REMARKS 
ON THE 
EMPLOYMENT OF PESSAEIES 
WITH THE 
§jesol]ptto 0I i U*w Httjitvtttttittt* 
(with illustrations) 
E. NOE6GERATH, M.D., 
OF NEW-YORK, 
(REPRINTED FROM THE “NEW-YORK JOURNAL OF MEDICINE,” FOR SEPT. 1858. 
WITH ADDITIONAL REMARKS.) 
NEW-YORK: 
Manufactured and sold by G.‘. TIE MANN & CO., 
PRINTED BP HENRY LDDWIQ, 39 CENTRE-STREET. 
No. G3> Chatham-strect. 
185 8 . The more intractable a disease has proven to treatment, 
the greater is the number of so-called infallible remedies 
proposed against it. This is true of prolapsus uteri. Every 
year, almost from the days of Hippocrates, has enriched 
the number of uterine instruments for the cure of falling of 
of the womb, and still the mystery seems to be undissolv- 
ed. This is partially owing to the fact that till now no 
instrument has been constructed that satisfies practi- 
tioners in general, partially to the inventing-mania of some 
of our professional brethren. 
There are two classes of physicians, one of which be- 
ing disgusted with the host of mechanical appliances, now 
lauded, now rejected, has almost entirely abandoned 
the application of pessaries ; while the other treats the 
slightest deviation with a mechanical support. Though 
the latter do more harm than the former, neither of them 
proceed upon the correct principle. 
As to the comparative value of the bloody operation 
for prolapsus, the question is not yet settled. When we 
attempt a final solution of the question, whether the ave- 
rage number of subjects operated upon are permanently 
benefitted by it or not, we are overwhelmed daily with the 
most cantradictory reports of its value. Moreover, the 
greatest number of practitioners are called upon to treat 
cases not in the hospital, but private patients, who claim 4 
a right to dispose of themselves just as they choose. And 
most of them are alarmed at the very sight of a bistoury. 
And still there are physicians, some of the highest 
standing, who try to avoid the use of a pessary by treat- 
ing cases of prolapsus, on the so-called radical plan, i. e. 
by removing the original disease, chronic metritis, hyper- 
trophy of the womb, &c., applying afterwards adstringent 
injections and suppositories, while the patients are laid 
up for two or six months, to be discharged with an abdo- 
minal supporter! The great objection to this plan is the 
fact, that it is crowned with success only in an exceedingly 
small number of cases, while its employment is perfectly 
out of the question in the largest majority of cases, because 
that class of society among which prolapsus is commonly 
found, has neither time nor means to resort to it. It is 
the working portion of the sex which is stricken with this 
complaint, and they want a prompt and cheap remedy for 
their complaint. 
In regard to abdominal supporters ( Annan, Hull, Ha- 
milton, Giehrl) I consider them as an excellent adjuvans 
in the treatment of prolapsus, but altogether the relief de- 
rived from them is by far less than that offered by a well- 
adapted pessary. 
The only operation which is always followed by great 
relief, is the amputation of the cervix, in cases where the 
prolapsus is owing to hypertrophy of the lower section of 
the womb. Dr. C. Mayer of Berlin, the well-known 
obstetrician, has resorted to it with the fullest satisfaction 
in a great number of cases. 
In recommending the use of pessaries in the treatment 
of prolapsus uteri, I am far from a method too often resort- 5 
ed to in every-day practice, viz., that of diagnosticating pro- 
lapsus uteri and prescribing a pessary at once. Nay, there 
are cases which do not justify instrumental treatment at all, 
while almost every single case demands a preparatory treat- 
ment before a pessary can be applied. The necessity of a 
scrutinous examination, and a full consideration of the 
present complications cannot be urged strongly enough. 
The neglecting of this principle is the common source 
of failure in the treatment of prolapsus. For the same 
reason no physician should prescribe a pessary on the sole 
assertion of the patient herself, that she suffers from fall- 
ing of the womb. I have frequently met with patients, who 
believed themselves to be subject to this complaint, who, 
upon examination, were found to have metritis or other 
malpositions and flexions of the womb. It is obvious, 
that a pessary in this class of cases would be injurious 
instead of beneficial. 
