INTRA-PELVIC TECHNIC (Manipulative
Surgery of the Pelvic Organs)
PERCY H. WOODHALL, M.D., D.O.
Tampons and Pessaries
Tampons are useful, chiefly for two purposes: as media for the application
of various medicaments to the cervix and vagina, and to support the uterus
and the pelvic blood vessels.
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
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
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
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,
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
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
Fig. 60. Hard Rubber Stem
Fig. 61. Glass Stem Pessary.
Fig. 62. Ferguson's Draining Pessary.
Fig. 63. Chamber's Stem
Fig. 64. Soft Rubber Stem
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
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. 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.