Observations on some of the more important diseases of women / by James Blundell ; edited by Thomas Castle.

  • Blundell, Dr., 1790-1878.
Date:
1837
    for him to interfere manually with the part, in order to introdace the instrument. Having effected this, he places by the hed-side some three or four of the pessaries, which appear, on comparison, to be best fitted to the vagina ; and of these he selects one, lubri- cates it abundantly, places the woman either in the recumbent posture, or else, which is perhaps, on the whole, fully as convenient, and more agreeable it may be to female delicacy, he advises her to take position upon the left side, in the usual obstetric posture. These preliminaries arranged, he lays hold of the pessary, and planting it in the pudendal entrance, with a sort of rotatory motion, he rolls it upwards and backwards along the surface of the sacrum towards the promontory of this bone, with as little force and compression as may be; the plane of the instrument, at this time, lying parallel with the sides of the pelvis; and then, when he has reached the upper part of the vagina, he places the plane in apposition with the mouth of the uterus, which then rests upon it as on a shelf, and thus obtains an effectual support. These in- struments, however, are very apt to turn edge-ways. If the pes- sary be too large, it can easily be removed at the pleasure of the patient, and a small pessary is easily replaced, when necessary, by one of larger diameter. When you pass up the pessary, you ought to tell your patient that the first size will not, perhaps, prove of fit measure for the vagina, and therefore she must not be disappointed, should a change become necessary. To remove the pessary is ex- ceedingly easy; you pass the finger into the vagina, lay it in the central aperture of the pessary, and then roll it downward, careful that you do not injure the vaginal orifice. The great nicety of in- troduction consists in carrying it upwards and backwards, and not against the point of the pubic arch. I have said you are to carry it upwards and backwards towards the promontory of the sacrum ; because, if you carry it directly upwards, you will occasion a great deal of pain, and, at the same time, the instrument cannot be introduced, as it must fall into collision with the symphysis pubis. In all women, the ring pessary may be employed ; it is an excel- lent form of pessary for general use, but for married women it is
    more especially accommodated, as it does not materially obstruct the vagina. BALL PESSARY. The ball pessary may be made of silver, of ivory, of box-wood, ■of various other materials—but box-wood is, in general, preferred. By the turner it is hollowed, in order to make it lighter, and, at the two poles, there are apertures of small size, perhaps the more numerous the better, to allow of the discharge of the catamenia, provided the period of menstruation be not yet passed. With this instrument should be connected four ties of strong red tape, which, by giving a bearing, may facilitate its abstraction from the vagina. When using the ball, you ought to be provided with a succession of three or four different sizes ; then placing the woman as before, either recumbent or laterally, the left side being the more decorous posture, and the instrument, as before, being placed in the vaginal opening, roll it upwards and backwards towards the promontory of the sacrum. Some little pain may be expected on passing the orifice of the vagina, but the admission of the instrument becomes more easy as it advances along the canal, for, as I formerly observed to you, the vagina, in the upper part, is often far more capacious than below. If you wish to remove this instrument, this may be done by laying hold of the tape and drawing down ; but, should the tape give way under your efforts, what are you then to do? Why, in this conjuncture, you may have recourse to an instrument, the pessary-forceps, (and which I have used in the hospital,) to be managed precisely in the same manner as you would manage the obstetric forceps—the blades are separable, like those of the obstetric forceps ; they are applied to the ball, and are afterwards brought into operation, in the customary way, by which method the ball may be more easily abstracted than by the action of the tape. These pessaries are admirably adapted to prevent the descent of the parts, because the parts get a broad bearing upon the instrument, which is of easy introduction. By the E
    surgeons among the black population of some of our plantations, these instruments are much employed.* SPONGE PESSARY. A piece of sponge, introduced into the vagina, may be used as a pessary; but unless judiciously managed, it operates but badly, because, if it is not well fitted in size, it tends to dilate like a sponge tent, so as to increase the original cause of the disease ; but if the capacity of the vagina is well examined, and the sponge is cut down, and formed into the oviform shape, it may be accom- modated to the cavity, and may be used in those cases, more especially, where, frono^tft^^T^itabilityo^ the parts, the pessaries before commended cjilinot' be_employed, ©i). fl^aighton was partial to this variety of pessary,,,^^indemned by sobA and thought that he found advantage from it/ HeM-ecoTBrowideM tapes to facilitate is removal, and wak (a^^pinkmN^IJiat som^ .a^antage might be derived from imbuing tii^riis|:rnifient,'d^y,^^ith some astringent lotion, alum, for instance, the^streagthof which should be gra- dually increased. With three or four of these sponge pessaries the patient ought to be provided, and every day the one that has been in use should be removed, to undergo a thorough ablution^ to be introduced on some future day. If the vagina be prone to contraction, the pessary may be cut smaller and smaller, with scissors. Dr. Haighton thought, by using the pessary in this way, we might not merely support the parts, as by the ordinary instru- ment, but that we might reasonably hope, now and then, to pro- duce some constriction of the vagina, so as to obtain, perhaps, a radical cure of the disease. * Thompson, of Little WindmiU Street, seUs a pessary, in principle like the ball, the con- trivance, I believe, of Mr. Pointer, and which may be called a balloon pessary. It is longer in one diameter than in the other. It consists in a firm texture, of a sort of canvass, covered over with common Indian rubber. This instrument is easily introduced, and easily removed. If the removal be obstructed, all that is necessary is to make a small aperture in the instru- ment, when it will collapse, and come away with ease. Thompson recommends that we should employ the plare of epgs for its lubrication, in preference to oil, which has a tendency to dissolve the caoutchouc. Dr. Blundell.
