For retroversion Graily Hewitt has also devised pessaries, the posterior bar of which is thickened, but they are in every respect inferior to the Schultze instrument, which will shortly be described.
In order to prevent rotation of the pessary in the vagina, the same gentleman has adapted to the Hodge instrument, at the anterior ex tremity, a solid tongue-like process which in part projects from the vagina. In addition to these pessaries, a number of variously con structed instruments have been devised by Scattergood, Galabin, Kinloch, Chamberlain and many others.
The pessary devised by Graily Hewitt for retroversion has the ad vantage of filling the posterior and thereby preventing back ward sinking of the body of the uterus. It, however, is only available for lessening the displacement of the uterus. In order to cause complete rectification of the displacement and to overcome the action of the intra abdominal pressure, Schultze, in 1872, devised two varieties of pessaries, which answer well the purpose of correcting the rotro-displacement, and further fulfill the aim of an extra-uterine apparatus, that is to say, the cervix is fixed backward in the pelvis so that the body of the uterus cannot sink below it, and yet the vagina is not distended overmuch in the trans verse direction. The first of his pessaries is a figure of eight in shape, and is constructed of copper wire covered with rubber. One of the circulars is for the reception of the cervix, and is shaped according to the size of the organ; the other, the larger, takes purchase on the pelvic floor, or indirectly on the pubes. The curve of the circulars must be carefully adapted to the uterus and the vagina, and the pessary ordinarily has an S-curvature. The anterior part of the eight may also be bent into a sling, which hangs from the vulva, and gives the patient an excellent means of removal and for insertion of the instrument. Since in case of tense, narrow vagina, it is essential that the cervix be fixed, and the deep projection of the anterior circular carries with it so many disadvantages, that I use by preference Schultze's second form of pessary more frequently.
The second form (the sleigh pessary) is curved as in Fig. 110. The larger, broader end lies in the posterior cu/-de-Rar, the anterior sharply curved extremity presses against the cervix, and fixes it backwards. The curved bars of the pessary press forward on the rami of the pubes. Schultze recommends this instrument above the former in cases where the vagina is relaxed and the cervix is short, since the organ would readily slip out of the first form. The second takes better purchase in the vagina, and holds up to better advantage the prolapsed vaginal walls. In cases of descent of the retroverted uterus, these pessaries retain the organ very well; where there is sagging of the vaginal walls, the instru ment must be made broader (as in b) . If we take care to select a suit able instrument of this type, then it is generally worn without trouble, intercourse is not interfered with, as it is when the figure of eight pessary is inserted, and the displacement of the uterus is unquestionably better rectified than by any of the previously described instruments.
The idea of maintaining the cervix in retroposition is fulfilled also, by Veuillet's instrument, devised in 1871, the anterior part of which is curved to correspond to the convexity of the anterior uterine wall. In 1869 I used a similar instrument in case of retroversion (Fig. 112.) In all these instruments we must not only see that the curved portion has the proper dimensions, but that the distance between the larger and lesser curvature is considerably greater than the thickness of the uterus.
Ths uterine wall does not press upon the anterior border of the curved portion, but rather on the side bars which enter into its formation. In case the curvature of the pessary is too great, and the space between the two curvatures too small, then the cervix is compressed, the circulation is interfered with, the os gapes, there results eversion, and the anterior uterine wall is indented to a greater or less degree where the anterior border of the curved portion rested.