often thrown upon the uterus than its suspensory supports can bear (crowding it down against the pelvic floor), while during muscular relaxation but little power is required to return and hold it in a normal position.

As a consequence, much advantage will be gained by supporting the uterus until stretched ligaments have become retracted, and any chronic indurations or cicatrizations sufficiently absorbed or stretched to allow the corpus uteri to incline over the bladder without restraint. Mechanical supports or pessaries accomplish this by taking advantage of the pivot or ball-and-socket action of the cervical supports, and pry the fundus forward by turning the cervix backward. They may be divided into four classes: (1) those acting in front of the cervix by keeping it in the back part of the pelvis; (2) those acting behind the cervix by drawing the cervix backward; (3) those combining the action of both of the above methods, and (4) those acting similarly upon the cervix within its canal.

Pessaries Acting in Front of the Cervix, or Barrier Pessaries.

The advantages of pessaries acting in front of the cervix are that they interfere but little with the natural uterine supports, restrict but slightly the normal motions of the uterus, and can be removed and introduced by the patient.

The great disadvantage of this form of instrument is that it requires the fundus to rest without restraint in front of the superior strait so as to receive the abdominal pressure upon its posterior surface. When from lateral or other traction, or retroflexion, the fundus does not remain well forward, abdominal pressure, which at times is all-powerful, will turn the fundus back and either pry the cervix over the barrier, or else pry up the barrier out of place. A short vaginal portion of the cervix, short anterior vaginal wall, a flabby uterus, tenderness in front of the cervix, are also not uncommon conditions that limit its usefulness. These barrier-pessaries, therefore, find their chief use after other more powerful supports have been used, and it has become desirable. to partly withdraw the artificial support and allow the uterine ligaments to assume function. They supplement but do not supplant the ligaments as do the firmer supports. They are especially useful after labor, at which time the size of the uterus affords them greater advantage. In case of laceration of the cervix they should especially be tried, as they both lift the cervix from the posterior vaginal wall and hold the torn lips together.

On account of the possibility of a retroversion occurring while they are apparently in proper place, the patient should assume the kneechest position two or three times in twenty-four hours and admit air to the vagina, and thus replace both uterus and pessary in case they should be displaced.

The simplest form of the barrier pessary is a piece of ordinary cotton loosely rolled in the shape of a spool of thread, and introduced over and behind the rectal promontory, in front of the replaced cervix. It should be changed once in twenty-four or forty-eight hours, when an antiseptic vaginal douche may be used. Having been thus used for a time it may be removed at night and another introduced in the morning. The patient may even learn to introduce it herself in the knee-chest position; or in the knee-elbow position after having thus replaced the uterus. She can of course remove it by first attaching a string to it.

Similarly a collapsed rubber ring may be introduced by the patient in the knee-elbow position after thus replacing the uterus, and then inflated.

Courty's barrier pessary consists of two bars resting on the pelvic floor, joined in front where they impinge against the pubes or vaginal entrance by a cross bar, and curved up posteriorly around either side of the cervix so as to meet in front of it. The neck thus made for the

cervix forms a rigid barrier to keep it back. Dr. T. D. Fitch of this city, without having seen Courty's instrument, invented, during an extended series of experiments, an instrument similar to it.

By turning the posterior end of an Albert Smith in front of the cervix I devised an instrument which, although I did not know of Courty's pessary, was practically a modification of it (Fig. 256). The difference lay in the tongue shape of the anterior end, the curving of the bars to correspond to the posterior vaginal wall or (if that were relaxed) the pelvic floor, and the depression of the middle portion of the collar for the reception of the cervix. The consequent action of the pessary is elastic, for a slight rocking motion is allowed by the curved arms. Where there is danger of the pessary slipping, the arms may be separated and the tongue curved back under the pubes, as in Fig. 257. Fig. 258 shows the pessary in place.

