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10 CHASE: MECHANIOAL SUPPORT IN UTERINE Dl!>PLACEMENT.<. y)s.\. Med. Jour., MECHANICAL SUPPORT IN UTERINE DISPLACEMEJSTTS, WITH REKERENCE TO THE MANAGEMENT OF CERTAIN CX)MPLI('ATIONS.» By WALTER B. CHASE, M. D., BROOKLYN. Among the vexatious cases which occupy the time and tax the patience Cost Of Levitra At Walmart Pharmacy and skill of the practitioner are those of uterine displacements requiring mechanical support, in which oftentimes Cost Of Levitra At Walmart Pharmacy the use of pessaries will not be tolerated. There arc physicians who have discarded the use of all mechanical aids in the treatment of uterine displacements Cost Of Levitra At Walmart Pharmacy and boldly assert that tliey should never be employed. No argument will be entered upon. to prove their position erro- neous, and it is assumed that mechanical support, when properly applied, is not only useful but indispensable. If we were to know their experience and the reasoning by which they arrived at their conclusions, it would probably reveal the fact that the cases in which they failed and were disappointed (and who of us has not frequently met with failure and disappointment in like circumstances ?) were those in which no support was indicated, or that the kind of support was not adapted to the case. While a very considerable proportion of the cases of uterine displacement admit of easy and successful manage- ment by the use of pessaries, without preparatory treat- ment, there are cases, not primarily allowing of rigid me- chanical support, which, as regards the methods to be em- ployed, will be the Cost Of Levitra At Walmart Pharmacy principal topic of this paper, including some allusion to certain errors in the diagnosis of uterine displacements, and the methods to be adopted in their treat- ment, with brief mention as to some contra-indications for interference. There are cases of uterine displacement, more or less pronounced — particularly that of anteflexion in girls at the menstrual period, in single women of more mature years, and in those who are sterile — in which the differentiation between the pain and discomfort which arise from such displacement and those of a true neurosis require careful study and close discrimination, and, as elsewhere in pelvic diseases, accurate differentiation is always requisite to intel- ligent and rational treatment. The varying mobility of the uterus in different women in health is a subject worthy of careful consideration, and, as there can be no fixed standard for judgment, the limit of normal mobility in every individual case must be determined by the observer, and the treatment governed accordingly. This will embrace a correct estimate of the causes and forces, both local and general, which enter as factors in the pro- duction of these displacements, and include accurate knowl- edge of the appropriate methods of relief, and skill in their a])plication and adaptation. Just here all the tact of the physician will be called into requisition, and nowhere in the domain of medicine will the knowledge and skill of the attendant be placed under larger and more exacting contribution. • Read before the Medical Society of the County of Kings, April 20, The diagnosis of uterine displacements is commonly reached by a study of the symptoms subjectively and ob- jectively, together with a pelvic examination, manual, bi- numual, and, it maybe, instrumental, made when the patient is lying down. The question of uterine fixation, the results of adhesion and peritoneal and cellular exudation, with or- ganization of inflammatory products — which is of the high- est importance — may be properly estimated with the patient upon her back or side ; but the Cost Of Levitra At Walmart Pharmacy conclusion as to the degree of mobility, particularly mobility with displacement, and the displacement for which the patient seeks relief, is not always so accurately decided upon. If the case is one of anteversion without fixation, a supine position, allowing gravity to operate, tends to return the uterus to the normal position, and in some cases will correct the displacement ; and, vice versa, in a case of retro- version the prone position may, by the operation Cost Of Levitra At Walmart Pharmacy of the same law, correct the uterine axis, while a patient in the Sims position, with the vagina distended after the intro- duction of a Sims speculum, if the uterus is mobile, may give evidence of lateral or forward displacement, which is apparent rather than real. As most patients with uterine displacements have the maximum of pain and discomfort when in an upright posi- tion, the final estimate of the degree of abnormity of posi- tion can best be decided upon when the patient is examined standing. This is particularly Cost Of Levitra At Walmart Pharmacy true in prolapsus, and failure to make such an examination is, I am satisfied, a cause of serious error in estimating the degree of falling, the amount of resistance to be overcome, and the support required to correct the displacement. The influence of visceral pressure from above in car- rying the uterus downward while the patient is standing — which is oftentimes far more pronounced than when the patient is lying down — seems to have been over- looked or improperly estimated by many as a factor in procidentia. Apropos of this I recall the case of a lady who became my patient eighteen months since, suffering from all the sub- jective symptoms of prolapsus uteri. She had been under the care of a very intelligent physician, who had repeatedly examined her with a speculum while she was lying upon her back, and had given his unqualified opinion that her uterns was in a healthy condition, and that there was no displacement. A digital examination with the patient upon her back gave little evidence of displacement, but, while she was standing, I could demonstrate to iny own and the patient's satisfaction that there was marked descent ot the uterus, resting as it did upon the floor of the pelvis; and this was accompanied by el^arac- teristic pain, which was instantly relieved Cost Of Levitra At Walmart Pharmacy by lifting the uterus, thereby relieving the utero-sacral ligaments of strain and ten- sion.