The patient must be examined as well in an erect as 
in a horizontal position, as it often happens, that a prolap- 
sus disappears entirely when the patient is lying on her 
back. After the presence of prolapsus has been ascer- 
tained in this way, the patient must be subjected to a tho- 
rough examination, while in a horizontal position. It is 
best to begin with the palpation of the abdomen, in order 
to get a knowledge of abnormities in the supra-pelvic and 
pelvic cavities. Hereafter the prolapsed portions them- 
selves must be inspected, and the state of the anterior and 
posterior Avail and that of the womb itself have to be 
taken into consideration. 
Moreover, the color and condition of the respective 
mucous membranes have to be taken into consideration, as 6 
well as the presence of ulcerations, their different charac- 
ter, their seat in the cervical canal, near the orifice or on 
the walls of the vagina. Hereafter the prolapsed portions 
have to be touched all around with the fingers, in order to 
ascertain their condition, and the possibility of full or par- 
tial reduction. In order to get a full view of the position 
of the uterus, it is well to introduce one or two fingers 
into that portion of the vagina which is inside of the pelvis. 
By examining through the rectum, we may ascertain how 
far it is involved in the prolapsus. Hereafter the situation 
and size of the womb has to be ascertained with the probe 
and that of the bladder with the catheter. After this the 
parts must be pushed upwards, in order to examine the 
sexual organs inside of the pelvis and the pelvis itself. In 
those cases, where the neck of the uterus is not in sight, 
it has to be explored with the speculum. 
The different forms which a prolapsus may represent, 
are as follows: 1) one of the walls of the vagina may 
prolapse, without participation of the womb, viz.: 
b) Prolapsus of the posterior wall. These cases are 
generally recorded under the name of cystocele and rec- 
tocele vaginalis. 
a) Prolapsus of the anterior wall of the vagina. 
2) Prolapsus of one or both vaginal walls, with partial 
prolapsus of the womb. 
a) Prolapsus of the anter. wall of the vagina and partial 
prolapsus of the womb. 
h) Prolapsus of the posterior wall of the vagina and 
partial prolapsus of the womb. 
c) Prolapsus of both walls of the vagina and partial 
prolapsus of the womb. 7 
The cases of prolapsus of the anterior wall and the 
uterus are very often connected with retroversion and flex- 
ions of the womb. The body of the womb is generally 
turned somewhat backwards, pressing upon the os-sacrum 
and rectum. These cases, therefore, are very often com- 
plicated with very troublesome constipations of the bow- 
els. 
3) Prolapsus of both vaginal walls and complete prolap- 
sus of the womb. This variety is the most commonly 
met with, because, women affected with the disease very 
often do not apply for medical advice until 20 or even 40 
years have passed since its first start. 
4) Prolapsus of the uterus. This is of very rare ocur- 
rence. The inferior portion of the womb, generally hy- 
pertrophied in a great measure, protrudes between the la- 
bia majora as a thin cone, which sometimes attains the 
length of three or four inches. As its lower end is 
rounded off, and perforated by the orifice, it looks just 
like a penis. 
In most cases of prolapsus the lining membrane is the 
seat of superficial or deeper ulceration. The ulcerations 
coincident with prolapsus must be divided into two differ- 
ent classes, viz., those, which are the consequence of an 
idiopathic uterine disease, and those which are the result 
of mechanical insults. This distinction is important with 
regard to treatment. The ulcerations of a mechanical 
nature are confined by irregular, sharp, callous edges, their 
base is discolored with a brownish hue, yielding a dirty, 
thin, often very offensive secretion. The ulcerations from 
chronic metritis are of a more inflammatory character, in- 
clined to bleeding, spreading rapidly on the slightest oc- 8 
casion, and very obstinate to treatment, unless the metritis 
has been subdued beforehand. 
