The essential part of every intra-uterine pessary is the stem which is intended for insertion into the cavity of the uterus in order to keep the organ straight. In order to maintain the stem in position and for ease of withdrawal the earlier instruments were attached to a handle which was fastened outside of the vagina (Valleix, Kiwisch, Kilian), or else the stem was split so that the halves spread apart (Kiwis* C. Mayer, Wright, Greenhalgh, Chambers, Bantock). Beresford advocated passing two needles to hold the stem in position. All these methods, however, are to be rejected as dangerous, since they cause pressure on the inner sur face of the uterus and irritate the organ, while the first-mentioned means exposes it to injury during sitting, riding, etc. It is not astonishing that in the majority of instances where damage was inflicted on the uterus, such faulty instruments were used. According to Winckel, after the use of Kiwisch's instrument, Scanzoni, Haartmann, C. Mayer, Riese, wit nessed severe attacks of peritonitis and deaths; after Greenhalgh's divid ing stem, there occurred a death; and after Valleix's instrument Aran, N6laton, Cruveilhier, witnessed fatal cases. In a case of Haartmann's the wall of the uterus was cut almost through from pressure by the blade of the instrument. The frequently recommended instrument of is no better, the stem of which is attached to a Zwanck pessary, forming the continuation of the long axis of the pessary.
The simplest intrauterine pessary, called by Martin " simple regula tor," is Amussat's ivory stem. The stem must be from one•quartor to one-half an inch less in length than the depth of the uterine cavity, otherwise it will touch the. fundus and injure the organ, but it must also reach at least three•quarters of an inch above the internal os, else it will not be effective in straightening out the uterus. The thickness of the cylindrical or conical stem should vary according to the width of the in ternal os; too slender stems readily slip out, while if they aro too thick it is difficult to insert them and they ordinarily cause sharp pain. The stem may be either solid or hollow; in any event the extremity within the uterus must be well rounded, and the entire surface must be smooth and carefully polished. The hollow stems, which permit the free outflow of the uterine secretions, since the entire instrument is slender, neces sarily have thin walls, and therefore readily break in the vagina. At the external, non-uterine extremity of the stem there is a concavo-convex, round, slender cup, a thick knob or a ball, which answers the purpose of steadying the stem. The diameter of this cup is at least three-quarters of an inch, ordinarily a trifle more, the greater indeed the wider the ex ternal os and the more relaxed the tissue of the uterus. The chief utility of this cup is to prevent the stem from slipping into the cavity of the uterus, and it further prevents the stem from slipping out, since it rests against the vaginal wall and indirectly against the levator ani (Hilde brandt), or else is supported by one or another of the means to be men tioned later. Flat cups and round knobs do not maintain the stem in
position as well as those which are concave upwards, that is, towards the uterus, and I have had them constructed after a plaster cast of the vagina, a procedure which Fritsch also favors. In order to maintain the uterus better in position Amann, and Eklund as well, have substituted for the cup a trowel-like body. It is of advantage to have a depression in the cup or knob which serves the purpose of allowing the insertion of a sound for guiding the instrument into position, but it should be remembered that when this opening is central the strength of the stem suffers con siderable diminution.
As for the material from which the simple stems or regulators are constructed, the first, that of Amussat, was made from ivory. Martin had the knob made of wood; Olshausen used horn for the stem, cork for the knob; Byford had the instrument constructed of elm-wood; C. Braun, who no longer uses the intrauterine stem, G. Braun, Schroder, Amann, Beigel, and before them Simpson, used hard rubber; Simpson also used, with reference in particular to amenorrhea, pessaries made of zinc and copper; Hildebrandt, Amann, Noeggerath, recommended ldad stems; Chadwick a malleable stem; Morris, Meadows, Saltzmann, used glass. The stem should above all be unchangeable and light. Hard rubber is, therefore, a good substance, and the stems may also be made of silver or copper, or gold-plated, and these are light, being hollow, and the cup may be very thin. For a number of years I have used aluminium almost without exception.
In case of anteflexion, where the vagina is not specially relaxed, the simple stems remain quite well in the uterus; but where the uterusand vagina are relaxed, and in case of retroversio-flexio the stems generally slip out to such an extent that the extremity of the stem lies below the internal os, and the instrument, therefore, not only does not subserve its purpose, but the stem, lying in the cervical canal and forming a lever of the second class with the fulcrum at the external os, will irritate or injure the organ. This is one of the objections which Spiegelberg had to the intrauterine stem.
In order to guard,against the slipping out of the stem, Graily Hewitt, Hildebrandt, Winckel, place under the cup of the stem vaginal pessaries, generally rings or rubber inflated pessaries. Schroder and Amann tam poned the vagina with cotton, or else the stem may at the outset be fastened to the vaginal pessary. Winckel tied the stem to a ring pessary; Simpson, and later E. Martin, adapted the stem by a movable joint with the pessary, and Martin called his instrument a movable regulator. Jor dan and Seigel fastened the stem to an air pessary which was inflated in the vagina; Kinlocli places a double rubber band over a Hodge pessary, and the stem rests on this band. Graily Hewitt and Schultze have placed a cross-bar on a Hodge pessary, to support the stem, which is attached to the bar by a movable joint.