts. Demy Svo, 7s. 6d. G. OLIVER, m.d., m.r.c.p. 1. THE HARROGATE WATERS : Data Chemical and Therapeu- tical, with notes on the Climate of Harrogate. Addressed to the Medical Profession. Crown Svo, with Map of the Wells, 3s. 6d. ON BEDSIDE URINE TESTING: including Quantitative Albumen and Sugar. Second edition, revised and enlarged, fcap. 8vo, 2s. 6d. JOHN S. PARRY, m.d. Obstetrician to the Philadelphia Hospital, Vice-President of the Obstetrical and Pathologi- cal Societies of Philadelphia, &c. EXTRA-UTERINE PREGNANCY ; Its Causes, Species, Pathological Anatomy, Clinical History, Diagnosis, Prognosis and Treatment. 8vo, 8s. E. RANDOLPH PEASLEE, m.d., ll.d. Late Professor of Gynecology in the Medical Department of Dartmouth College ; President of the New York Academy of Medicine, &c, &c. OVARIAN TUMOURS : Their Pathology, Diagnosis, and Treatment, especially by Ovariotomy. Illustrations, roy. 8vo, 16s. 12 Catalogue of Works Published by H. K. Lewis. G. V. POORE, M.D., F.R.C.P. Professor of Medical Jurisprudence, University College; Assistant Physician to, and Physi- cian in charge of the Throat Department of University College Hospital. LECTURES ON THE PHYSICAL EXAMINATION OF THE MOUTH AND THROAT. With an Appendix of Cases. 8vo, 3s. 6d. R. DOUGLAS POWELL, m.d., f.r.c.p. lond. Physician to the Middlesex Hospital, and Physician to the Hospital for Consumption and Diseases of the Chest at Brampton. DISEASES OP THE LUNGS AND PLEURJE. Third Edition, rewritten and enlarged. With Illustrations, 8vo. [In preparation. AMBROSE L. RANNEY, a.m., m.d. Adjunct Professor of Anatomy in the University of New York, etc. THE APPLIED ANATOMY OP THE NERVOUS SYS- TEM, being a study of this portion of the Human Body from a stand- point of its general interest and practical utility, designed for use as a Text-book and a Work of Reference. With 179 Illustrations, 8vo, 20s. RALPH RICHARDSON, M.A., m.d. Fellow of the College of Physicians, Edinburgh. ON THE NATURE OF LIFE : An Introductory Chap- ter to Pathology. Second Edition, revised and enlarged. Fcap. 4to, ios. 6d. W. RICHARDSON, m.a., m.d., m.r.c.p. REMARKS ON DIABETES, ESPECIALLY IN REFER- ENCE TO TREATMENT. Demy 8vo, 4 s. 6d. SYDNEY RINGER, m.d. Professor of the Principles and Practice of Medicine in University College; Physician to, and Professor of Clinical Medicine in, University College Hospital. A HANDBOOK OF THERAPEUTICS. Tenth Edition, 8vo, 15s. II. ON THE TEMPERATURE OF THE BODY AS A MEANS OF DIAGNOSIS AND PROGNOSIS IN PHTHISIS. Second Edition, small 8vo, 28. 6d. Catalogue of Works Published by H. K. Lewis. 13 FREDERICK T. ROBERTS, m.d., b.sc, f.r.c.p. Examiner in Medicine at the Royal College 0/ Surgeons ; Professor of Therapeutics in University ColUge ; Physician to University College Hospital ; Physician to Brompton Consumption Hospital, &c. I. A HANDBOOK OF THE THEORY AND PRACTICE OF MEDICINE. Fifth Edition, with Illustrations, in one volume, large 8vo, 21s. 11. NOTES ON MATERIA MEDICA AND PHARMACY. Fcap. 8vo. [Nearly ready. D. B. St. JOHN ROOSA, m.a., m.d. Professor of Diseases of the Eye and Ear in the University of the City of New York ; Surgeon to the Manhattan Eye and Ear Hospital ; Consulting Surgeon to the Brooklyn Eye and Ear Hospital, &c.,&c. A PRACTICAL TREATISE ON THE DISEASES OP THE EAR, including the Anatomy of. the Organ. Fourth Edition, Illustrated by wood engravings and chromo-lithographs, large 8vo, 22s. J, BURDON SANDERSON, m.d., ll.d., f.r.s. Jodrell Professor of Physiology in University College, London. UNIVERSITY