VAGINAL PESSARIES.
The most frequent indication for the use of vaginal pessaries is change in position, and to a lesser degree in shape of the uterus, that is to say deviations downwards, forwards, backwards, laterally, flexions, and lastly abnormal movability of the uterus, changes in position of the vagina, rectum, and bladder. Lees frequently the pessary is used to cause retention of an intrauterine stem, to limit the movability of other organs, in particular the ovaries, to correct incontinence of urine (Schatz's finally to stretch adhesions by pressure exerted through the instrument.
These indications have their limitations. Aside from the rare in stances where the displacement has been cured by the pessary, either as the result of pressure, gangrene and after-shrinking, or because the instru ment was inserted in recent eases, as during the puerperium, cures of displacements from the use of pessaries are not so very exceptional, although still infrequent. Often we are able simply to maintain the uterus temporarily in its normal position, and we must be content with lessening the displacement or the amount of flexion; often we cause an opposite displacement. As we will note further on, the use of pessaries is accompanied by a number of disadvantages which it is out of our power to overcome, and the value of pessaries is thence lessened when compared with other procedures. The plastic operations which have of late years been introduced into gynecological practice, the amputation and extirpa tion of the cervix, colpo-perineorrhaphy, etc., up to the " Gu(rison par la tenotomie utero-vaginale ign6e " of Abeille, these procedures have con siderably lessened the need of pessaries, and are able to restore the condi tions practically to the normal. In particular is this true of backward displacements of the uterus, and the results will increase the more patients learn not to fear the knife, and the greater the care taken in perfecting the methods of operation and of wound treatment.
Pessaries indeed are purely crutches, as every gynecologist daily finds, and they should only be resorted to when, on the one hand, cure by operation is not possible, on the other hand, when the anatomical changes or the functional disturbances produced by the displacement are so great as to outweigh the inconveniences resulting from the wearing of a pessary.
In case of every displacement and alteration in shape of the uterus, the rule holds: Replace the organ or the altered part, and then retain it in position. Retention is secured by the pessary; reposition is attained by the bimanual palpation, exceptionally by the sound or the previously described elevators, to which we must add Wallace's procedure of insert ing a curved sponge tent, on dilatation of which the organ is straightened out, a procedure analogous to Schultze's method of intrauterine straightening after divulsion of the cavity.
There are a number of considerations in regard to the insertion of pessaries from the side of the genital canal and of the patient.
It was formerly believed that the pessaries took purchase on the bony walls of the pelvis. It is very evident that such cannot be the case, because, on the one hand, we can never use large enough pessaries to attain this, and on the other hand, because if we should the functions of the bladder and of the rectum would be interfered with or at least dis turbed. Without question the pessaries, in particular the purely internal, are held in place by simple contact with the undistended vaginal walls; additional retention is indirectly yielded by the anterior part of the leva tor ani, the descending rami of the pubes, the symphysis, and the pelvic floor. In order that a pessary may be retained in the vagina, in addition to the permeability of the canal, there must exist equable distensibility of the vaginal walls. Cicatrices must first be overcome by dilators or by the knife. Similarly, tumors in and external to the vagina often interfere with this distensibility, and occasionally prevent altogether the insertion of a pessary. The vagina further must have its normal curve, approxi mately at least, and the walls must not be so relaxed as not to allow of a certain amount of stretching. Great prolapse of the vaginal walls, fol lowing on laceration of the genital canal and of the perineum, must first be rectified by the rectal or the vaginal suture.