Other complications very often connected with prolap- 
sus are retrojlexio, retroversio, and antejlexio. Every 
complete prolapsus uteri is followed by hypertrophy of the 
organ, which attains in most cases the longitudinal axis, 
while at times the womb is considerably increased in thick- 
ness. In the first instances the probe may be advanced 
into its cavity as far as five or seven inches. In other 
cases the cervical portion alone or one of the lips only 
are hypertrophied. 
In consequence of the displacement of the bladder, al- 
ways present in cases of prolapsus of the anterior wall 
of the vagina, the urethra is often covered with fungous 
vegetations, which at times attain the length of half an 
inch in diameter. Hernia recti and prolapsus ani are of 
comparatively rare occurrence, while rupture of the peri- 
neum is not seldom. These and other complications 
have to be removed as far as possible before the applica- 
of a pessary can be thought of. The treatment of some 
is very tedious, and demands a good deal of patience from 
the attending physician and the woman herself. 
Chronic metritis, hypersemia and painfulness of the 
prolapsed parts must be treated withleeches, scarifications, 
anodynes, resorbents, &c. The ulcerations have to be 
cured thoroughly before a permanent retention of the 
womb can be thought of. It is perfectly contradictory to 
experience, that the reposition of the parts into the vagina 
is sufficient for the cure of these ulcerations, an opinion 
cherished by some of our very first obstetric physicians. 
The only complication which requires no treatment 9 
before the application of a pessary is simple hypertrophy 
of the womb. 
The most efficient remedies for treating these ulcerations 
are, nitrate of silver, acidum pyrolignosum, scarifications, 
removal with the knife of the callous edges, fomentations 
with lead-water, slight cathartics. 
The ulcerations of the vaginal walls are of a very intrac- 
table nature, they are never benefited by the application 
of caustics, such as nitrate of silver ; scarifications repeat- 
ed every third or fourth day, and the applications of acid, 
pyrolignosum answer much better. They often require 
twelve or eighteen months’ treatment before a sufficiently 
firm scar has been attained. The ulcerations seated in 
or near the cervical canal must be healed up, at least as 
far as they spread over the lips, before a pessary can be 
introduced, while the treatment of the intracervical ulcera- 
tions may be continued afterwards with the speculum. It 
must never be forgotten, that all ulcerations which are 
touched by the pessary will increase and make the use of 
an instrument impossible. Only in those exceptional 
cases, where the ulcerations resist the most rational and 
persevering treatment, one may cover them with a piece 
of soft and dry lint, and introduce a pessary afterwards, 
and continue treatment intra vaginum. In those cases 
where bodily rest can be resorted to, it is of great value 
for the cure of ulcerations, at any rate, in treating these 
affections, the greatest cleanliness must be observed, the 
parts must be thoroughly sponged after going to stool, and 
they must be covered always with a clean piece of dry 
linen. 
The use of a pessary seems to be connected with the 10 
greatest difficulty in those patients, where prolapsus is 
complicated with both hypertrophy and flexion of the 
womb. 
In the very first days of its application violent back-ache, 
a sensation of bearing-down and prolapsus of one of the 
vaginal walls make their appearance. When examined, 
the body of the retroflected uterus is found very painful, 
and, ulcerations appear on different places. 
In these cases it is a good plan to elevate the retroflect- 
ed womb by the uterine sound, thus fixing it towards the 
promontory. Hereafter a pessary may be introduced and 
absolute rest recommended for some time. If this is not 
sufficient, the only means left, is to introduce a soft sponge 
behind the cervical neck, which in many cases does re- 
tain the prolapsed womb in its position. The sponge has 
to be removed, cleansed and re-introduced daily for some 
weeks before another application of a pessary may be 
tried, which at first must be applied in connection with 
the sponge. By a strict and indefatigable adherence to 
these rules, finally a pessary is endured without any in- 
convenience. 
After a full consideration and treatment of the different 
complications, it is of the greatest importance to choose the 
right kind of instrument. 
The requisites of a good instrument are as follows: 1. 
It must retain the womb in or near its natural position. 
