Every pessary acts more or less as a foreign body on the mucous membrane of the vagina, according to the amount of distension it pro duces. We cannot know beforehand how much the vagina will react against the irritant, and how it will stand distension. There are patients who cannot wear the most accurately adjusted pessary, or else in whom it must be changed, and there are other women who can wear most unsuit able instruments for a long time without damage. In general it may be stated that the tolerance of the vagina varies directly in proportion to its sensitiveness to pressure, and to the extent and degree of an existing in flammation of its mucous membrane. Any disease of the mucosa will inevitably be made worse by the insertion of a pessary, and even where the vaginal walls are healthy, there results almost always catarrh, par ticularly when careful cleansing of the canal and of the instrument does not obtain. The choice of the pessary as regards size, form, material, etc., is in this connection of great importance. Ordinarily the mistake is made of choosing too large an instrument, one which stretches the vagina overmuch; the examining finger then detects great distension, particularly in the anterior fornix, and the vaginal folds are effaced. The pttient soon complains of pain, and of a frequently profuse watery dis charge; the functions of the rectum and of the bladder are interfered with; the epithelium is rubbed off the spot where the pessary presses and an ulcer results. The pessary in a very short time causes a depression in the vaginal walls and becomes covered with granulations, or else perfo rates into a neighboring organ. The choice of a proper pessary is purely a matter of experience and practice, which does not lie within the reach of every physician. The width and distensibility of the vagina may be best accurately determined by careful examination; the so-called vagin ometers do not answer, since they only inform us as to the distensibility in one direction. It will often be necessary to insert a pessary, generally a ring, for the purpose of measurement of the amount of allowable dis tensibility.
There are certain considerations, further, from the side of the uterus. This organ must be movable and replaceable. Only in ease of anterior displacement is previous reposition unnecessary; backward and down wards displacements must always be rectified manually or instrumentally, although exceptionally a pessary is inserted in order to stretch adhesions. A further postulate from the side of the uterus is the absence of recent acute inflammatory affections. The general and good rule should be, first modify the inflammatory process, then reposit, and lastly retain the organ. Diseases of the mucous membrane of the cervix should always first be treated, for they are intensified by the use of pessaries, papillary excrescences and erosions readily forming; still we are frequently obliged to insert a pessary in order to modify the disturbances in nutrition, which result from alterations in the circulation which are due to the flexion.
The uterus furthermore should not be too heavy; disturbances of nutri tion, new growths, especially fibromata in its walls, often render the organ so heavy that the pessary cannot afford the necessary support to hold it in proper position. In case of many displacements, it is further essential that the uterine tissue should be rather dense, or else the fundus will flex over the instrument.
Inflammatory affections of the uterine adneva contra-indicate the use of pessaries; as also many tumors of the organ, which limit its movability. Very often, in case of retroversion, it is the enlarged, sensitive ovaries, lying in Douglas's fossa, which render it impossible to adjust a pessary.
Pregnancy of itself does not contra-indicate the use of a pessary; on the contrary, one is often inserted in order to render conception possible, to prevent miscarriage, to relieve excessive nausea or other symptoms, apparently dependent on the displacement. We must always take into account, however, the rapid increase in size. of the organ, and the result ing insufficiency of the pessary, wherefore it must be frequently changed. Generally pessaries are only used in the early months of pregnancy; as soon as the organ has risen above the brim, the pessary has no further effect on it, and it is then used, if at all, on account of displacement of the vagina.
It goes without saying, that the pessary should not interfere with the function of the genital apparatus, and the neighboring organs; there are displacements, however, which cause such severe symptoms that to re lieve them we may feel called upon to interfere with one or another less essential function.
The more complicated the apparatus used, the more likely it is that complications will result, and we should ever, therefore, aim at using simple instruments.
In many instances, and happily they are not rare, the orthopedic treatment gives immediate, often brilliant results; and in many others still the treatment is tedious, requires time and rest on the part of the patient, frequently indeed it eventuates in causing diseases, and this is reason enough, before beginning treatment, for estimating carefully the individuality of the patient, and perhaps then determining not to resort to it.
The choice of a faulty instrument, neglect of the necessary rules, may result in great disadvantage to the patient, even in serious symptoms. The most frequent result of the insertion of a faulty pessary is, as has been stated, pain; then interference with the function of the bladder and the rectum; next, as the result of irritation of the vaginal mucous mem brane, there is increased discharge, at the outset watery, and then puru lent, bloody, of unpleasant odor; finally, erosion or ulceration of the mucous membrane. The discharge roughens the pessary, and it becomes covered with concretions; on the eroded surfaces granulations form, which spread over the instrument and fix it, or else the vagina is perforated and eventually the bladder or the rectum.