TAMPONADE, MORE TAMPONADE, MOST TAMPONADE: Frances A. Harper, M. D., Pittsburg, Kansas. Two years ago I read a paper before this association on "Malpositions and Distortions of the Pelvic Organs," outlining in a general way treatment for their correction. As the title of my paper gave no hint of its character-whether surgical or non-surigcal-and as these conditions are largely viewed from a surgical standpoint, it was placed in the surgical section. The warmth of the discussions and adverse criticism voiced by some of the members might lead one to believe that their experiences along these lines had been anything, or everything, but satisfactory. Quoting from the discussions: "The treatment of these uteri with tampons and all that sort of thing has never accom. plished a thing. That seems a broad statement, but it has taken many years to find it out. Operative treatment has grown with the education and intelligence (save the mark!) of the gynecologist, and we know that it is the only way by which we can accomplish anything in these conditions. Read before the Medical Association of the Southwest at Kansas City, Mo., October 8, 1913. WHY IS MOST "In regard to these displacements of the uterus, I have had experience in dealing with them for a good many years under the tutorship of a man who was the greatest packer (?) in the world. He put in as many as twenty-one tampons into one vagina, and could get more of them in there than anyone I ever saw. He tried out that method thoroughly, and a good many of us have done the same thing. Therefore," etc. So, as a practical sequence to my former paper I have chosen the title: "Tamponade, More Tamponade, Most Tamponade: Why is Most Tamponade a Failure?" There certainly must be some good ground for the conclusions reached by so many operators who have discarded their former methods of local treatment in favor of surgical measures, some good reasons for the unsatisfactory results obtained from such treatment. In my endeavor to discover if possible, why such conditions might be reached-why such radical statements could be made, and why their treatments had failed, so far as ultimate results were con 277055 cerned, I have here as the result of several months of diligent research a fairly good history of non-surgical methods of treating pelvic displacements from the time of Oribasius (A.D. 326-403), nearly sixteen hundred years ago, up to the present time. Of course I shall not attempt to read all this, as much of it is immaterial, but will make REPOSITION OF AN ANTEVERSIO-FLEXION. RULE.-The point at which force is applied in overcoming a displacement is the fixation-point for its correction. Observe that the finger is placed behind the cervix in overcoming this displacement. A packing placed at this point after reposition is accomplished, is but a continuation of the force which overcame the displacement, and will thus prevent its recurrence. use of a few extracts bearing particularly upon methods of using the tampon in treating for the correction of pelvic displace ments. The statement is often heard that there is no branch of medical science which has shown such marked improvements, such rapid advance, during the past fifty years, as that of gynecology-the treatment of diseases of women. I believe that I made some such statement as that myself, some years ago; but really I think I must have said it because someone else had said it, and I wanted to believe it. However, since making this research, I have experienced somewhat of "a change of heart" in this respect; and I want to contradict that statement here and now, by saying that, outside of surgical procedures, I cannot see where we have taken one forward step in methods of treating for the correction of pelvic displacements of women during the past fifty years! and I am here to prove my statement. The fact of the matter is, we have been working round a circle, which leads to nowhere, and the imperfect methods of the ancients are still in vogue, and used indiscriminately for all sorts of conditions, without rhyme or reason. Historical. In ancient and mediaeval medicine, displacements of the uterus, other than prolapse, received but little at tention. Aetius describes various displacements of the womb, but says little about treatment, except to mention the kneechest position and the use of the sound. But Aetius, Oribasius and other ancient writers describe the method of treating the prolapsed uterus "by placing the patient on her back, elevating the pelvis, pressing the uterus upwards, and then placing in the vagina a ball of wool, with a string attached to it" (McKay). (Hundreds are still using this very method, with little variation, in treating all sorts of pelvic displacements, even in this enlightened age.) a Vaginal tampons were also used as means of applying medicines to the vagina and womb. In the Middle Ages prolapsus was treated by the use of solid pessaries, wood and similar materials being used for making them. Pare was the first writer to describe a number of these instruments (1573), but they were probably used before this time. It was not until the middle of the nineteenth century that uterine displacements came to occupy an important place in gynecology; and at that time the treatment of these conditions was almost entirely by means of pessaries, many hundreds of different forms being