2. It must neither irritate the womb nor the vagina. 3. 
It must not interfere with the patient’s moving round, sit- 
ting, or excretion of urine and faeces. 4. It must be com- 
posed of a substance, which resists the corrosive influence 
of the secretions from the genitals. 5. It must be con- 11 
structed, so as to be easily introduced, removed and clean- 
ed by the patient herself. 6. It must be as cheap as 
possible. 
The different pessaries may be divided into two sec- 
tions, viz; those, which support the womb directly, and 
those which support it indirectly, by elevating the vagina. 
Until late years only the former class was exclusively ap- 
plied, as this idea most naturally suggested itself at first 
sight. They are divided again into stalked and unstalked, 
the former being in use ever since medical science was 
established. Both are intended to give a direct support 
to the fallen uterus. Later researches seem to show, 
that the chief and most natural support of the uterus was 
presented by the vagina, and in this view surgical opera- 
tions as well as instruments were invented, and as it seems, 
successfully applied for the cure of prolapsus. 
The first man who clearly followed this indication in 
constructing his pessary, was Pkof. Kilian, in 1846, 
and he called it elvtromochlion, i. e. vaginal supporter. 
■ His instrument consisted 
of a thin steel spring, 4 in- 
ches long, the points of 
which ended in wooden but- 
tons, and the whole of it 
was covered with a thin lay- 
er of india-rubber. In in- 
troducing the instrument, 
the ends of it are approxi- 
mated to each other as much 
as is required for its easy introduction into the vagina. 
In applying it, it must be elevated in the direction of 
Fig. 1. 12 
the lateral diameter of the vagina, while its convex por- 
tion is directed towards the anterior walls of the pelvis. 
The instrument thus bent is gently pushed upwards, so 
that its points take a position to the right and left side of 
the uterine neck, as high up as possible in the laquear 
vaginae. 
Although the instrument has been abandoned by the 
profession, owing to the fact, that very few women can 
bear the pressure which it necessarily must exert, in or- 
der to sustain itself in the vagina, the elytromochlion of 
Kilian has been applied in some cases successfully, thus 
proving that the theory of its construction was based upon 
sound principles. 
In 1853, Dr. Zwank, of Hamburg, published the de- 
scription of his new hysterophor. It consists of two ovoid 
thin pieces of metal, covered with india-rubber, or of wood, 
connected on one end by a joint. In the neighborhood of 
this joint, on the external surface of the wings, is a me- 
tallic pin, on each side two inches long, which can be 
screwed together at the lower end. In applying the instrument, the wings are approached 
as much as possible (fig. 2) and introduced, so that its con- 
vex portion is turned towards the os-sacrum, and pushed 
upwards, as high as possible, towards the anterior portion 
of the laquear vaginae, in front of the neck of the uterus. 
Afterwards the lower ends of the metallic handles are 
compressed, and fastened by the screw (see fig 3.) In this 
position the instrument is retained by itself. 
About the same time, Dr. Schilling, of Munich, in- 
vented quite a similar instrument to that of Zwank; the 
only difference being, that the movement of the wings is 
effected, and can be regulated by the screw at its lower 
end. The purpose of both instruments is, to gently ex- 
pand the lateral portions, and sustain the superior wall of 
the vagina, thus preventing its inversion, and consequent- 
ly, the falling of the womb. 
Dr. Zwank’s instrument was received enthusiastically 
by the profession in Germany. Such men as C. Mayer, 
Chiari, Braun, Scanzoni, Breslau, &c. thought it of suf- 
Fig 2. 
Fig. 3. 14 
ficient importance, to publish their observations in favor 
of this instrument, and at the present time it has actually- 
supplanted all of its kind. 
