PATHOLOGY. 
the exaft fize of the vagina is a matter of great moment. 
We have before Ihown, that the contraction of the vagi¬ 
na is one of the means by which the difeafe is cured. It 
is therefore obvious, that any fubdance which would pre¬ 
vent this contraction, or would in the flighted: degree di¬ 
late the canal, mud be improper. At the fame time the 
peflary mud be large enough to Jill the canal, or it will 
Aide out of it. Dr. Clarke dates, that it is feldom proper 
to ufe a peflary of more than two inches and a half in 
diameter, on account of the preffure it would exert on 
the meatus urinarius and reftum. When, therefore, the 
calibre of the vagina is larger than thefe proportions, it is 
proper to ufe the oval peflary, which, as its long diameter 
reds tranfverfely in the vagina, may receive fupport from 
the fides of this canal, without prefling on the urinary 
paffage before, or the reftum behind. Should the vagi¬ 
na be fo dilated that a fmaller one cannot be retained, 
we may ufe an oval peflary nearly as large as four inches 
in its long diameter. The chief objection to this inltru- 
ment is, that it is didurbed by fexual intercourfe. This 
objection is of themore force, becaufe pregnancy is a de- 
flderatum in procidentia uteri, inaftnuch as the afcent 
of the womb during that date cures the difeafe. 
The following are the directions for pafling thefe in- 
flruments, given by Mr. Clarke in his Obfervations on 
the Difeafes of Females. The woman fliould be placed 
upon her left fide, and clofe to the edge of the bed; and 
her knees fliould be drawn up towards the abdomen. 
The praftitioner is then (having previoufly examined the 
fize of the vagina) to deleft a peflary, according to his 
judgment, of a proper fize. This indrument is then to 
be covered with fome fimple unftuous matter; and, if 
its form be circular, it is to be placed between the labia, 
fo that one edge will be turned towards the os pubis and 
the other to the reftum : it is then to be moved in a cir¬ 
cular direftion on its own axis, prefling it at the fame 
time towards the perineum, till it has fairly entered the 
vagina. As the indrument pafles the edge of the exter¬ 
nal parts, fome little uneafinefs is always felt by the wo¬ 
man ; but this ceafes asfoon as it has reached the vagina, 
to the upper part of which it is to be carried, and it is to 
be fo placed that the uterus may red upon one of the 
broad furfaces of it. The indrument is now to be left 
in the vagina, and a fyringe full of fome cold adringent 
injeftion fliould be thrown into the parts, to give tone 
and contraftion to the dilated os externum, as, in cafes 
where the vagina is very much relaxed, it may make a 
fmaller peflary anfwerthe purpofe of fupport than would 
be required if no fuch means were reforted to. What¬ 
ever may be the ihape of the peflary introduced, the wo¬ 
man fliould continue for fome minutes in the recumbent 
podure. 
An oval peflary requires great care in the mode of in- 
troduftion, and is either a very good or a very bad indru¬ 
ment, according asfft is well or ill applied. In the choice 
of it, the fize of the vagina is to be firft compared with 
that of the indrument, the extremities of which fliould 
not be too acutely pointed, led they fliould injure the 
parts. The indrument being covered with fome unftuous 
fubdance, one end of it is to be placed between the la¬ 
bia, with the fliort diameter rulining from before to be¬ 
hind ; and in this direftion it is to be carried up into 
the vagina. The praftitioner is then to infert the 
point of his fore-finger into the opening in the centre of 
the indrument, and to place it acrofs the vagina fo that 
the extremities may be turned towards the fpinous pro- 
cefles of the os ifchium : if the direftion of the opening 
in the peflary is made to correfpond with that of the long 
diameter itfelf, this will be eafily accompliflied. The 
peflary is now to be paffed as high into the vagina as it 
can be without giving pain, and to be left there. 