COLLEGE COURSE OP PRACTICAL EXERCISES IN PHYSIOLOGY. With the co-operation of F. J. M. Page, B.Sc, F.C.S. ; W. North, B.A., F.C.S., and Aug. Waller, M.D. Demy 8vo, 3s. 6d. ALDER SMITH, m.b. lond., f.r.c.s. Resident Medical Officer, Christ's Hospital, London. RINGWORM : Its Diagnosis and Treatment. Second Edition, rewritten and enlarged. With Illustrations, fcap. Svo, 4s. 6d. J. LEWIS SMITH, m.d. Physician to the New York Infants' Hospital; Clinical Lecturer on Diseases of Children in Bellcvue Hospital Medical College. A TREATISE ON THE DISEASES OF INFANCY AND CHILDHOOD. Fifth Edition, with Illustrations, large Svo, 21s. FRANCIS W. SMITH, m.h., k.s. THE LEAMINGTON WATERS; CHEMICALLY, THERAPEUTICALLY AND CLINICALLY CONSIDERED; with observations on the climate of Leamington. With Illustrations, crown Svo, 2s. 6d. JAMES STARTIN, m.b., m.r.c.s. Surgeon and Joint Lecturer to St. John's Hospital for Diseases oj the Skin. LECTURES ON THE PARASITIC DISEASES OP THE SKIN. VEGETOID AND ANIMAL. With Illustrations, Crown 8vo, 3s. 6d. 14 Catalogue oj Works Published by H. K. Lewis. LEWIS A. STIMSON, b.a., m.d. Surgeon to the Presbyterian Hospital ; Professor of Pathological Anatomy in the Medical Faculty of the University of the City of New York. A MANUAL OP OPERATIVE SURGERY. With three hundred and thirty-two Illustrations. Post 8vo, ios. 6d. HUGH OWEN THOMAS, m.r.c.s. I. DISEASES OP THE HIP, KNEE, AND ANKLE JOINTS, with their Deformities, treated by a new and efficient method. With an Introduction by Rushton Parker, F.R.C.S, Lecturer on Sur- gery at the School of Medicine, Liverpool. Third Edition, 8vo, 25s. II. CONTRIBUTIONS TO MEDICINE AND SURGERY :- Part i. — Intestinal Obstruction ; with an Appendix on the Action of Remedies, ios. ,, 2. — The Principles of the Treatment of Joint Disease, Inflamma- tion, Anchylosis, Reduction of Joint Deformity, Bone Set- ting. 5s. ,, 5. — On Fractures of the Lower Jaw. is. ,, 8. — The Inhibition of Nerves by Drugs. Proof that Inhibitory Nerve-Fibres do not exist, is. (Parts 3, 4, 6, 7, 9, 10, are expected shortly). J. ASHBURTON THOMPSON, m.r.c.s. Late Surgeon at King's Cross to the Great Northern Railway Company. FREE PHOSPHORUS IN MEDICINE WITH SPE- CIAL REFERENCE TO ITS USE IN NEURALGIA. A contribution to Materia Medica and Therapeutics. An account of the History, Phar- maceutical Preparations, Dose, Internal Administration, and Therapeu- tic uses of Phosphorus ; with a Complete Bibliography of this subject, referring to nearly 200 works upon it. Demy 8vo, 7s. 6d. J. C. THOROWGOOD, m.d. Assistant Physician to the City of London Hospital for Diseases of the Chest. THE CLIMATIC TREATMENT OP CONSUMPTION AND CHRONIC LUNG DISEASES. Third Edition, post Svo, 3s 6d. EDWARD T. TIBBITS, m.d. lond. Pliysician to the Bradford Infirmary ; and to the Bradford Fever Hospital. MEDICAL FASHIONS IN THE NINETEENTH CEN- TURY, including a Sketch of Bacterio-Mania and the Battle of the Bacilli. Crown Svo, 2s. 6d. LAURENCE TURNBULL, m.d., ph.o. A ural Surgeon to Jefferson Medical College Hospital, &c, &c. ARTIFICIAL ANAESTHESIA : A Manual of Aneesthetie Agents, and their Employment in the Treatment of Disease* Second Edition, with Illustrations, crown 8vo, 6s. Catalogue of Works Published by H. K. Lewis. 