What is the reason of this 1 Is it because the profes- 
sion seized upon the instrument, because it was a new in- 
vention ? Is it because an instrument was wanted ? or has 
it fulfilled what it claimed to do 1 
The question which we propose to consider, is whether 
this instrument has any advantage over those other means, 
hitherto applied for the same purpose. It certainly has ; 
because 1. it is lighter; 2. it only a compara- 
tively small circumference of the vagina, and scarcely any 
portion of the womb; thus preventing irritation and ulce- 
ration of the vagina, incarceration of the uterus, fluor-al- 
bus, uneasy feelings ; 3. it can be easily introduced and 
removed, easily brought to its proper place, easily clean- 
ed by the patient herself. This is a combination of ad- 
vantages, sought for in vain among the host of previously- 
invented pessaries. On the other hand, the hysterophors 
of Zwank and Schilling have some disadvantages, owing 
to the substance of which they are composed. The great- 
est number of them, as now in use, are covered with a 
coat of vulcanized india-rubber. The discharges of the 
vagina destroy it in a very short time. After this has 
been done, the metallic portions begin to rust and decay, 
thus irritating the vulva; the furrows of the screw at the 
lower end of the instrument begin to crust, or the screw, 
if turned too firmly, cannot be untwisted. Some patients 
have little dexterity, and do not know how to manage the 
screw at all. An illustration of these facts I arn seeing 
daily, in the case of a lady belonging to the first class of 15 
society. She is the widow of a well-known physician 
of this city, and has suffered from prolapsus uteri ever 
since her first confinement, many years ago. The most 
thorough examination is unable to detect anything abnor- 
mal about her genital organs, except prolapsus uteri. She 
has been under the very best treatment of general practi- 
tioners and uterine specialists. Everything has been re- 
sorted to, to effect a radical cure, and all kinds of pessa- 
ries employed, but in vain. At length, one of Zwank’s 
pessaries was suggested. She has worn it now for a 
year, and is perfectly satisfied ; the only drawback being 
the loss of the india-rubber coating and the rusting of the 
metallic skeleton. 
In order to avoid these inconveniences, Dr. Eulenburg, 
of Coblenz, modified Dr. Zwank’s pessary, and described 
his instrument in a short thesis, in 1857. It is made en- 
tirely of boxwood, and its wings are a little differently 
shaped, viz.: they are slightly curved downwards at both 
ends, so that the lower side forms a concave surface. In 
consequence of this shape, the lateral branches closely 
adapt themselves to the inner surface of the ramus de- 
scendens ossium pubis; thus presenting a kind of hook, 
which gives a strong hold to the instrument when in the 
vagina. Both wings move in the centre part by two joints, 
thus leaving a hole in the middle, through which the se- 
cretions of the vagina are allowed to escape. Instead of 
the screw, Dr. Eulenburg perfected the opening and shut- 
ting of the wings, by means of an elastic india-rubber 
ring, which runs in a channel around the body of the hys- 
terophor, immediately below the two joints. 16 
By this contrivance, the introduction of the instrument 
is greatly simplified, and as it shuts on its own account, 
by the elasticity of the india-rubber ring, its application 
becomes very easy, thus requiring not the least ingenuity 
upon the patient’s part. (See figs. 4 and 5.) As every 
Pig. 4. 
Pig. 5. 
particle of metal is avoided (except the small pin, running 
through the joint), and as the box-wood resists more than 
any other substance the corrosive influence of the vaginal 
discharges, it is lighter, will keep longer, and will cause 
less irritation than the other instruments. 
The author found four different sizes, fitting to the greatest number of cases, viz : for the measure from side 
to side, 2f", 3", 3J" and 3Jr", and correspondingly the 
largest antero-posterior diameter of every wing, 1" 3", 
for the two largest sizes, and for the following, 1" 4" and 
■yn §/// * 
The first application of the instrument ought to be per- 
formed by the physician himself, who has to choose the 
size required for every case. His judgment will be con- 
ducted by the sensation of the patient, after walking to 
and fro for awhile, and more so, by the way in which the 
india-rubber ring contracts. If the extravaginal portion 
is not shut entirely, the instrument is too large, and has 
to be removed; if it shuts too quick, a larger one must be 
chosen. The following duties devolve upon the patient 
herself, viz : removing and cleaning it at bed-time, and 
re-adjusting it before getting up in the morning. This is 
performed by seizing the buttons at the lower end, and 
while separating them from each other, as much as pos- 
sible, the other end of the instrument is to be gently intro- 
duced into the vagina till it cannot go any farther; and 
(when left alone) now it shuts on its own account. The 
same way is followed in its extraction. Before its intro- 
duction, it ought to be well oiled. In order to render this 
pessary even more harmless, it is advisable to cover its 
branches with a kind of glove, made of soft deer-skin, 
which coat may be moistened with cod-liver oil before 
every application. 
