internum was constricted. I incised it and dilated until I could pass a No. 9 English sound. At the same time I used Elliott's adjuster to straighten the uterus, and carried the fundus backward. This was accomplished with unusual facility, the uterus making no resistance to bending in any direction. The instrument was withdrawn, and the patient placed in bed to rest; there was no pain or inflammation following this treatment. Three days afterward I made a digital examination, and found the uterus retroflexed. By using again the Elliott adjuster I was able to change the retroflexion back to the original anteflexion, which remained so for several days. It being necessary to pass the sound every third day to prevent the recurrence of the stricture at the internal os, I took advantage of the opportunity, by changing the flexion a number of times, and found that whatever position I placed the body of the uterus in, it would remain there.

The dilatation of the os externum gave the patient great relief from the dysmenorrhoea. The usual treatment for congestion and hyperesthesia was continued, and the canal kept dilated by the use of the sounds. A stem pessary was tried, but she could not tolerate it except by keeping in bed. She improved so much in two months that she left the hospital, and only returned occasionally as an outpatient. For two years I kept her under observation and, although she was not entirely free from pain, she was able to make her living. In this case I feel sure that the trouble originated in an imperfect growth at the time of secondary development.

In one other case of which I have full notes, the flexion came after the patient's second confinement, and, perhaps, was due to a derangement of involution.

Injuries to the Pelvic Organs Caused by the Improper Use of Pessaries.-The dangers of stem pessaries have already been referred to in the chapter on flexions, so far as their liability to cause acute inflammations of the uterus, pelvic cellular tissue, and peritonæum. There are still other injuries which they may give rise to. When the stem is small and badly adjusted with reference to the character of the flexion, the point of the instrument may become imbedded in the wall of the uterus, or the lower part of the stem may divide the posterior wall of the cervix. Both of these injuries I have seen in practice.

In one case, an anteflexion of the cervix, a small stem of steel with a hard-rubber disk at its end was introduced by a general practitioner, and left in place for three months. The patient soon began to suffer from a purulent discharge, which gradually increased, and there was much pain, greatly aggravated by walking. When I saw her the relations of the stem and uterus were as shown in Fig. 161. After the removal of the stem, the cervix presented exactly the same appearance as that seen after Sims's operation for flexion, except that there was more thickening of the edges of the wound and more inflammation than I have ever before seen after discision of the cervix by the surgeon. The inflammation subsided under ordinary treatment, and she

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was at least none the worse for having worn the stem.

Another patient came under my observation while wearing a stem pessary, which had been introduced six weeks before by her medical

attendant. She had suffered pain and tenderness from the time that the stem was introduced, and for a week before she came under my care the suffering was so great that she was obliged to stay in bed and take opium freely; she had also a purulent discharge, and at times bleeding. The stem was about the thickness of a No. 9 catheter. It was made of hard rubber, and was held in place by a cup pessary in the vagina. While the stem was still in place (the vaginal pessary having been removed) the body of the uterus was found to be markedly anteflexed, and its anterior wall near the fundus was unusually prominent, as if it contained a small fibroid

tumor.

The flexed shape of the uterus led me to suppose that the stem must be curved, but on removal it proved to be straight.

I then passed with some difficulty, owing to the tenderness of the uterus, a much-curved sound into the cavity of the uterus, and then after straightening the sound, it was passed into the groove made in the posterior wall by the stem. One might suppose that the cavity of the uterus was simply dilated so that the sound could be curved forward and then straightened and passed along the posterior wall, but I am confident that such was not the case. The posterior wall of the body was flexed forward and rested upon the anterior wall on either side, and the sulcus made by the stem was in the center.

Fig. 162 shows the conditions as they appeared to me during my examination.

There was considerable bleeding after the removal of the stem, and the uterus became more flexed apparently as soon as the support was withdrawn. There was relief from the acute symptoms and inflammation caused by the instrument, but the dysmenorrhoea was worse than before.