Procidentia uteri iometimes occurs in women whofe 
perinaeum has been lacerated to a great extent in labour ; 
in fuch a cafe, neither the circular nor the oval peflary can 
333 
be retained; but thefacrofciatic ligaments and the os coc- 
cygis will fuflicientlycontraft the lower aperture of the pel¬ 
vis toenable aglobular peflary to be retained. Thispeffary, 
prefling equally in all direftions, is very conveniently 
borne; and it may be ufed for widows who have lod the 
catamenia with great advantage. The fize of the indru¬ 
ment being adapted to the capacity of the parts, its fur- 
face is to be covered with unftuous matter as before, and 
it is to be placed between the labia; by a gentle preffure 
it is to be carried into the vagina, giving a degree of ro¬ 
tatory motion to it as it pafles along, which greatly faci¬ 
litates the introduction. 
In thofe cafes in which the tumour protrudes out of 
the body, it is obvious that this mud be reduced before 
the peflary can be made ufe of. Previous to attempting 
the reduction of a completely-prolapfed womb, we mud 
enquire whether at any period of the difeafe inflammatory 
l'ymptoms have been manifed; as for infiance, lading and 
acute pain, with third, heat, ftnall pulfe, abdominal ten- 
dernefs, vomiting, &c. becaufe, if thefe fymptoms have 
been prefent, there will be much reafon to fear that the 
peritoneum has contrafted adhelions which it would en¬ 
danger the life of the patient to break through by any 
forcible attempt at reduftion. 
When tumours on or above the uterus are the caufe of 
this difplacement, it will feldom be advifable to reduce 
the womb. In faft, all prolapfes in which the effort at 
reduftion is attended with much pain, fliould be aban¬ 
doned. When it is determined, however, to reduce a 
prolapfus uteri, the bladder and reftum mud be emptied 
of their contents : the patient mud then be laid on a bed 
with her hips much raifed, that the abdominal vifcera, 
which are dragged down into the cavity of the pelvis, 
may not oppofe, by their weight, the return of the womb. 
The patient being now direfted not to drain, or in any 
way to aft with her abdominal mufcles, the praftitioner 
is to apply his finger and thumb to the lower part of the tu¬ 
mour, where the os uteri is fituated ; and, by a gentle pref¬ 
fure, this is to be carried up into the centre of the tu¬ 
mour itfelf. This done, the fame preffure is to be conti¬ 
nued, and the parts are to be returned into their proper 
place in the pelvis. A peflary is then to be introduced 
into the vagina; and the patient fnould continue to lie 
upon an inclined plane, with the hips elevated, for feve- 
ral hours. In almod all cafes in which the degree of the 
difeafe is confiderable, every peflary which can be intro¬ 
duced will be forced away by the (lighted efforts of the 
woman: even the globular peflary (which is the bed) 
will not be retained, neither can it be kept in the vagina 
by any common bandage. But by the following contri¬ 
vance the globular peflary may be kept in the vagina. 
In the firfl place, a peflary is to be chofen of the fize 
which the cafe requires, and a fmall flip of brafs is to be 
attached to it by its two ends, leaving a fpace between 
the indrument and the centre of this piece of brafs : a 
belt of leather, long enough to go round the patient’s 
body, is alfo to be prepared ; to the centre of which, be¬ 
hind, a brafs wire, as thick as a common quill, is to be 
attached by a fcrew. This wire is now to be properly 
bent ; and, the peflary being introduced into the vagina, 
the wire is to be paffed between the peflary and the piece 
of brafs attached to it; and, being brought up between 
the thighs, it is to be attached to the fore part of the cir¬ 
cular flrap. The reduced parts are by this means fup- 
ported by a peflary, and this is kept in its place by the 
unyielding piece of metal. 
When a feparation of the ligaments of the pelvic bones 
has taken place in conjunftion with a prolapfed uterus, 
the patient mud wear, in addition to the meafures before 
noticed, a broad circular belt paffed pretty firmly round 
the hips : this of courfe anfwers the fame purpofe as an 
artificial ligament, and moreover facilitates the re-union 
of the lacerated or lengthened flrifture. Strangury re¬ 
quires the ufual treatment. 
( 3 . Retroverfa, 