* The instrument has been modified in the construction of the 
joint after my suggestion, so that the pessary can be easily taken 
in two lateral pieces, thus allowing a more thorough cleansing, 
while even the small metallic pin of Dr. E.’s pessary is avoided. 18 
Of great importance is the breadth and direction of the 
pubic arch, because this is the chief guide for the selec- 
tion of a pessary. This can be ascertained by introdu- 
cing the 2d and 3d finger behind the arcus and expand 
both fingers till every one of them touches one side of the 
arcus. The distance of the fingers thus obtained may 
guide our judgment in the choice of an instrument. As 
a general rule it may be stated, that a comparatively small 
instrument ought to be tried first, because it very often 
happens, that even the most extensive prolapsus are bene- 
fitted by small instruments. 
After the instrument has been closed, the patient must 
be questioned, as to what her sensations are. If the in- 
strument was too large, a singular kind of smarting is 
perceived and considerable uneasiness expressed. It is a 
good plan to have the patient walk around, in order to as- 
certain if the prolapsus will be perfectly retained by the 
instrument. 
Even in cases where the perineum has been ruptured, 
our instrument has been used with perfect success, the 
only precaution to be taken is the choice of a broad pes- 
sary. 
On the second day after the application of the instru- 
ment, the patient must be seen again by her attending phy- 
sician, because at this time generally certain symptoms 
occur, which originate from the presence of a foreign 
body in the vagina, and which prove, that the instrument 
is too large, if they are very intense. 
The symptoms alluded to, are a chilly sensation, heat, 
headache, trembling, nausea, want of appetite, obstinate 
constipations. The instrument must be removed, and the 19 
vagina must be examined with the speculum, to see if a 
portion of it is inflamed or ulcerated, a condition always 
met with, if the instrument chosen was too large. After 
the third day is over, chills and heat are very trifling, and 
dissappear entirely some time afterwards. 
If the instrument is borne after some days with no dis- 
comfort at all, the patient must be taught, how to use it, 
she must repeat the manoeuvre of adjusting and removing 
it several times in the presence of the physician. 
At the time of the monthly courses, the patient had better 
have the instrument removed, provided she can keep quiet. 
At times it happens, that a portion of the anterior wall of 
the vagina falls beneath the pessary. In this case a broad- 
er instrument must be chosen, or a small piece of plug- 
ged linen must be placed in the midst of the instrument, 
corresponding with the prolapsed portion, which is easily 
retained by this contrivance. 
In recommending these instruments, and especially the 
latter one, to the consideration of the profession, I am 
sustained by the experience of our European brethren, 
who have used them with such general satisfaction, that 
scarcely any other form is now in use. Lately Dr. A. 
Maybe, of Berlin, has published a paper on the use of 
Zwank’s pessary, wherein he reports to have successfully 
applied it in 230 cases. For my own part, I avoid the use 
of pessaries as much as possible. But I have had under 
my care a number of cases, in which a pessary was the 
only means justifiable. I have tried a great variety of 
them, and have now come to the conclusion that Zwank’s 
(or Eulenburg’s) hysterophor answers better the requi- 
sites of a good pessary than any other. 20 
I therefore ask practitioners to give it a fair trial. I do 
not mean to buy a hysterophor, and sell it to the next wo- 
man with prolapsus uteri, but after carefully selecting the 
case, in which nothing but a good pessary will give suf- 
ficient satisfaction, let the different sizes be tested, until 
the proper instrument is found. 
E. Noeggerath, M. D. 
No. West 26th-street.