Atrophy of the muscular tissue of the vaginal walls from overdistention by pessaries that are too large is quite frequently seen. Practitioners who are not skilled in the use of pessaries, yet nevertheless use them, produce this injury of the structures of the vagina. The same unfortunate results are effected by those who believe in the theory that in order to keep the uterus in place, in retroversion, for example, it is necessary to use a pessary large enough and sufficiently curved to force the posterior wall of the vagina far up in the pelvis above its normal elevation.

The following case will illustrate this: The patient had children, and was said to have had a displacement; probably retroversion. She was treated with a variety of pessaries, so she told me, but did not get well; when she came to me, she had much backache, pelvic pain, and vaginal leucorrhoea; she was then wearing a pessary nearly large enough to fill the pelvis, and much curved both in front and behind.

The uterus was in about its proper place in the pelvis, but the vagina was greatly overdistended and its walls were thin, especially the posterior wall behind the cervix. On removing the pessary, a

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difficult task owing to its size, the vaginal wall, and the rectal wall also, I think, fell downward and formed a rectocele high up.

Fig. 163 will give an idea of the state of the parts as they appeared to the touch, after the pessary was removed.

The part of the thin wall of the vagina bulged downward, and felt to the touch exactly like the ordinary rectocele, except that the

FIG. 163.—High rectocele due to improper pcs- protruding mass was at the

sary.

upper part of the vagina instead of the lower; when seen through the speculum introduced about an inch and a half, this was confirmed by the eye.

The first impression obtained by the touch was that of a portion of intestine distended with gas lying behind and below the cervix uteri. The patient felt a little more distress, strange to say, after the pessary was removed; when she tried to walk without it, she suffered from pain and tenesmus very severely. This I have found to be the case in all instances of overdistention of the vagina; patients suffer with the support, and for a few days suffer more without it.

This is much the same experience as ladies have who can not go without corsets, and the tighter they lace them and the more damage they do, the more they miss them when they discontinue their use.

This patient was kept rather quiet for a time, and astringent injections were used, which, after a long time, restored the vagina more

nearly to its normal caliber. There remained for over a year, when I last saw her, and perhaps ever since, a sagging of the upper part of the posterior vaginal wall.

Another case, somewhat of the same character, came to me from the West. She was forty, and single; her health and strength had been good until she was thirty-six years of age, when she began to have a variety of nervous symptoms clearly due to general debility. She was treated by several reputable physicians, but not recovering as fast as she desired, she consulted still another, who told her that she had falling of the womb, which caused all her troubles. There was not a symptom that pointed to any disease or displacement of the sexual organs, but a Cutter pessary was introduced and the patient wore it about two years. Her general health improved very little, and the pessary soon caused her trouble; still she persisted in wearing it because the doctor said she must do so; her condition became so wretched that she came East, in the hope of gaining relief.

When she came to me she had some vaginitis and vulvitis caused by the pessary, but the uterus was perfectly normal in every way. The Cutter pessary had pushed up the posterior vaginal wall far beyond the cervix, which lay on one side of the instrument, not between the bars as it should have done.

The condition of the posterior vaginal wall at the upper part was about the same as in the case just related. The lower part of the vagina was normal, excepting the inflammation caused by the pessary. The vulva was also inflamed, and she suffered greatly from this, especially in taking exercise. This patient also felt the want of the pessary when it was removed, but only for a short time. She was examined seven months after the removal of the instrument and was found to be perfectly well.

Injury of the Posterior Vaginal Wall by the use of Pessaries in Cases of Incurable Retroversion. This case illustrates a class which, though not large, deserves notice. In retroversion with fixation of the uterus, either from a congenital state or because of adhesions or shortening of the post-uterine ligaments, there is sometimes a slight mobility of the uterus which admits of its being partly restored. This leads the practitioner to hope that, by the use of the pessary, the displacement can be corrected. The result is that the posterior portion of the pessary makes too great pressure upon the vaginal wall and produces inflammation and abrasion. This usually causes a free vaginal discharge and pain enough to make the patient seek relief before much permanent injury is done. In all such cases pessaries should not be used at all, but if one is employed in the hope