the pessary and heating it in a spirit lamp. Pessaries are also made of gutta percha, which has the advantage of being easily moulded; these cannot, however, be worn for a long time, as the gutta-percha is absorbent and, retaining the secretions, sets up irritation. The patient can wear one for a few weeks till we see that it fits comfortably and is effective, and then we can substitute one of a similar form made of vulcanite.

The form of the Hodge is an elongated horse-shoe, with a straight transverse bar joining the free ends. Seen from the front (fig. 213),

it has a curved upper end which is adapted to the posterior fornix; the lower end consists of a straight bar which serves to keep the sides

Fig. 215.

Side view of Albert Smith Pessary. The Hodge is similar, but has the lower curve less marked.

apart, and lies under cover of the symphysis pubis; the external angles of this end are rounded to prevent their cutting the vagina; the sides run almost parallel. Seen from the side (fig. 215), it is a mould of

the vaginal slit; there is an upper sacral curve, which is long and wellmarked; there is a lower pubic one, which is not necessarily present or is only slightly marked. The pessary lies so that the concavity of the sacral curve looks forwards, that is to say, the upper end of the pessary (like the posterior fornix vagina) curves forwards. The Albert Smith (fig. 214) contracts in its lower half to a more or less beak-shaped end; seen from the side, it has the pubic curve more marked (fig. 215). Scientifically it is the more correct form, because the posterior wall of the vagina is narrower below than it is above. The lower end should

Fig. 216.

Introduction of pessary.

not be too much contracted, otherwise it is apt to interfere with married life; also when the vaginal orifice is wide, it favours the expulsion of the instrument. A second modification of the Hodge is recommended by Thomas, in which the upper bar is thicker, the sacral curve more pronounced, and the whole instrument longer.

The choice of an instrument suitable to the case must be made. The pessary should be narrower and shorter than the posterior vaginal wall,

so that it produces no tension when it is in position. The upper bar should be of such a size that it can be passed in easily; the lower should be narrower than the upper, but not too narrow for the reasons given above. The proof of a good fitting instrument is that the patient does not feel its presence, nor should it interfere with married life.

The mode of introduction of the pessary demands special attention. It is important that this apparently simple manœuvre be effected without causing pain to the patient.. From the fact that the vulvar orifice is antero-posterior while the cavity of the vagina is transverse, the instrument must be introduced with its plane surface horizontal (the patient is supposed to be on the side) and afterwards rotated so that this comes to be vertical. From the position of the cervix, the instrument is very liable to run into the anterior fornix. When in position the upper end must curve forwards. Having oiled the instrument, grasp it with the lower end (the square end in the case of the Hodge, the narrower end in the case of the Albert Smith) between the finger and thumb of the right hand. Separate the labia with the first and second fingers of the left hand; when the vaginal orifice is

Fig. 217.

Pessary carried on by finger.

narrow hook back the fourchette with one finger, or get the posterior corner of the end which is being introduced within the vaginal orifice,

and press back the perineum with it so that the anterior corner is not pushed against the clitoris or vestibuli. Now push the pessary backwards in the axis of the vagina till it is half within the cavity (see fig. 216), and rotate it so that the concavity of the sacral curve looks forwards. Pass the index finger behind the instrument into the vagina, and place the tip of it against the upper bar; carry the pessary onwards, keeping the upper bar well against the posterior vaginal wall to prevent its slipping up in front of the cervix (fig. 217).

The position and action of the pessary when in situ are as follows:— It lies exactly adapted to the vaginal walls (see fig. 218); the upper

α

୬

Pessary in situ in the vagina, ad naturam.

Fig. 218.

a perineum, bb pessary, e anterior and d posterior vaginal wall, e anterior and posterior lip of cervix.

end being in the posterior fornix behind the cervix, the lower just within the vaginal orifice. It is kept in position through its resting on the oblique anterior face of the sacral segment of the pelvic floor, against which it is compressed by the posterior face of the pubic seg

ment.

The student will readily understand and remember the position of the pessary in the following way. Hold the hand inclined as in fig. 219, with the palm slightly inflexed. It resembles the posterior vaginal in the following points: (1) it is broader above than below; (2) it curves forwards above; (3) from its obliquity, it allows the pessary to sit on it. Now place the pessary on it. It will only lie adapted to the

Ꮓ

hand when the broad end is above and the upper curve is directed forwards.

The Hodge pessary does not act as a lever; that is to say, the intra

Fig. 219.

Hand holding Albert Smith pessary.

abdominal pressure does not act specially on the lower bar and depress it, causing the superior one to rise. The intra-abdominal pressure acts nearly equally on both bars, of which fact the student may satisfy himself clinically. Its action is that the upper bar gives a point d'appui to the posterior fornix. The posterior vaginal wall runs round the upper bar as on a pulley, and, as it is inserted into the cervix, the latter is thereby drawn upwards and the fundus thrown forwards (fig. 220). The pessary, therefore, has the same action as the utero-sacral ligaments, if we suppose that these keep the cervix backwards. This is only the action in the case of a retroverted uterus which has been replaced. A vaginal pessary, however, gives relief even though we may not be able to replace the uterus. In this case we must suppose that it acts by supporting the uterus as a whole, thus diminishing tension on the ligaments and passive congestion.*

Another way of showing how the Hodge pessary acts is as follows. With the patient lying on her left side, pass the index finger into the posterior fornix vagina and push it up in a direction parallel to the

* See Hart on The Structural Anatomy of the Female Pelvic Floor; and Granville Bantock on The Use and Abuse of Pessaries, London 1878.