The insertion of these pessaries is more difficult than that of the others. Veuillet inserted his instrument with the patient in the knee chest position, by means of a long dressing-forceps, and instead of this the instrument devised by Sims for grasping pessaries may be used. In case the introitus vaginae is wide, then, after reposition of the uterus, the pessary is inserted by the hand, so that first one side of the curved por tion, then the anterior part, and then the other side is placed iu the vagina, and lastly the pessary is adjusted so that the greater curve is behind, and the lesser in front of the cervix. It is more painful to the patient when the posterior is inserted first, and it tends always to glide into the anterior fornix, and when we endeavor to prevent this by hook ing a finger on this border, and placing it behind the cervix, then the anterior extremity catches at the symphysis, and must be depressed by the thumb.
Before the removal of any pessary, the vagina should be irrigated with some disinfecting fluid. All pessaries with an opening receive the cervix within this, and straight traction, in the axis of the vagina, exerted on the pessary, necessarily causes great dislocation of the cervix. The pessary hence must be drawn down until it is released, or else it may be removed sideways. To remove the Hodge pessary, the finger is hooked from below upwards on the anterior bar, and traction is made upon it in about a right angle; then it is removed vertically from the vagina. Where the pessary is thick, in particular with the ring pessaries, it may be difficult to hook the finger in, since there is not sufficient space be tween the instrument and the cervix. Then the instrument must either be pushed down with the finger, or else it may be pulled down by a broad, smooth hook. When the ring has been detached from the cervix, it is
turned in the vertical diameter and rolled out of the vagina. The same remarks apply to the removal of the complicated instruments, only we must bear in mind the shape of the instrument, but this we cannot know unless we have ourselves inserted the pessary.
When the pessary has been removed, then by the touch and through the speculum, we search carefully for erosions and ulcerations, and where necessary institute the therapeutic measures we have already laid stress upon. As for the position of the uterus we must remember that the organ often maintains for hours or days the one in which it was held by the pessary.
It is difficult and may be dangerous to remove a pessary which has grown into the vagina, and is surrounded by granulations and organized bands which have sprouted through its lumen. Narrowing or adhesive union of the vagina below the pessary also renders removal of the instru ment a difficult matter. Divulsion of the stenosis or cutting of the ad hesions often lead to profuse hemorrhage, and there is danger of septic infection at the site of these fresh wounds, through the vaginal secretions.
In case we are obliged to resort to such measures, then most careful dis infection is a pre-requisite. Where possible it is preferable to break up the pessary in the vagina and to remove it piecemeal. For this purpose the instrument is pulled down strongly and the lower border is cut through with wire scissors, chain-saw, or other instrument. The pessary is then turned around a half-circle and cut at the opposed portion. The halves of the instrument are then readily extracted from the vagina with the finger or the forceps.