Where a cystocele exists an excellent instrument, as long as it remains in situ, is the Gehrung. This instrument tends, however, to turn back wards, and further it retroverts the uterus. Still, while in place it more effectively holds up the cystocele than any other instrument at our dis posal. The position of this pessary is well shown in Fig. 126.
For prolapse of the uterus, the best palliative means of retention is the insertion of one or more cotton tampons, for where the perineal body has been destroyed and the pelvic floor has lost its integrity, we possess no pessary which is effective unless such a large ring be chosen as will ultimately, from distension of the vagina, make the condition worse. The proper treatment for prolapse is the operative (colporhaphy, .perineo rhaphy, Alexander's operation). In instances, however, where the uterus is prolapsed and the pelvic floor is largely intact, Byrne, of Brooklyn, has devised a pessary which he states will effectively remedy the displacement. The instrument is intended chiefly for women who have passed the meno pause, and in whom it is either not desirable to operate or else impossible, owing to refusal on their part.
These additional forms of pessary, together with the well-known Albert Smith retroversion instrument, will be found to amply answer routine purposes. Each practitioner indeed soon becomes accustomed to a certain number of pessaries, and finding that by means of them he can usually accomplish his aim, he takes no account of the thousand and one other forms which are at his disposal. In no gynecological subject, how
ever, is it of greater importance not to be a creature of routine. That practitioner will be the most successful in the application of pessaries who possesses the requisite amount of ingenuity to ever adapt the pessary to his patient, instead of, as is frequently the case, endeavoring to make his patient fit a certain form of instrument. As general rules for guid ance it may be stated that the uterus should always be replaced before the pessary is inserted, seeing that the instrument is intended to keep the uterus in position, and not to place it there; further, that pessary is the best one for the individual case which, when- in position, interferes the least with the normal range of motion of the uterus; lastly, after the insertion of a pessary, the best way to determine as to whether it will probably prove effective and not harmful, is to examine the patient in the erect position, when the additional factors, gravity and the superin el:nbent weight of the abdominal viscera, are in action.
In regard to the stem pessary, there is no occasion for any additional statement. Every practitioner will decide for himself, from experience, as to whether it is a safe instrument. Our own impression is that it should rarely be used, and when it is, the precautionary measures taken cannot be too stringent.—ED.]