A NEW UTERINE REPOSITOR.

By H. L. GETZ, M. D.,

MARSHALLTOWN, IOWA.

PHYSICIANS experienced in uterine flexions must have met with cases where it was impossible to introduce into the cavity of the womb any of the instruments commonly in use for that purpose, or, if it was accomplished at all, it was at the expense of not a small amount of injury to a portion of the organ in question. It was the study of such a case that caused me to devise the instrument exhibited, which I have used for about six years, with, I think, as much satisfaction as could possibly be expected in the treatment of this class of cases. I claim for it simplicity, cheapness, efficiency, and durability over all other instruments of the kind now in use. The instrument consists of six bougies, Nos. 2, 4, 6, 8, 10 and 12, English gauge, and a steel stylet the length of a common bougie, at the end of which is attached a revolving disk, which will easily enter a No. 10 or 12 bougie. From the point, for about four inches, the stylet should be considerably lighter than the remainder of the staff, which, toward the handle, may be without any temper or spring, while the four inches from the point must have considerable elasticity. The material or shape of the handle is unimportant.

In using, begin by introducing the largest size bougie which the uterine canal will admit. These bougies (or catheters of the same material will answer as well) are introduced with comparatively little difficulty. They are flexible, and follow with ease varying curves, and yet are sufficiently firm to bear the application of considerable force. Having introduced the first bougie, allow it to remain a few minutes, then remove it, and use in the same manner a next size larger, and so continue until a No. 10 or 12 will enter, when the stylet should be

brought into requisition. The object of the bougie is to afford direction to the stylet and protection to the intra-uterine structures, while the necessary force for lifting the womb into position is applied by means of using the stylet as a repositor. Care is needful in the introduction of the stylet, which must enter the entire length of the instrument. Thus introduced, allow it to remain perhaps an hour, and remove the bougie with its stylet. This being straight, or nearly so, will straighten the bougie when it is removed; and it is impossible to tell, by the appearance of the instrument, whether the uterine flexion has been corrected. To prove this, attempt the introduction of the instrument as removed (stylet in bougie). If it enters easily, the object has been accomplished; otherwise, withdraw the stylet, introduce the bougie, and again replace the stylet, and allow it to remain longer. The object can always be accomplished in this way, unless adhesions or some peculiar malformation exist.

The principal advantages of this repositor are

1st. It is simple, not liable to get out of order.

2d. It is cheap, and yet durable.

3d. With any ordinary amount of skill or care, the womb cannot possibly be injured by its application.

4th. There is a larger surface to which the force necessary to lift the womb into place is applied than any other instrument, consequently less danger of injury to the uterine mucous membrane. In the use of this instrument other minor advantages will be apparent.

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A FEW PRACTICAL POINTS ON THE TREATMENT OF RUPTURED PERINEUM.

BY H. L. GETZ, M. D.,
MARSHALLTOWN, IOWA.

REPAIR of the perineum is either primary, to which preference should be given, or secondary; in each instance the usual method is by suture. We were taught to regard the rupture of the perineum as a serious obstetrical complication. During the earlier years of practice, although successfully treated by the usual methods, such cases gave much trouble and anxiety. A careful study of cases taught that the tendency of the torn edges was to remain in close contact constantly when a patient was lying upon either side (upper hip should incline considerably forward), so long as the extremities were kept close together. The deduction was that the success of cases depended not upon the sutures employed, but upon position of patient, thereby keeping from the wound the secretions. Since then we have treated all cases without suture, and with good results.

Soon after the injury, cleanse the parts thoroughly from clots of blood or foreign matter, and place the patient in such a position as will prevent any discharge from entering the wound. Secure the knees, placing between them a few folds of some soft article; linen or muslin will answer. It will be unnecessary to keep one knee directly over the other; the position may be changed a little, with much comfort to the patient, by allowing one knee to drop back or in front of the other, for this variation would amount to little practically in the results of the uniting of the torn perineum. If there has been no dejection before or during confinement, an enemata should be used before the parts are put in apposition; for it is very important not to have a movement of bowels for at least four or five days after the injury. When a movement is deemed necessary after this time,

a cathartic, which will insure an easy dejection, should be given. Keep from the wound every foreign substance, even to carbolic acid, until union has taken place, which will occur in a few days, after which you may use mild carbolic injections with advantage to the patient.

The advantages of treatment without suture are :—

1st. It can be done under almost any circumstances, no condition of patients being any excuse for not at once attending to the treatment.

2d. You save your patients from the effects of an anesthetic, or pain, fear, and shock, either of which might considerably retard convalescence.

3d. By the "lateral and upper-hip-forward position," cleanliness is assured, and the danger of septicemia is in large share avoided.

If these conclusions are correct, there is no excuse for the neglect of a patient, or necessity to defer treatment and entail upon the patients much suffering, anxiety, and inconvenience, when the difficulty can be so easily, simply, and thoroughly remedied.

Where the rupture involves the sphincter, it may be best to approximate the edges of muscle by suture. The patients, during first few days, must not be allowed to assume a supine position, but must be kept in a position inclined to prone, and while changing from one side to the other, it must be done with the face downward. This position must also be maintained while

voiding urine.