Tampons are made either of cotton or wool. The cotton may be in the form of gauze or absorbent cotton though sometimes ordinary cotton may be used. Cotton is less suited for supporting purposes than is wool. When it becomes saturated with the secretions it collapses. This is less true of gauze and ordinary cotton than it is of absorbent cotton. Wool absorbs secretions less readily, possesses a certain degree of elasticity and does not collapse to the extent that cotton does. It sometimes proves irritating to the vaginal mucous membrane and it may be necessary to cover it with cotton.

Tampons are usually made by taking a piece of the desired material, folding it to the proper size and looping a string about its middle, at which place the tampon is folded. If it is desired that the patient remove the tampon herself, the string should be left long enough to reach outside the vulva. When tampons are made of gauze, one or more strips may be used the length and width of each strip suited to the purpose intended. These strips of gauze are packed into the vagina with a dressing forceps with the aid of a bi-valve or a Sim's speculum.

The medicaments used are usually of an antiseptic, a counterirritant, a hygroscopic or an astringent nature. Almost numberless substances have been used for these purposes though boracic acid, tannic acid, iodine, alum and iron in some form have been most popular. Glycerine, in some form or combination, has been used for its hygroscopic action. It is believed that glycerine compounds deplete the tissues by abstracting moisture from them, and in this way, relieve congestion and inflammation.

If a solution is being applied applied the tampon is saturated with it, the excess of fluid pressed out, and with the aid of a speculum and forceps, the tampon is introduced and placed at the desired spot. If a powder is used a "nest" is made for it in the tampon and it is then introduced. One or a number of tampons may be used.

It must be remembered that many chemicals may be absorbed when introduced into the vagina and systemic symptoms produced. Fatal poisoning has occurred in this way.

Tampons that are used to support the tissues can not be introduced in a haphazard manner but must be carefully placed with a definite idea in mind as to what is to be accomplished. They are to form a support upon which the uterus rests and by pressure to also support the walls of the distended blood vessels. They sometimes give great relief. Such tampons may be used in a dry state or with some of the compounds before mentioned upon them. They are best inserted in the Sim's, (Fig. 35), or the knee-chest posture.

Tampons, as a rule, should not remain in place longer than twenty-four hours. Their removal should be followed by a copious douche of hot water.

Tampons are generally more useful in acute than in chronic conditions.

A pessary is to the displaced uterus merely a crutch, an artificial support to be discarded as soon as the natural ones can function. Should the various agencies supporting the uterus fail to resume their functions, then the pessary must be retained until something better can be provided. Pessaries do not correct displacements and the use of a pessary is rarely advisable until replacement has been accomplished.

In recent years the trend toward surgery has been so great, surgeons have become so skillful and daring that many cases formerly treated by the use of pessaries are now referred to the surgeon, consequently the use of pessaries is less common than it once was. The fact remains however that many patients can be relieved or cured of displacements by proper intra-pelvic technic supplemented, when necessary, by the use of pessaries. Besides there are many cases in which the hazard of surgery is either out of proportion to its possible benefits or is contraindicated altogether.

Pessaries remain most useful devices in the treatment of many common displacements and to discard their use is to limit one's ability to properly care for many troublesome conditions. A study of their application will amply repay anyone.

Pessaries are usually made of hard or soft rubber, occasionally of metal, glass or some other material. Besides the purpose of supporting the uterus and the vaginal walls they are sometimes used to straighten or dilate the cervical canal. They are arbitrarily divided according to form into (1) ring pessaries, (2) modified ring pessaries, (3) ball pessaries, (4) cup pessaries, (5) stem pessaries, (6) belt supported pessaries. (Figs. 47, 67.)

The ring pessaries need no special description. They may be made of hard rubber, or of a spiral spring covered with rubber, or a copper ring covered with rubber or of soft rubber and inflated with air. The inflated ring is perhaps most frequently used.

The modified ring pessaries are rings so modified as to be somewhat quadrilateral in form, having two lateral and an anterior and a posterior bar with the angles rounded. They have a slight S curve from behind forward, the posterior end looking uppward, the anterior end downward. This curve is to conform to the curve of the vagina and is to prevent the pessary slipping out too readily. Of this form the most frequently used are the Hodge, (Fig 47), the Smith, (Fig. 48), the Thomas, (Mg. 49), and the Gehrung pessary, (Fig. 51).

The ball and the cup pessaries are not frequently used. (Figs. 57, 58.)

Stem pessaries are so called because they are provided with a stem which projects into, and sometimes through, the cervical canal. (Figs. 59-66.)

Belt supported pessaries are fastened to a belt which fits around the waist. From it rubber bands pass beneath the thighs and they in turn support hard rubber stems of various designs. These rubber stems pass into the vagina and are fitted at their upper ends with a cup, or a ring, to receive the cervix. (Fig. 67.)

