There are in addition other pessaries, the stem of which does not sub serve the purpose of maintaining the pessary in place, but which obtain . their support by transverse distension of the vagina. Breslau has de scribed an apparatus of this nature which was devised at the beginning of this century, and Kilian's elythromochlion was based upon the same principle, consisting of a II-shaped steel spring, which in expanding dis tended the vagina transversely. About thirty years ago Zwanck devised a hysterophore, which has been extensively used as modified by Schilling and by Eulonburg, and which is known as the Zwanok-Schilling pessary (Fig. 103). This instrument consists of two perforated, crescentic or 111c: 61, horn, or rubber, which are connected by a hinge joint so as to close together. These wings are opened and shut by means of a screw stem. After reposition of the uterus these pessaries are in serted into the vagina closed, and the wings are then separated by turn ing the screw until the distension of the vaginal walls is sufficient to maintain the instrument in position.
These wing-shaped hysterophores have been recommended by the most distinguished gynecologists, such as Mayer, Mikschik, Franqu6 and others, and they are still used by physicians who do not possess the skill requisite for the adaptation of a proper pessary. They are all open to objections, however, for owing to the complexity of their construction, it is difficult to keep them clean; they irritate the vaginal walls and the cervix more than all other instruments; they readily slip from position, and the wings by pressure on the vaginal walls often lead to inflammatory processes, to gangrene, and even to perforation (Beigel, Heftier, Churton, Hope, Buchanan, Hegar and Kaltenbach, Galabin, Habit, Pagenstecher and others). I have repeatedly removed these winged pessaries, where deep abrasions had been made in the vagina, and I have observed a case where the wings of the instrument had perforated the vagina and the rectum totally, and the fEeces were passed through the opening in the wing which lay in the vagina.
The internal pessaries take purchase from the vagina and the cervix. They are, in general, far better and less likely to cause irritation than the vagino-abdominal, and should always be used in preference whenever there is sufficient support to allow it. Even when the vagina is distended and relaxed, and the curve of the canal and the resistance of the pelvic floor is lost, and there exists an extreme degree of prolapse of the vagina with cystocele and rectocele, it is not always essential to use a vagino abdominal pessary, but the purely internal may still be retained in the vagina by applying a T-bandage with a perinea' cushion, which presses the introitus vaginae from behind forwards, and re-enforces partially the pelvic floor.
The older internal pessaries were disc-like, cylindrical, round, oval, pear shaped, and were either solid or perforated. Such instruments were devised by A. Par(', Hildanus, Meister, Roonhuysen, Bruninghausen, Mauriceau, Chapman, Warrington, Levret and others, but they have been forgotten, even as have also the great majority of more recently devised instruments. To-day in the correct endeavor to use simple instruments, we resort only to a few somewhat similar in construction, and of these we will here speak.
Simple, closed or open, round or oval pessaries (the latter readily slip out), have, been devised by C. Mayer, Martin, IIegar and Kaltenbach, C. and G. Braun, and others, and are recommended in particular in cases of prolapse of the uterus and the vagina. These rings have either a central or an eccentric opening (pessaire d contraversion, Martin), which is in tended for the feception of the cervix. In this category belongs the flat, cradle-shaped pessary of Fritsch (" querriegel ").
The rings constructed of linen filled with hair and covered with rubber, still to be found in the shops, are to be rejected. They quickly become rough and irritate the mucous membrane, and furthermore the central opening is in general too small. Those made of box-wood, horn, tin, copper or silver-plated, are preferable. Aluminium is without ques• tion the best material for pessaries, although partially on account of its price, and partially owing to the difficulty of working it (and this is being lessened daily), hard rubber is the most frequently used material. It can be shaped readily, scarcely alters at all, is not attacked by the vaginal secretions, and may be polished smoothly. Rubber rings, if thick, are, however, heavy, and it is preferable to have them made hollow, as C. Braun has recommended, and then they are light enough to float in water. Furthermore their volume may then be increased, a point on which suffi cient stress cannot be laid, since with the thickness of the instrument there is greater contact with the vaginal walls, and, therefore, there is less likelihood of their slipping out, or their cutting into the mucous membrane. The surface of these rings should be carefully inspected to see if the polish is thorough, for during the process of hardening of the ring a small opening may have formed, which has been only superficially closed. If such a ring bo placed in the vagina, the polish wears off, secretion enters the opening into the cavity of the pessary, where it stag nates, smells foul, and irritates the vaginal mucous membrane.