A large number of cases of perforation of the rectum, bladder, or both, have been collected by Busch and Franqu6, and also by Schuh, Murton, Hope, Heftier, Buchanan and others. Ltiders has recorded an instance of perforation in Douglas's fossa. There are also numerous instances recorded of constriction of the cervix or a portion of the vaginal mucous membrane, as the result of swelling of the parts in the lumen of the instrument. Verneuil witnessed myelitis follow on the wearing of a pessary; Hegar and Kaltenbach noted an instance of development of car cinoma at the site where the instrument pressed. I have latterly myself seen carcinoma develop rapidly from the granulations which had sprouted over an imbedded pessary.
Much more frequently than the above sequel* do we find instances where the pessary has only partially eroded the vaginal wall, and where granulations and cicatricial bands have grown over the instrument, mak ing its removal very difficult, and necessitating its rupture. Instances of this nature are also recorded by Busch and Franque, and latterly Burrow, Rokitansky and others, have reported similar ones. We must then incise the cicatricial bands or scrape away the granulations which surround the instrument, or else we must break the latter, as will be mentioned further on. In case a pessary is left in situ for years, physiological changes occur in the genitals, which greatly interfere with the removal of the in strument. This happens most frequently in women who have passed the climacteric, in whom the genitals have atrophied, or in whom the vagina has become narrowed from adhesive union between the walls.
When a pessary has been inserted, it should be carefully tested to as certain if it fits. The patient should be examined while bearing down, and then in the erect position, after she has walked around, lifted heavy objects, etc. Further, the position of the instrument should be tested when the bladder and the rectum are filled and when empty. Since, however, we can never be certain as to whether the pessary will answer or not, the patient should be given strict directions in regard to it. If the pessary be too small, it will slip out of position, and project, particu larly on bearing down at stool. If the instrument be too large it ordi narily soon causes pain, discharge, and interferes with the emptying of the bladder and rectum. The patient must be directed to remove the
instrument in case it causes symptoms, or, if it only projects on effort, she should be told to push it in place. The patient should always be in formed of the fact that a pessary has been inserted. The majority of women can themselves remove without difficulty a simple pessary; they should be informed to bear downwards in the squatting posture, to hook the finger in the instrument and to pull it downwards and backwards. The removal of complicated pessaries requires more skill than the patients possess, and they must be directed to report to the physician.
In case the genitals or their surroundings are sensitive, the patients should remain quiet for awhile, possibly in bed. We are often obliged to increase the tolerance of the vagina by the insertion of tannin and glycerine tampons or of small, soft, elastic pessaries, such as the rings, and thus also to test the sensibility. Indeed the preliminary tamponade of the vagina, which procedure many authorities, Bell for instance, prefer to pessaries, is advantageous, in particular in cases where reposition of the uterus is difficult. At the outset of the treatment patients should be cautioned against hard work, but later they may resume their accustomed habits of life.
A properly fitted pessary should cause the patient no symptoms, and she should be able while wearing it to ride, jump, dance, etc., without the instrument being specially disturbed; indeed instead of causing symp toms the pessary should directly relieve, for the insertion of the instru ment frequently is purely symptomatic.
Since, as we have stated, every pessary is more or less of an irritant, and becomes encrusted or at least roughened, it is absolutely essential that cleansing vaginal douches should be administered. Water with the addition of permanganate of potass, carbolic, thymol, etc., may be used. For similar reasons even the most accurately adjusted instrument must be removed and cleansed from time to time. As to the proper intervals for removal no definite statement can be made. Godson saw a case where a pessary had been worn continuously for twenty-six years without damage; it is not, however. by any moans advisable to remove the in strument daily, since thus we irritate the genital canal. An exception to this statement is made in case of the intrauterine stem.