Fig. 47. Hodge Pessary.

Fig. 48. Smith Pessary.

Fig. 49. Thomas Pessary.

Fig. 50. Thomas-Hodge Pessary.

Fig. 51. Gehrung Pessary.

Fig. 52. Byford-Smith.

Fig. 53. Inflated Rubber Ring Pessary.

Fig. 54. Rubber Covered Spring Wire Pessary.

Fig. 55. "Anatomical" Pessary.

Fig. 56. Menge or Vienna Pessary.

Fig. 57. Glass Ball Pessary.

Fig. 58. Aluminum Cup Pessary.

Fig. 59. Aluminum Stem Pessary.

Fig. 60. Hard Rubber Stem Pessary.

Fig. 61. Glass Stem Pessary.

Fig. 62. Ferguson's Draining Pessary.

Fig. 63. Chamber's Stem Pessary.

Fig. 64. Soft Rubber Stem Pessary.

Fig. 65. Gold Stem Pessary. Closed with gelatine capsule for introduction and opened after introduction.

Introducer for Soft Rubber Stem Pessary.

Fig. 66. Wire Stem Pessary.

Fig 67. Belt Pessary.

Pessaries support the tissues either directly or indirectly. In their turn they are supported by the pubic arch, the muscles and fasciae about the vaginal entrance, the vaginal walls and the pelvic floor. The pelvic floor when normal, through the medium of the intervening tissues, keeps the pessary held snugly against the pubic arch. Indirect support is by the so-called "lever action" in which the cervix is held backward and upward in the hollow of the sacrum (Fig. 68.) As before mentioned the uterus as a whole has a certain amount of normal rigidity because of which any elevation of the cervix tends to depress the fundus and vice versa. Thus, it the cervix be held upward and backward, the fundus must be downward and forward, unless the normal tissue rigidity has been overcome, as in cases of flexion. To maintain the cervix upward and backward is the purpose of the lever pessary. The posterior end of the pessary fits snugly into the posterior vaginal fornix, tensing the tissues here at their attachment to the cervix. The anterior end of the pessary gets its support primarily from the pubic arch and the pelvic floor. Unless the pelvic floor has been destroyed the vagina is more capacious within than at its opening. The narrow vaginal entrance aids in preventing the pessary from slipping out after it has been introduced.

Some direct support is exercised by every pessary but particularly is this so of the ring, the ball, and the belt pessaries in prolapsus.

Fig. 68. Lever Action Pessary.

It should always be remembered that pessaries must be "fitted" in the strictest meaning of that term. It is an easy matter to place a pessary in the vagina but unless it is properly fitted to the case it is either a useless contrivance, or on the other hand, may be the cause of irreparable harm. A pessary that is too small affords no support and is useless. One that is too large may by pressure cause inflammation, ulceration or perforation of the vaginal walls. A pessary should be so fitted and adjusted as to support the uterus in its normal position, to preserve its normal mobility and to restore to it, and not hinder, its normal circulation. To add to the difficulty of properly fitting a pessary is the fact that the contents of no two pelves are exactly alike. Vaginae differ in dimensions, in depth, in breadth, in capaciousness, in tonicity or relaxation of their walls. Uteri differ in size, in weight, in relation to the vagina and in their degree of displacement. The failure to properly appreciate these facts accounts for many of the unsatisfactory results in the use of pessaries. The correct fitting of a pessary is an operation that requires mechanical skill and a thorough knowledge of the contents of the pelvis and their possible variations. Especially is this true when a hard rubber "lever action" pessary is being used. It is nearly always necessary to reshape these instruments to fit the particular case.

Reshaping may be done by placing the pessary in hot water or by heating it over the flame of a spirit, or gas, lamp until it becomes pliable. It can now be reshaped by holding it with a towel and either lengthening, shortening, widening, narrowing or changing its curves as the indications may require. When the desired shape is secured the pessary is plunged into cold water which causes the new form to become permanent.

Pessaries may be used in practically all displacements, but are particularly useful in retro-displacements and in prolapsus, not only of the uterus, but of the vaginal walls as well. In retroversion, during pregnancy and the puerperium, they are of distinct value. A retroverted uterus is prone to abortion and even though this does not occur, nausea and vomiting are more common when pregnancy occurs in such a uterus. In prolapse, pessaries are sometimes invaluable. In many cases it is a matter of choice between the use of a pessary and an operation. Operations are at times positively contra-indicated. I recall the case of a hemophiliac who refused to have a perineal laceration repaired but was restored to a condition of usefulness and comfort by the use of an inflated ring pessary. Also in cases of pregnancy with prolapsus they are of great usefulness.

Stem pessaries are sometimes successfully used in anteflexion, to straighten the cervical canal, and to relieve the accompanying dysmenorrhoea and sterility.

