APPLICATION OF PRESSURE BY THE TAMPON TO THE CAVITY OF THE UTERUS FOR DISEASES OF THE ENDOMETRIUM, SUBINVOLUTION AND PROLIFERATION OF CONNECTIVE TISSUE.

BY V. H. TALIAFERRO, M. D.,

PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN IN THE ATLANTA MEDICAL COLLEGE, ATLANTA, GEORGIA.

In 1871, and while living at Columbus, Georgia, I published a paper upon "Uterine Cloth Tents in Diseases of the Body and Cavity of the Uterus." In that paper the following language is used: "For some years previous to the adoption of the cloth tent I had used strips of cotton cloth or linen, saturated with Churchill's tincture of iodine, solution of carbolic acid, or other substances to be used. One end of the strip, placed over the point of a small probe, was passed to the fundus of the uterus; the probe being withdrawn, was again and again introduced, carrying with it at each time an additional fold of the cloth until the cavity was completely packed. This packing was permitted to remain until expelled by the contraction of the uterus, which required usually from six to twelve hours. The firmer the packing the more active the contractions and the quicker its expulsion."

In 1882, in a paper published in the Atlanta Medical Register, upon the "Application of Pressure in Diseases of the Uterus, Ovaries, Peri-Uterine Structures," occurs the following: "In very old cases of this kind, where the tissues have

become thoroughly hardened, and the progress of the cure is found to be slow, we often extend the pressure to the uterine cavity, by means of the tent, to the cavity of the uterus, in conjunction with the vaginal tamponade. Upon each renewal of the tampon, an additional tent is used until as many as five or six are introduced at one time. In this way we get thorough dilitation and softening of the uterine structures without confinement to bed and without discomfort to the patient."

In February, 1884, I first used the cotton tampon to the uterine cavity for the purpose of pressure upon the diseased structures of the uterus in lieu of the cloth tents. I at once saw the great advantage in the more uniform and thorough pressure thus obtained. Since this time a great many cases have been treated. It will be seen that, step by step, I was led to the use of the intra-uterine tampon to the cavity of the uterus in the diseases of its mucous membrane, as well as its parynchematous structures.

As a therapeutic measure, the intra-uterine tampon is simple, safe and marvelous. Chronic inflammation, granular erosions, mucous fungosities, together with the usual subinvolution, rapidly disappear under the influence of the pressure. With the proper observance of the contra-indications, to all intra-uterine applications, the remedy is perfectly safe. It should, of course, never be used when there is the vestige of inflammation in the peri-uterine structures. I have now a patient at my private infirmary whose uterus has been packed from the fundus to the end of the cervix for more than a month, who rarely goes to bed, except by my instructions, for some hours immediately following the application. So long as there is sufficient oozing of blood to saturate the tampon, it is removed and re-applied daily; otherwise it remains for two days. If iodoform is used with the packing,

as should always be done, the patient is secure against sepsis, the dressing removed being clean and free from odor, though it remain for days. I not unfrequently leave it alone for three days.

The illustrations convey quite a correct idea of the method of applying the tampon. The patient is placed in the kneechest position, or Sims' semi-prone, and the perineum retracted with a Sims speculum, or with any perineal retractor. I use my own speculum, as it separates the vulva and vaginal orifice better, and gives a more satisfactory command of the parts. The anterior lip of the cervix is seized with a

tenaculum and the uterus lifted forward toward the vaginal outlet. A little pledget or roll of cotton, with a thread wound about it, is now seized with the dressing forceps (with small blades) and carried in the uterus quite to the fundus; this being done, the blades are sufficiently separated to loosen their hold and partially removed, and the cotton roll caught in a new place and carried up, as was the first, the maneuvre being repeated again and again until the little roll is thoroughly packed away in the uterus.* These little cotton rolls are repeated one on another until the entire cavity is filled. Each piece of cotton is wound about (as represented in the

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diagram) with strong spool thread with a long end left to better facilitate and insure removal. The size and length of the cotton roll should correspond with size and depth of the cavity to be filled. I have packed as much as one and three-quarter yards of lamp-wick in a single piece in the cavity of the body. The cavity in this case was unusually large and filled with granulations. I tried the lamp-wick because of its convenience, but discarded it on account of its hardness and want of elasticity. Nothing does so well as

"In the beginning of the treatment in ordinary endometritis the tampon should not be carried further than just within the internal os-the cavity being gradually and carefully encroached upon until the fundus is reached. When the uterus is filled with fungus granulations the tampon should be carried at once to the fundus. The intra-uterine tampon should always be accompanied by a small but firm vaginal tampon-using glycerine and iodoform on the first pledgets. The patient should be kept in bed for some hours following the treatment, or if there be pain, so long as this continues. If pain is persistent the tampon should be removed.

new clean cotton. The new cotton does not need washing or other preparation. Absorbent cotton does not do so wellit packs too hard and is inelastic. I usually get clean sample cotton from the cotton factors. In this way we can feel sure of using an article that has never been in use.

It will be observed that the intra-uterine packings were in my first experiments expelled by the contractions of the uterus induced by pressure. I have since learned that this occurred then, as it does now, in a certain class of cases, where there is simply mucous inflammation, with more or less sensitiveness. Where there is a large patulous cavity none occurs, nor does it occur in any case if the uterine cavity is slowly and gradually encroached upon and tolerance induced.