In case a conductor is used, the stem is removed from it by pressing on the cup of the stem by the finger in the vagina, while the conductor is withdrawn.
Every intra-uterine stem, when properly adapted to the case, must penetrate well into the cavity of the uterus, and the cup must rest well against the external es.
If the stem has been inserted into a retroflexed uterus, the organ must still be anteverted. When this has been accomplished, then, following Schriider's and Amann's directions, sufficient cotton tampons are to be inserted into the anterior cul-de-sac to maintain the cervix in retroposi tion, or else one of the previously described pessaries may be used.
It is much more difficult to insert the stem when it is united with a vaginal pessary, as, for instance, Martin's regulator. It is inserted by means of the finger, or else, as was Simpson's custom with his own, by impinging the stem on a conductor. The vaginal pessary must, of course, be introduced proportionately to the degree of entrance of the stem. Where the uterus is retro-displaced, this is often readily accom plished;, where the uterus is anteriorly displaced, the procedure is more difficult, in which event the vaginal pessary must be pressed greatly against the sacrum in order to permit the insertion of the stem into the os. The pessary of Kinloch is to be preferred to Martin's regulator, be cause it does not limit so much the movability of the uterus, and since this limitation is purely within our hands by choosing varying grades of rubber bands. It is further more readily introduced than the regulator. In case of retroflexion it is so inserted that the cup of the stem points backwards and the extremity forwards.
The stems connected with elastic pessaries are inserted in the same way. Since the vaginal pessary may in this instance be compressed, it readily passes the introitus, but when the entire instrument is in the vagina, then the lack of space makes manipulation difficult. The air pessaries carrying a stem are inserted on a conductor and then inflated.
It is not superfluous to state that all instruments should be most care fully cleansed and anointed with some fatty substance. The complicated pessaries, in particular, have a number of angles and depressions in which the carriers of infection may readily lodge.
To remove the intra-uterine stem the finger is inserted above the cup of the instrument, and makes gentle traction downwards. In case of the concave cup which accurately fits over the cervix, it may be necessary to hook a broad, blunt tenaculum over it, and by means of this to draw the instrument far enough downwards to permit the finger to complete the removal.
Amann's stem is grasped by a long dressing-forceps; the Kinloch pessary is removed by simple traction on the vaginal portion of the in strument; the regulator (Martin's) is brought into the position which it assumed when inserted, and the stem portion is withdrawn from the uterus as the vaginal portion sinks outwards.
When an intra-uterine stem has been inserted, the patient should keep quiet in bed for at least two days. Slight bearing-down pains fre quently are present for awhile, but any other pain, particularly tender ness on pressure, or the least elevation of temperature,—and the ther mometer should be used to determine this,—necessitates the immediate removal of the stem, and energetic treatment against the metritis should be instituted, such as poultices, local venesection, narcotics, etc. In case, however, the patient bears the stem well, then she may shortly resume her accustomed habits of life, although great effort, and dancing, riding, jumping, or carrying heavy weights should be forbidden. It is essential that the bowels and the bladder should be regularly emptied, and the vagina should be kept clean by a daily injection of water with the addi tion of whatever seems requisite.
At the first menstrual period the patient must again remain absolutely quiet, the stem often causing increased and even profuse hemorrhage, and it must frequently be removed. It is wiser, as is Schroder's practice, to take it out at the onset of menstruation. It frequently falls out at this period, either because it is pushed out by a coagulum, or by bearing down pains, or the uterus straightens out still more during menstrua tion, the flexion becomes entirely effaced, and the stem escapes.