Sexual intercourse during the wearing of the stem must be counted as injurious, and Olshausen in one instance thought a peritonitis followed on copulation. There are, however, certain uteri so tolerant that they will not react against almost any injury, and Aushinder has devised a funnel-shaped pessary to be worn for the cure of sterility, that is to say daring copulation.
From time to time an examination should be made to determine if the stem is maintaining the correct position. It readily glides from the uterus, so that its apex, as we have stated, lies in the cervical canal (Spiegelberg). The instrument must then be re-inserted or replaced by another, but we must first ascertain if an endo-cervical catarrh, or an erosion or ulceration has become established. In the event of this being the case, the complication must be treated before the re-insertion of the intra-uterine stem.
The action of the intra-uterine stem on the uterus is chiefly to straighten its axis, but in addition the drainage of secretion is facilitated, the circulation is equalized and the formation of vegetations is prevented. A further constant effect is swelling of the uterine tissue, the result of the irritation produced by the stem, but this swelling shortly subsides. Not only, according to Winckel, is the uterus caused to contract, but also its ligaments, and this leads to improvement in the position of the organ. As to whether the establishment of a more normal circulation, and the irritation caused by the stern, produces the so frequently apparent thick ening in the uterine wall, from the growth of muscular fibres or not, has not been as yet determined. The cases are not very rare whore the wall of the uterus opposite the stem becomes thickened, while it is being worn. An almost constant effect of the intra-uterine stem is irritation of the mucous membrane of the uterus, which shows itself by increased secretion, frequently through hemorrhage, although in a single case Haartmann was unable to detect any change in the mucosa.
The length of time requisite for intra-uterine treatment is very varia ble. It is useless in the absence of indication to remove the stem every day, or to allow it to be worn only a few hours daily. It must, however, be frequently removed, after a few weeks, and possibly changed.
Martin has left his regulator in situ for nine months, Winckel for as much as a year, without unpleasant sequelse. have personally left aluminium stems for six to eight months without injury.
[In addition to the pessaries described by Chrobak, there are a num ber which are used in particular in this country, and to which we would briefly refer for the sake of completeness.
In antoversion with downward sagging, the latter being the main factor productive of symptoms, the Thomas open cup will frequently be found of service, its effectiveness being dependent on the fact that it lifts the body of the uterus upwards to a degree and thus takes the traction off the neck of the bladder. In case of retroflexion or retroversion with prolapse of one or both ovaries, after reposition of the displaced organs, the Thomas or Mund6 bulb pessary will be found efficient in that the posterior fornix is thus filled, and the ovaries, in particular, are kept from falling down again.. Ordinarily, the Muncie will be found preferable to the Thomas shape, in that being broader at the anterior end it is not so likely to protrude from the introitus vagina. In case of retroversion associated with a wide, relaxed vagina, and a greater or less degree of downward sagging of the uterus, the Noeggerath and the Fowler pessary are valuable. The latter, in especial, we have found useful in instances where it was not so much the retroposition of the uterus as the down ward sagging which caused the symptoms. Downward sagging of the organ by making traction on its suspensory ligaments is the chief source of that frequent symptom, " dragging pains in the back, extending into the abdomen," a symptom which is obviously intensified when the patient assumes the erect position, and the cause of which is therefore best de termined by examining the patient in this position.
Where retroversion or retroposition with anteflexion exists, associated, as is not uncommonly the case, with shallow vagina and short vaginal portion of the cervix, the purely internal vaginal pessaries will not answer to keep the uterus elevated, and here an instrument which will frequently prove of service is the Thomas-cutter. The objection to this instrument is that it is apt to abrade the posterior commissure, but this objection is scarcely valid where the patient is of sufficient intelligence to learn how to introduce the instrument herself, for then it may be removed at night and re-inserted each morning. The ultimate effect of prolonged wearing of this instrument is a decided deepening of the posterior vaginal fornix, whence it may be possible to substitute later on one or another of the internal forms of retroversion pessaries.