Latterly Breisky has advocated in case of chronic prolapse the egg shaped pessary, and has had them constructed of hard rubber in various sizes, and when they are well borne they prove very efficient. To re move these pessaries Breisky used metal or wire forceps, shaped like ob stetrical.
After the ring pessaries the Hodge lever is recommended and used by Schrijder, Scanzoni, Spiegelberg, C. and G. Braun, Winckel, Hueter, Coghill, Gervis, Hermann, Cocks, Trenholme and others. These pessaries are either slightly S-shaped or cradle-shaped; they are either closed or else open in front, although the latter are not to be commended, since the open extremities very readily may perforate the anterior vaginal wall. When these instruments were devised sixty years ago, they were wrongly supposed to act on a lever principle, and were called' lever pessaries.
Hueter, Martin and others, have dispelled this illusion, and have called them lifting pessaries. The action of these pessaries, even as with the rings, depends on the stretching of the vaginal walls antero-posteriorly, whereby the cervix is slightly fixed in the median line; they also work secondarily in that they prevent the body of the uterus from falling back wards or forwards. In a measure then these pessaries have a lever action, although they do not act as such, but the uterus forms the lever with fixed point as the insertion of the vaginal walls.
The simple Hodge is useful in case of version and flexion of the uterus, less frequently in case of prolapse. They are good retention instruments, but they only lessen the pathological condition; they do not, however, cause the uterus to maintain a normal position.
These pessaries are constructed of horn, wood, zinc, aluminium, lead with a covering of celluloid, or, and most frequently, of hard rubber. Pessaries of this material may be softened in hot water or over an alcohol lamp, so that the requisite shape may be given them, but we must be careful not to crack the instrument, and to hold it in the desired shape until it has cooled.
The selection and the fitting of these pessaries, as regards length, breadth, curvature of one or another extremity, require generally great patience on the part of the physician and the patient, since frequently very slight changes are necessary in order to adapt the instrument per fectly. In order to attain our aim, we may not only use malleable pessaries, to obtain a model, but also resort for permanent use to pessaries, such as have been devised by Sims, Halbertsma, Schultze, Prochowuik and others. Sims shaped pessaries from block tin, Halbertsma and Schultze from copper wire covered with rubber or gutta-percha. The
gutta-percha covering is without comparison inferior to the rubber, since after a while it breaks off. The solid metal pessaries are too heavy, and the English hollow tin rings are preferable. In case the genitals are very sensitive, the pessaries which are elastic are to be commended.
In case of anteversion this pessary is inserted so that the broad end lies in front and is directed upwards, the narrower end lying behind and being directed downwards. The pessary lies as nearly as possible on a level, but it does not maintain this position. It sinks to one or another side, but still stretches the vagina properly and fixes the cervix. If, in addition to the anteversion, there is lateral displacement or curvature, then the pessary is curved a little more on the et,rresponding side, and the uterus is thus supported a trifle.
In case of retroversion, where generally there is coincident relaxation of the pelvic floor, the pessary is inserted so that the greater curvature lies posteriorly, and the point presses on the floor of the pelvis.
This instrument is introduced in a similar manner to the ring. It is inserted in the vertical diameter of the introitus vagina?, and the proper bar is carried by the finger behind the cervix, so that the organ occupies the lumen of the instrument.
Of the great number of instruments constructed on the principle of the Hodge, there are only a fe'w which may be used to advantage in special varieties of uterine displacements. Graily Hewitt has devised a number of pessaries, which sufficiently maintain the uterus in position when the vagina is much relaxed, the introitus is very wide, and there exists coincident displacement of the anterior vaginal wall. All the earlier pessaries, the rings as well as the Hodge, are displaced by the downward sagging of the anterior wall of the vagina. The anterior part of the instruments is pressed downwards, sinks forward and out of the vagina. In these cases the cradle pessary of Graily Hewitt answers well. It consists essentially of two oval rings, which are curved slightly on the flat, and are united together at about a right angle; afterwards Graily Hewitt inserted a cross-piece at the junction of the branches of the pessary. One of these rings is intended to receive the cervix, and the other rests against the anterior vaginal wall, the pessary being so inserted that its open angle looks backwards and downwards. The more relaxed the parts the larger and wider must the anterior portion of the pessary be. This form of pessary may also be used in case of retroversion, since it takes greater purchase in the vagina than the previously described forms.