When such measures are insufficient to relieve the pain and weakness in the back and pelvis, or when the relief is only temporary and symptoms return with, or soon after, the cessation of treatment, the effect of re placing the uterus and keeping it in position with a pessary should be tried. .1 lmost everyone is familiar with Schultze's method of reposition, which consists in first raising the fundus from the hollow of the sacrum by means of two fingers introduced into the vagina. The fingers of the other hand then grasp the fundus through the abdominal wall, while the vaginal are placed in front of the cervix and press it backwards so that the uterus is brought into a position of anteversion. This manoeuvre is more easy to describe than to carry •out. It is facilitated by a preliminary course of tampons and douches, by placing the patient for the manipulation in the lateral position, with her hips elevated on a pillow, and sometimes by introducing one finger into the vagina, and the second finger into the rectum. It is by no means easy to get the uterus to stay anteverted even when the method has succeeded.
When the uterus has been replaced, and sometimes as a means of effecting replacement when that cannot be accomplished satisfactorily by the manual method, a pessary is inserted. In some cases the wearing of this instrument for some months enables the round ligaments to regain their tone, and is followed by restoration of the normal position of the uterus for a longer or shorter period after removal of the pessary. Such a happy result is not to be generally expected, and the restoration to the normal cannot he expected to be permanent when retroversion is combined with descent of the uterus, the usual condition in parous women. But even though we do not look for a radical cure, the measure undoubtedly relieves symptoms in very many eases, and should be tried as an adjunct or a sequel to the local therapy already described, when the relief afforded has been merely temporary, and when operative measures are inadvisable or are refused. A pessary should not be used when active inflammation of the uterus or adnexa is present, when there is a pyosalpinx or pelvic abscess, or where there is an enlarged tender prolapsed ovary.
The most commonly used pessary for retroversion is a Smith-1 lodge, which theoretically puts the vagina on the stretch longitudinally, and so carries the cervix backwards. The finger should be introduced into the posterior fornix after the uterus has been replaced, if possible, and the length of the vagina to a point just behind the urethral orifice measured. This gives the approximate size of the pessary which should be used. During its introduction, the forefinger of the left hand should hook the perineum backwards, and the pessary should be held obliquely, pressure being made with one side of it downwards against the right of the perineum, while the other side slips in to the left of the urethral orifice. When it
has been introduced, the posterior bar is carried by the forefinger snugly behind the cervix, while the anterior bar rests on the perineum. It is more satisfactory to make the wider end anterior. If the pessary, when introduced, causes undue stretching of the vagina, or if discomfort or actual pain is complained of, it should be removed and a smaller instru ment inserted. Any patient who is wearing a pessary should be directed to douche the vagina at least twice a week with two quarts of warm water, to which two teaspoonfuls of a mixture of soda bicarb. and boric acid (equal parts) have been added. She should have the pessary removed for a week every three months, and she should be instructed to return for examination at any time if pain, excessive leucorrhcea or abnormal hmmorrhage arises. A round rubber ring is sometimes used for retro version, especially if associated withyrolapse. It is usually recommended that this should be of vulcanite or hard rubber for the sake of cleanliness. If the precautions detailed above are insisted on, a " watch-spring " soft rubber ring may be used with safety, or a " combination fluid pessary," which consists of a ring covered with a soft rubber cushion filled with glycerin. These pessaries often give relief in cases of irreducible retro version. Ring pessaries are best introduced by depressing the perineum and rolling the ring in over it in an oblique position as described for a Smith-Hodge. It is scarcely necessary to say that the pessary, after pass ing the vulva] entrance, lies in a transverse plane in the vagina.
Operative Treatment.—Operation should be resorted to when local therapy and pessaries fail, when the patient objects to the wearing of a pessary, or persistently neglects the hygienic precautions necessary while wearing one; when the case is complicated by the presence of erosion, ectropion or such a degree of perinea] laceration that a pessary cannot be retained, or by enlarged, tender and prolapsed ovaries, pyosalpinx, pelvic abscess or adhesions binding down the fundus. It should not be under taken solely for the restoration of the normal position of the uterus, but only for the relief of symptoms which have withstood a thorough trial of measures directed to the cure of the complications mentioned, and the appropriate operative treatment of these complications should form a part of the operation undertaken.