Elderly women in whom operations are extremely hazardous often secure great relief from the use of pessaries. In these, especial care must be taken to keep the instrument clean and to prevent incrustations upon it, because of the proneness of the thin vaginal walls of the aged to inflammation.

In complete prolapsus the belt pessary with supporting cords may be necessary. The vaginal walls themselves are thick and prolapsed; the pelvic outlet is relaxed, or destroyed, by a laceration and there is no support for any other form of pessary.

A pessary should be rendered surgically clean by scouring with soap and water, as a preparation for its introduction. It is then placed in an antiseptic solution and immediately preceding its introduction is well covered with a suitable lubricant.

In introducing the usual form of the modified ring pessary, that is those with a diameter longer antero-posteriorly than transversely, hold the anterior bar of the pessary with the thumb and index finger of the right hand and visualize its position and action when it is properly adjusted. Depress the perineum with the index finger of the left hand and introduce the posterior end of the pessary with its transverse diameter approximately in the direction of the vulval cleft, the bar of the pessary which is uppermost being kept to one side of the urethra to avoid painful pressure. After being introduced about half way the pessary is turned so that its transverse diameter lies horizontally with its posterior end directed upward. It is now gently pushed backward until the posterior bar meets the resistance of the anterior surface of the cervix. The index finger of the right hand is now passed into the vagina beneath the pessary, the posterior bar is reached and disengaged from the front of the cervix and pushed behind it. The pessary is now in place and should be settled there by passing the index finger around it and gently lifting it upward and backward a few times. It should give neither pain nor discomfort when the patient gets upon her feet and walks about. In fact, if there is a consciousness of the presence of the pessary, it does not fit properly and it should be removed and either a smaller one, or one of another form, fitted.

A Hodge, a Thomas or a Smith pessary is most frequently used for retro-displacements. While these appear very similar they each present some peculiarities that adapt them to different cases. Of these the Thomas pessary is most generally useful. Its broad posterior bar affords a larger surface for pressure and lessens the liability to erosion or ulceration. Its small anterior end fits well up under the symphysis and offers no interference with douching or copulation. Its decided curves from before backward offer good points of support by the tissues of the vaginal walls.

The Hodge pessary with its wider anterior bar will sometimes give better support if the floor of the pelvis is badly damaged. The broad posterior end of the Thomas pessary is sometimes too large to fit into the posterior fornix of the vagina, especially when the latter is small or shallow. The Smith pessary may be better adapted to this condition.

For prolapsus some form of the ring pessary is usually used. This pessary is primarily for support and has none of the lever action which is so essential in maintaining the uterus in its normal anteverted position. It merely raises and supports the uterus and the attached tissues. It is one form of pessary that may be used, and which may give a great deal of comfort, without the correction of the displacement. It secures its support by pressure against the vaginal walls and whatever muscles and fascia there may be remaining in the pelvic floor and about the vaginal outlet.

The simple ring pessaries are the flexible ring (made of coiled wire covered with rubber), the copper wire covered with rubber, the hard rubber ring and the soft rubber inflated ring. The latter is perhaps the most useful of these, but because of its broad surface, especial care is necessary to keep it clean and free of incrustations. It should be removed and thoroughly cleansed at least every week or ten days. Besides this a daily douche is necessary. After being worn for some time they may become deflated. They may be reinflated by means of a hypodermic syringe, the needle being inserted through a thickened spot that is easily found.

Both the elastic ring and the inflated ring pessaries have the advantage that they can be introduced in a partially compressed state. They then expand within the vagina.

A11 of the ring pessaries have a tendency, after being worn for a short while, to shift their positions and turn edgewise to the vaginal entrance and to slip out. To prevent this a ring with a bar running crosswise its center from which a stem projects into the vagina, has been devised. This is called the Minge or Vienna pessary (Fig. 56.) The ring may be of hard rubber and the stem detachable, or the entire pessary may be made of soft rubber. The hard rubber ring is introduced as usual and the stem then secured in the opening provided for it.

The Hewitt pessary, is a tier of inflated soft rubber rings, the smallest at the upper end. It is large, heavy and fills the vagina completely. Its supporting surfaces are extensive and it has corresponding liability to irritate the vaginal walls and to collect and retain the secretions. It requires great care, frequent cleansing and prevents satisfactory douching.

Fig. 69.

Fig. 70.

Fig. 71.

Fig. 72.

Fig. 73.

Fig. 74.

Fig. 75. Gehrung Pessary in Position.