It may be introduced turned sideways or upside down, or any way in which it enters best, until the collar passes behind the pubes, and

then turned right side up. The patient can easily place it by introducing it far enough for the collar to rest behind the pubes, and then assuming the knee-chest position and allowing it to slip into position. She can remove it by turning it partly around and giving it a little twist as she withdraws it, or by turning it upside down and rolling or prying it out. On account of the difficulty in altering the arms so as to fit the posterior vaginal wall in the hard rubber instrument, I have so far made my instruments out of the soft rubber, elastic, Thomas and Albert Smith pessaries or, when a large one was required, out of the largest size ring of copper wire covered with soft rubber, as found in the shops.

ແ

FIG. 258.

Byford's Retroversion Pessary in Place.

By depressing the collar the barrier may be placed in front of the lower end of the cervix and get a powerful leverage upon the fundus; by raising the collar the barrier holds the whole cervix back, but gets less of the leverage power. The straighter the arms the less is the rocking motion and the firmer and more rigid the barrier. During defecation it is always advisable for the patient to press the finger against the end of the pessary and prevent its coming forward, and to assume the knee-chest position afterward.

I have had better success in permanently curing retroversions with

this pessary than with any other. Its inefficiency in many cases is in accord with its non-interference with uterine motion, for it allows the uterine ligaments to resume healthy motion.

Pessaries acting behind the Cervix, or Traction Pessaries.

The advantages of the pessaries acting behind the cervix are that they take a firm hold upon the posterior vaginal wall, and draw the cervix up as well as back, and thus prevent ordinary abdominal pressure from bearing upon the anterior uterine wall and reproducing the displacement. Contractions beside the uterus which prevent the barrier pessaries from acting efficiently, have but little effect in repro

ducing the displacement when the traction pessaries are used because of the firm elevation of the cervix. Another advantage is their mechanical simplicity, and the ease with which they can be successfully used by the general practitioner.

Their disadvantages are that they are apt, by distending the vagina, to weaken the pelvic roof; they draw the cervix higher than natural and thus interfere with the normal action of the supports; they are apt to retrovert the uterus when removed by the patient, and they cannot be replaced by the patient. In proportion as they are modified to lessen these disadvantages they become either less efficient or more difficult of adjustment. They are, however, and will probably remain the most generally useful pessaries for retroversion.

The Hodge closed lever pessary is the oldest and most efficient of the almost infinite varieties to be found in the shops. It consists of an elongated ring bent somewhat abruptly upward behind the cervix, and more gently upward in front, so as to impinge against the anterior vaginal wall behind the pubes. It is liable to turn in a roomy

vagina and to find inefficient support against a relaxed vesico-vaginal septum. These disadvantages have been overcome in the Albert Smith pessary by narrowing the anterior end of the ring, and turning it down so as to project slightly under the pubic arch. An increase in the curve of the arms elevates the cervix, increases the anteversion, and renders the pessary mechanically more efficient. A separation of the bars diminishes the tendency to turn sideways and slip out at the vulva.

As an excessive elevation of the cervix is unnatural and often harmful and unbearable, Emmet diminishes the length and abrupt ness of the posterior upward curve. He also employs a larger bar than others. Hewitt's retroversion pessary is simply an elongated

FIG. 261.

TRUAX&CO.

Hewitt's Cradle Pessary.

ring with a gentle curve on the flat. It is particularly useful when the vagina is small, but it is liable to press injuriously behind the pubes. Schultze's sleigh pessary is a modification well adapted to a relaxed vagina. (See Fig. 241.)

The Scott, Thomas, Cutter, Priestly, and Lazarewitsch pessaries with external supports are also valuable when the relaxed vagina does not retain the other forms. (See Figs. 245, 246.) Hanks, Noegerath, Schroeder, Gehrung, and others have devised other slight modifications.

The ordinary material for such pessaries is the hard rubber. The Albert Smith pessary is made also of spring wire covered with soft rubber, and constitutes an excellent instrument for the general practitioner. Any form, however, may be given to the copper wire rings covered with soft rubber, and after a thorough and satisfactory trial may be reproduced by the instrument dealer, in hard rubber.

Pessaries Acting both in Front and Behind the Cervix.

The advantages of pessaries acting both in front and behind the cervix, are a firmer grasp of the cervix, and a dividing of the force between the traction and pressure. They are particularly applicable when the posterior vaginal wall is relaxed and voluminous, or when the cervix is lacerated. The disadvantages are an unnatural confine