Simple pessaries constructed from hard, non-absorbent, smoothly pol ished substances, such as hard rubber, silver, aluminium, tin, porcelain, glass, celluloid, etc., may remain longer in the vagina than those with uneven surface and of porous material. Pessaries made from vulcanized rubber and from soft rubber alter very quickly.
A change in the instrument will, however, be necessary, since both the pessary and the vaginal walls may alter their dimensions. We are most frequently obliged quickly to change the larger instruments, since the vagina, as the result of continuous pressure, becomes larger and more relaxed. Changes in the uterus also necessitate the use of a different in strument. In particular at the time of menstruation are the conditions so altered that the pessary must be removed. Menstruation itself is no indication for the removal of the instrument, but only when associated with symptoms which can be laid to the score of the pessary.
Where it is possible it is preferable to give the genitals a few days rest before the re-insertion of the same or of a new instrument. In case profuse discharge, abrasions, or irritability of the mucous membrane is present, this must first be allayed. Attention should be directed to the regular evacuation of the rectum and of the bladder. The greater the collection of Neal masses in the intestine the greater the liability of change in the position of the instrument and of the occurrence of painful pressure on the uterus.
Pessaries are divided into two classes, those which are purely internal vaginal, and those which are held in place by some external attachment.
The first vagino-abdominal pessary was devised by Roonhuysen in 1663, and since many forms have been invented by Stratilin, Camper, Seidele, Stein, Zingerle, Kniphof, Zeller, Hunold, Schmidt, Villerme, Romero y Linares, Saviard, Recamier, Clay, Mayor and many others. The majority of these were in principle so devised as to be retained in the vagina by ono or many bands passing between the thighs and then at tached to an abdominal binder. They were round, pear-shaped, or disk like, attached to a blade which diverged into two or more. All these pessaries, which were in general use in case of prolapse of the uterus and the vagina, havoihe disadvantage that not only the vagina, but also the introitus is irritated by the stem of the pessary, and that the free dom of motion of the patient is interfered with. Coitus is practically
interfered with, and in assuming the sitting posture the uterus and the vagina may be dislocated or injured.
Many of these vagino-abdominal pessaries, like those of Mouremans, Clay, Mayer, Kiwisch, Reser and Sf;anzoni, Breslau, Lazarewitsch, Sey fert, Babcock and others, are more or less firmly attached to a pelvic girdle. These pessaries are only of utility when the vagina is widely dis tended and relaxed, so that au internal instrument can find no support in the vagina. The Roser-Scanzoni apparatus consists of a pear-shaped body, the width of the vagina, which is connected by means of a U-shaped metal blade with a pad which is fixed above the symphysis by a pelvic girdle. The uterus is replaced, the pear-shaped body is inserted into the vagina and the metal blade is next connected with the pad, by means of a piece of rubber tubing.
In case of greater relaxation of the vagina with prolapse of the pos terior vaginal wall, Scanzoni devised a second apparatus, consisting of a cylindrical pessary attached to a simple pelvic girdle (Fig. 102).
The rounded pessary, constructed of wood, horn or rubber, is about an inch thick, and its stem about two and three-quarter inches long, and it is fitted in a ball-and-socket joint. This joint is attached to a band which passes between the thighs of the patient, and is connected in front and behind to a pelvic girdle. To insert the pessary, one end of the band is loosened from the girdle, the ball is placed in the vagina in its socket, and the band is re-attached. With this apparatus, and all the more so with the others, it is essential to test a number, and to change the length of the stem until the pessary fits accurately.
Many patients complain of the pressure of the band in the anal fold, and this may be obviated by dividing it into two diverging portions, which are attached to the sides of the pelvic girdle. To a similar appara tus round pessaries may also be affixed, and in order to ensure movability on the part of the pessary, the end of the stem where it projects from the vagina, may be converted into a ball-and-socket joint, which lies against a simple T-bandage, to guard against the instrument falling out.