The Gehrung pessary, a ring first flattened and the ends of the oval then bent toward each other, is valuable in the treatment of prolapse of the uterus or of the anterior vaginal wall, cystocele. Notwithstanding its value the introduction of this pessary is somewhat difficult and complicated. First straddle the pessary over the index finger of the right hand, (Fig. 69), and then gently grasp the loop nearest you with the thumb and index finger, the palmar surface of the hand looking upward. (Fig. 70.) The hand with the pessary is turned toward the left until its dorsal surface looks upward and to your left. (Fig. 71.) The point of the loop opposite the one that is grasped (the free loop) is hooked into the vagina, the point of both loops being directed toward the patient's left, or your right. The loop held in the right hand, with a sort of screwing motion, gently pressing inward all the time, is brought downward to (Fig. 72), and then past the posterior median line and on upward toward the patient's right. (Mg. 73). As the point midway between the anterior and posterior median lines is passed, and the loop is pointing somewhat upward, it is slipped within the vagina and carried to the anterior median line. (Fig. 74.) This loop (and the pessary as a whole for that matter) has now described nearly three fourths of a circle and lies just within the vagina. It is now pushed backward until it passes the urethral opening, the opposite loop lying just anterior to the cervix, supporting the base of the bladder and perhaps the uterus also. (Fig. 75.) The pessary is supported by the natural narrowing of the vaginal outlet. I have sometimes found it necessary to spread the limbs of the anterior loop of this pessary so that it is made wider. This gives it a more secure support within the vaginal entrance.

The belt pessary is only resorted to when all others fail. It is used, and sometimes affords great relief, when the pelvic floor is destroyed and there is no possible support for any other form of pessary.

Stem pessaries are sometimes successfully used in anteflexion for the relief of dysmenorrhoea and sterility. They may occasionally cause inflammation of the tubes, and are necessarily foreign bodes in the uterus, but notwithstanding these objections their use is justified in selected cases.

Certain forms of stem pessaries are self retaining and these are preferable to those that have to be retained by a vaginal pessary or by tampons. In using the self-retaining pessary it is sometimes necessary to maintain the uterus in place with a vaginal pessary.
The intra-uterine stem is usually either grooved, or it is hollow, to allow the passage of the menstrual flow and the entrance of the spermatozoa in cases of sterility. To introduce a stem pessary it is sometimes necessary to dilate the cervix under anesthesia, though most of them are easily introduced if they are previously curved to conform to the angulation of the cervix and body of the uterus.

A stem pessary may be left in place from six weeks to two or three months if no untoward symptoms manifest themselves. The patient must be under observation during this time and if pain or marked leucorrhoea occur the pessary must be removed at once.
Pessaries require constant observation and attention.

After a pessary is fitted the patient should be required to return in two or three days to see that the uterus is retained in position and that the pessary is also in place and has not caused any degree of irritation. Of course the patient is advised to return at once should there be any inconvenience, or discomfort, or any indication that the pessary had slipped out of position.

If, after the first visit, all is well, the patient is expected to call again within a week or ten days when she is again examined. At each of these visits the pessary is removed, cleansed and replaced. Although the uterus is properly supported, the old adhesions are again stretched bimanually and the uterus is freely moved in all directions. This is repeated every two weeks until two or three months have passed when the pessary is removed.

After the removal of the pessary the patient is requested to return after two or three days, and if on examination the proper uterine position is retained, she is told to return again in ten days or two weeks. If, on examination at this time, the normal position is still maintained, the patient is asked to call again in six or eight weeks for a final examination. If all is now well, she is discharged with instructions to report again should there be any indications that the displacement has returned.

If, however, after the first visit the uterus has not maintained its position, or the pessary has slipped or has shown evidence of irritating the vaginal walls, it must be removed, reshaped and refitted or another one better adapted to the particular case, introduced. The patient must return again in three or four days to determine if this newly fitted instrument meets all indications. If it does the visits are made at longer intervals, as before indicated.

If after the pessary has been worn for two or three months and is finally removed, should there be a return of the displacement, a careful search for the cause of this should be made. There may be some remaining adhesions not sufficiently relaxed: a failure of some of the factors necessary to retain the uterus in place or an improperly fitted pessary. The cause of the failure of the uterus to remain in place having been determined and remedied, if possible, the patient is kept under observation, as before, and the pessary again removed in two or three months. Should the displacement again recur the pessary may have to be worn indefinitely or an operation considered if the symptoms are sufficiently troublesome.

A patient when wearing a pessary, especially after it is first introduced, should take a copious douche of warm water daily. Boric acid or some other mild antiseptic may be added, if desired.

Women may wear pessaries almost indefinitely without irritation though if they are not properly fitted and cared for the irritation and inflammation caused by them may more than offset the good they may do. The toleration of the vaginal walls is almost incredible in some instances. I once removed a hard rubber ring pessary that had been in place without removal for at least thirty years. A patient of nearly seventy complained of a leucorrhoea and upon examination the pessary was found. It was considerably eroded where it fitted in the posterior vaginal fornix and at which point it was almost embedded in the tissues. It was removed without difficulty and with the use of mild antiseptic and cleansing douches the leucorrhoea ceased in a few days.