AN APPLIANCE FOR THE RELIEF OF INCONTINENCE OF URINE IN THE FEMALE.*

BY HORACE PACKARD, M.D., BOSTON, MASS.

In January, 1902, a case of incontinence of urine was referred to me for operation looking towards relief. The history of the case in brief was of an instrumental delivery a few months before, since which time the urine had dribbled from the bladder constantly without the slightest sphincter control. Patient waiting had failed to yield hoped for improvement, and electrical and medical treatment had also been unavailing. On examination a deep cleft was observed anteriorly just to the right of the meatus and urethra extending deeply through the vaginal wall towards the pubic bone, and ending in cicatricial tissue which seemed somewhat adherent. From the appearance of the parts it was assumed that the sphincter had been torn apart, with failure to unite that resulted in the sad plight in which the patient found herself.

An operation was thereupon performed consisting of laying open the urethra and sphincter to the bladder wall. All tissue which seemed to be cicatricial was dissected out and the freshened ends of the sphincter united with green cat-gut. A vesico vaginal fistula was established and a drain tube fixed therein for temporary drainage. Healing went on without interruption, but there was no improvement. The urine continued to dribble, the patient was constantly wet, and could be about on her feet only by the use of voluminous pads of absorbent material.

In October, 1902, further operative measures were attempted designed to lengthen the urethra and afford a valve like control. Since these were also failures I shall not take the space to describe them, except to say that they contemplated the supplementary use of a truss-like support or spring pad to press lightly upon the elongated urethra. All this, though failing in the ends sought, showed the impracticability of any mechanical contrivance deriving support from the exterior and thus turned speculation upon the possibility of an internal pessary-like arrangement fitted with a spring button to press lightly upon the urethra with just sufficient force to stop the flow of urine for intervals of three or four hours. Many and various were the experiments and mod

* Read before the Massachusetts Homœopathic Medical Society.

ifications extending over a period of months, until the appliance herewith represented was evolved.

The slightly bifurcated portion "a" is designed to engage in the vault of the vagina just back of the cervix. The curved portion "b" rests upon the perineum. The concave rectan

gular portion "c" engages the pubis and is actuated by a delicate spiral spring within the cylinder "d." The bar-shaped terminal "x" presses against the base of the bladder or beginning of the urethra with sufficient force to stop the outflow.

As to the actual practical use of the appliance it soon developed that a way must be devised to enable the patient to adjust and remove it at will; for while it fitted well and performed the function for which it was designed, a sense of lameness and discomfort developed after wearing it continuously for a day or two. It was obviously desirable also that it might be easily removed at night on retiring and especially at frequent intervals during the menstrual periods. Therefore, a repositor, shaped something like a forceps was devised which serves as a handle to facilitate introduction and is thereafter easily discarded by unsnapping the handles.

Before benefiting by the appliance the patient was limited in her movements within a very narrow range. She hardly dared go from her home and felt incapacitated from participatting in social functions of any kind. With it she has resumed

to a large extent the usual routine of life. She can feel assured of going dryshod three or four hours at a time, and then when the call to empty the bladder is appreciated, she retires to the toilet, assumes a squatting posture and with a suitable cup as a urinal, and pressure with the forefinger upon the part "z" releases the spring and permits the urine to flow out. From time to time slight modifications have been made to meet the changes in the vaginal wall incident to the stretching effect upon its tissues. For example, a small bulging piece will be observed at "o" which has been applied of late to give better engagement against the perineal floor. While the appliance does not by any means fulfill the place of the natural sphincter vesicæ, it may be truthfully said that to this patient it affords a degree of relief which would be sadly missed were she now deprived of it.

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ON THE NECESSITY FOR MEDICAL SCOUTING CORPS. The scouting-troop has been, since armies were, an indispensable component part of every army. The scouts do not sit as counsellors; their place is not on the firing line. Their well defined duties are to take the road well in advance of the main body of troops; to carefully note every sign that suggests means to further the army's advance, or that threatens peril to its safety; and from time to time to summarize and report their observations to the powers commanding.

Might not the great medical army, ever on active service against the foes that ever threaten mankind's welfare and sanity, copy, with advantage, this practice of the regular military service? Might not medicine, with very great advantage to itself, organize and maintain its scouting corps?

To be explicit. It would be to the very great advantage and enlightenment of every medical society, to maintain a standing committee whose duties should be closely analogous to those of the army's scouting troop. They should be instructed to examine into, and report upon, the medical signs of the road. No individual practitioner has the time or the facilities, few perhaps have the inclination, to investigate the manifold theories on medical practice, and experimentations in medical practice which almost yearly arise to bid for popular support. Thus the individual practitioner stands perpetually between

the Scylla of ignorance of some new and valuable weapon for his never-ending fight, and the Charybdis of dangerous or foolish personal experiments. Again, physicians are not few who curiously enough look upon medicine as a perfect and non-improvable science, to which their particular school alone has the key. Such are in very great danger of finding that the public is rapidly ceasing to agree with them; and that their dogmatism is costing them prestige, confidence, possibly even livelihood. There is, in short, no practitioner who can either afford time and costly personal experiment with new medical fads and fancies, or ignorance of how much among them may point new and safe roads toward the care of the sick. Here is the field for the scouts of medicine. Whenever a new system of treating the sick, has by a sufficient tenure of existence, and a sufficiently wide-spread acceptance on the part of the community, demonstrated its popular influence, then let the scouts of the regular medical army be instructed to examine into the claims of this new system, in a spirit of entirely honest, and open-minded, and courteous investigation. Let them learn from its leading exponents its modus operandi; let them study it, in demonstration; let them tabulate its statistics. Then let them bring the results of their investigations, at stated periods, -say, annually, in the case of state societies, and bienially in that of national societies, before the medical bodies with which they are affiliated, for consideration and discussion. By such a custom nothing could be lost; and very much potentially gained. For instance, there would be slowly dispelled from the public mind, the-alas! not quite unfounded ideas on medical bigotry now rather firmly established there. When questioned by a patient and what experience is more familiar? - as to the character and merit of some new method of treatment, instead of admitting his entire ignorance of it, coupled with slighting assurance of its worthlessness, a fashion of reply too common to our craft, and much more damaging to us in our patient's eyes, than to the thing we depreciate! the practitioner can reply that from the investigations of his society's committee, such and