15 W. H. VAN BUREN, m.d., ll.d. Professor of Surgery in the Dellevuc Hospital Medical College. DISEASES OP THE RECTUM : And the Surgery of the Lower Bowel. Second Edition, with Illustrations, 8vo, 14s. RUDOLPH VIRCHOW, m.d. Professor in the University, and Member of the Academy of Sciences of Berlin, &c, &c. INFECTION - DISEASES IN THE ARMY, . Chiefly Wound Fever, Typhoid, Dysentery, and Diphtheria. Translated from the German by John James, M.B., F.R.C.S. Fcap. 8vo, is. 6d. ALFRED VOGEL, m.d. Professor of Clinical Medicine in the University of Dorpat, Russia. PRACTICAL TREATISE ON THE DISEASES OP CHILDREN. Translated and Edited by H. Raphael, M.D. From the Fourth German Edition, illustrated by six lithographic plates, part coloured, large 8vo, 18s. A. DUNBAR .WALKER, m.d., cm. THE PARENT'S MEDICAL NOTE BOOK. Oblong post Svo, cloth, is. W. SPENCER WATSON, f.r.c.s. eng., b.m. lond. Surgeon to the Great Northern Hospital ; Surgeon to the Roval South Loudon Ophthalmic Hospital. I. DISEASES OP THE NOSE AND ITS ACCESSORY CAVITIES. Profusely Illustrated. Demy 8vo, 18s. II EYEBALL-TENSION: Its Effects on the Sight and its Treatment. With woodcuts, p. 8vo, 2s. 6d. III. ON ABSCESS AND TUMOURS OP THE ORBIT. Post 8vo, 2s. 6d. A. DE WATTEVILLE, m.a., m.d., b.sc, m.r.c.s. Physician in Charge of the Electro-therapeutical Department at St. Mary's Hospital. A PRACTICAL INTRODUCTION TO MEDICAL ELECTRICITY. Second Edition, re-written and enlarged, copiously Illustrated, Svo, gs. [Just published. FRANCIS H. WELCH, f.r.c.s. Surgeon Major, A.M.D. ENTERIC PEVER : as Illustrated by Army Data at Home and Abroad, its Prevalence and Modifications, .(Etiology, Pathology and Treatment. 8vo, 5s. 6d. [Just published. DR. F. WINCKEL. Formerly Professor and Director of the Gynecological Clinic at the University of Rostock THE PATHOLOGY AND TREATMENT OP CHILD- BED : A Treatise for Physicians and Students. Translated from the Second German edition, with many additional notes by the Author, by J. R. Chadwick, M.D., Svo, 14s. 16 Catalogue of Works Published by H. K. Lewis. EDWARD WOAKES, m.d. lond. Senior Aural Surgeon and Lecturer on Aural Surgery at the London Hospital ; Senior Sur- geon to the Hospital for Diseases of the Throat. ON DEAFNESS, GIDDINESS AND NOISES IN THE HEAD. Vol. I.— CATARRH, AND DISEASES OF THE NOSE CAUSING DEAFNESS. With Illustrations, cr. 8vo, 6s. 6d. [Just published Vol. II.— ON DEAFNESS, GIDDINESS AND NOISES IN THE HEAD. Third Edition, with Illustrations, cr. 8vo. [In preparation. E. T. WILSON, b.m. oxon., f.r.c.p. lond. Physician to the Cheltenham General Hospital and Dispensary. DISINFECTANTS AND HOW TO USE THEM. In Packets of one doz. price is. Clinical Charts For Temperature Observations, etc. Arranged by W. Rigden, M.R.C.S. Price 7s. per ioo, or is. per dozen. Each Chart is arranged for four weeks, and is ruled at the back for making notes of cases; they are convenient in size, and are suitable both for hospital and private practice. PERIODICAL WORKS PUBLISHED BY H. K. LEWIS. THE NEW SYDENHAM SOCIETY'S PUBLICATIONS. Annual Subscription, One Guinea. (Report of the Society, with Complete List of Works and other information, gratis on application.) ARCHIVES OF PEDIATRICS. A Monthly Journal, devoted to the Diseases of Infants and Children. Annual Subscription, 12s. 6d., post free. THE NEW YORK MEDICAL JOURNAL. A Weekly Review of Medicine. Annual Subscription, One Guinea, post free. THE THERAPEUTIC GAZETTE. 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Mr. Lewis's publications can be procured of any bookseller in any part of the world. London: Printed by H, K Lewis, 136 Gower Street, W.C. COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE y- .-* •' J - ■ . ' ,— \ C28 (747J MIOO N0V2 5 194B |4^Xiuc Annex