used. Webster says of this period (about 1855-70): "Sir James Y. Simpson reintroduced the sound, and showed how it could be used with the bimanual examination. His pioneer views. have been greatly modified, but his work was instrumental in directing attention to the need of thorough local examination." The tampon was used by a few physicians at that time, but as indicated by the above quotation, pessaries were used indiscriminately, and often with unsatisfactory results; finally, during the 80's the pessary was generally abandoned in favor of surgical methods. Percy says: "In the old days, many of these cases were held in place by the pessary. But in those days the practitioner was practically ignorant of infections, and what was gained by artificial means was often lost through the introduction of new infections by the injudicious use of unsterilized sounds, dirty fingers and speculi." Dr. Goldspohn, in discussing Bold't paper (1908), says: "The great evils which did occur in conjunction with pessaries, and therefore led the profession to exclude them from use were not due to the pessary, but to the ignorant use, the abuse, of the pessary in introducing it as if it were a lever or jackscrew to raise something." Tampons were advocated as a method of treatment in uterine displacements at the time when pessaries were so much used; but comparatively little attention was paid to them at that time, although a few physicians always used them. They have always been employed as a means of local application of medication, and as a plug to arrest hemorrhage. In later years a number of physicians have advocated the tampon as a means of treating uterine displacements, or as a preliminary treatment before a pessary is fitted. The following notes and quotations indicate the various methods of employing the tampon: Tauszky states that Dr. Nathan Bozeman of New York City about 1860 advocated the use of vaginal tampons for the treatment of complicated and uncomplicated cases of uterine displacements and adhesions. Taliaferro a southern physician, some years later published a pamphlet advocating the same plan of treatment, but gave no credit to Bozeman. Dr. Bozeman's method was as follows: In cases of retroflexion or retroversion the patient is placed in the knee-elbow position; Bozeman's speculum is introduced and his larger vaginal blade is made use of, this latter forming the third blade which elevates the perineum and posterior vaginal wall. Tampons of cotton saturated in one or two per cent solution of carbolic acid, pressed out dry, are then introduced into the posterior culdesac of the vagina as high up as possible, depressing it gently with the posterior blade. By a number of cotton tampons similarly introduced in rapid succession, until the vaginal column is complete to the perineum. The instruments are removed, and the patent is allowed to follow her daily avocation . . . Each tampon has a string attached to it for its easier removal. The tampon remains for fortyeight hours usually, when it is removed and a vaginal douche taken, and the tampon reapplied" (Tauszky). Davenport (1898) recommends packing the vagina to relieve retrodisplacements with adhesions. Benjamin (1901) says that in inserting the tampon: "In version of the uterus (presumably retroversion) the patient is placed in the knee-chest position, thus throwing the uterus forward, after which the insertion of a tampon in the posterior fornix of the vagina, and encircling the cervix in a semicircular fashion, will hold the uterus in its normal position. . . . Flexion (presumably anteflexions) should be treated with the patient in the dorsal position, and the tampon placed in the anterior fornix around the cervix." N.B. It will be observed that the common method used in placing tampons for the correction of displacements is as follows: In treating backward displacements the packing is placed "behind the cervix, in the posterior culdesac." In treating forward displacements, the packing is placed in the "anterior fornix, in front of the cervix." If the idea is to maintain or induce the given malposition, then the method works out all right; but, if the object of treatment by tamponade is to overcome and corrcet the displacement, the opposite method must be employed. 08 REPOSITION OF A RETRODISPLACEMENT. RULE.-The point at which force is applied in overcoming a displacement is the fixation-point for its correction. Observe that the finger is placed in front of the cervix in overcoming this displacement. A packing placed at this point after reposition is accomplished is but the continuation of the force which overcame the displacement, and will thus prevent its recurrence. Dr. Sarah McNutt (1905) uses strips of non-absorbent cotton or wool, packed up into the posterior culdesac for retrodisplacements, and emphasizes that "the cotton should be gotten well up behind the cervix. Palmer (1905) says: "a broad tampon of wool, adjusted well up into the posterior culdesac, while the patient assumes the knee-elbow posture." Souther (1906) in treating for retrodisplacements, uses "a tampon that will hold the cervix back," but does not state at what point he applies it for this purpose. Bandler in his Medical Gynecology (1909) advocates the use of glycerine gauze 'packed thoroughly into the posterior fornix, while the cervix is pulled down with 66 |