    STEM PESSARIES. In some cases it is necessary that the pessary should bo mounted on a stem, of which there are different kinds; for a ball, a ring, or any form you please, may be mounted in this manner. Of the use of this pessary, I have seen very little, having advised it only in one or two instances, and those did not remain under my own eye, so that I could not fully observe the result. In the general, I know that stem pessaries are not needed, and unless needed, they should not be employed. The cases best adapted for their use, are those in which the perineum is torn open, or in which the vagina is I'elaxed extraordinarily, insomuch, that no ordinary pessary will remain. Commonly, by the sciatic ligaments alone, a sufficient support is given to the pessary, to the ball more especially, so as to render it unnecessary to employ the instrument with a stem ; cases, however, may occur, with laceration of the perineum especially, in which a stem pessary may be usefully employed. Of the different kinds of stem pessaries, perhaps one of the best is that recommended by Dr. Clarke, and which I would advise you to essay. In using this pessary, the patient wears a bandage round the hips, and there is a ball for the vagina: down from the bandage in front there is a stem, or wand, of metal, which passes between the limbs and to the bandage behind ; so that this stem becomes incurvated, and when properly adjusted, passing between the limbs, has a bearing in the line of the pudendal opening, and lies on the ball, describing a line along its inferior hemisphere, from pubes to coccyx, so as to yield it an effectual support; but lest the pessary should slide out on the one side or the other, displacing the Avire laterally, there is a sort of staple fixed in the instrument, and through this staple it is that the wire passes. Now a stem pessary of this kind I have tried, and it answered very well, one inconvenience excepted, which was, that in the case referred to, much distress was occasioned in consequence of the softer parts being apt to get between the iron E 2
    stem or wand, and the staple, causing a painful compression, and the rather, because those parts are very sensible. Another stem pessary, tried on a patient in Guy's Hospital, la- bouring under procidentia, was found to answer very well. It con- sists of a ball elevated upon a stem of pewter, and the ball may be passed up to the os uteri, the stem being incurvated, and brought up to the bandage before mentioned, and fixed there at a proper elevation by means of screw and socket. This stem may be ad- justed in two ways, being accommodated to the bandage, either in front, over the symphysis, or between the nates behind. The great advantage of this sort of pessary is, that it may be adjusted to a great nicety, to the liking of the patient; if she wishes to wear it high, she can do so ; if she wishes to lower it, this may be done ; and if she is uneasy in any way, she can move it from one side to the other, or bring it from her person altogether; all this obse- quiousness depends, mainly, on the flexibility of the stem, which, however, is so stiff, that while it obeys your pressure, it neverthe- less retains the curve you give it. From the trial given to this instrument, I have reason to believe, that, on the whole, it is by no means a bad one. SECTION XIV^ GENERAL REMARKS ON THE USE OF PESSARIES. Whatever pessaries you use, there are different modes in which they may be employed. A woman may wear them for years to- gether, without removal during the whole term ; for, finding the part well supported by it, she becomes habituated to the instru- ment, and learns at length to bear it with contentment. Or, again: when this is preferred, the pessary may be employed in the day time ; if a woman is tolerably well, and more particularly if she is a. married woman, it may be better to wear it in the day time only.