INTRA-UTBRnTB 
PE^eKtES. 
A Reply to “M Pm for Women” 
In the Louisville Medical News of May 26, 1877. 
BY 
V. H. TALIAFERRO, M. D., 
ATLANTA, GA., 
Professor op Obstetrics and Diseases of Women and Children in the Atlanta Med- 
ical College; President of the Atlanta Academy of Medicine; Secretary 
of the Board of Health of the State of Georgia. 
FROM THE AUGUST NO. RICHMOND AND LOUISVILLE MEDICAL JOURNAL. 
LOUISVILLE, KY.: 
RICHMOND AND LOUISVILLE MEDICAL JOURNAL BOOK AND JOB STEAM PRINT, 
104 Green Street, 2d door west of Post-office, 
1877. httra-tttbe/IUe 
PESSARIES. 
A Revlv to “A Plea for Women” 
In the Louisville Medical News of May 26, 1877. 
BY 
V. H. TALIAFERRO, M. D., 
ATLANTA, GA., 
Professor of Obstetrics and Diseases of Women and Children in the Atlanta Med- 
ical College; President of the Atlanta Academy of Medicine; Secretary 
of the Board of Health of the State of Georgia. 
FROM THE AUGUST NO. RICHMOND AND JoU R?»A|..'; 
LOUISVILLE, kA 
RICHMOND AND LOUISVILLE MEDICAL JOURNAL BOOK AND JOB STlEAM PRINT, 
104 Green Street, 2d door west of Post-office, 
1877. INTRA-UTERINE STEM PESSARIES. 
“ A Plea for Women.”—Under the above title in the leading 
editorial of the 11 Louisville Medical News ” of May 26th, I am 
roughly taken to task in a discourteous and unscientific manner 
upon the subject of “A New Intra- Uterine Pessary,” recently 
presented to the Profession by myself. In this communication 
there appears to be reflections upon my professional character 
of a decidedly sjplenie nature. The author has voluntarily dis- 
claimed, in the most earnest and positive manner, any such 
intended reflections, and while necessarily compelled to accept 
such disclaimer, I must be pardoned for the expression, that he 
has a singular and careless way of putting together his English. 
It would seem, indeed, that while one thing is positively ex- 
pressed, quite another is as positively intended. 
The most casual reader of the paper criticised must have 
observed that it was designed simply as the presentation to the 
Profession of an instrument, with the method of its use, and 
not, as seems to have been inferred by my critic, a treatise upon 
intra-uterine pessaries. 
Now, when it is known that this editorial criticism comes not 
from the editor in fact, but from the editor so called—a mem- 
ber of and closeted at Army Headquarters of the South, rarely 
seeing a case of sickness, and still more rarely one in gynaecol- 
ogy, it must be acknowledged that the mountain indeed has 
labored ! 
When, in addition, as will be shown, this so-called editor has 
taken untenable grounds, to be explained only by the lack of 
information in the literature of his subject, then indeed his 
position is most unenviable; but certainly not more so than the 
journal which fathers and honors the production as its leader. 
When one assumes the r61e of critic, and especially the double 
role of critic and editor, it must be acknowledged that profi- 
ciency in the literature of the subject matter discussed is an 
essential prerequisite; certainly no position can be more pitia- 4 
INTRA-UTERINE STEM PESSARIES. 
ble than a lack of such proficiency, and while I “ would not 
willingly give the author a fraction of pain,” I shall be com- 
pelled to present him from this standpoint. 
Unfortunately for the Profession and the country, we have a 
class of medical men who have a mania for writing without a 
commensurate mania for study; a class who ridicule and criti- 
cise those things in which they know themselves most defective; 
a class who, “ armed with an endless variety of instruments, 
twist, poke, slash, cauterize and otherwise ” abuse the profes- 
sion that honors them. Unfortunate and pitiful class, and yet 
there is no way to save the country from their unmerciful med- 
dling. 
In the hands of the educated physician and gynaecologist 
the uterine organs are safe, as surgical diseases are safe in the 
hands of the educated and skillful surgeon. 
I have been presented by my critic as making a bold and 
dangerous innovation upon the established practice of gynae- 
cology, and in direct and positive antagonism to its declared 
teachings. While I have the right, and would not hesitate to 
make such innovation, properly sustained by facts, I have not 
done so in this instance. 
I am told that in introducing or recommending a stem pes- 
sary, I have done so “ in the face of the opinions of the leading 
gynceeologists of the world.”* 
To sustain this assertion that the leading gynaecologists of the 
world condemn stem pessaries, he brings forward Thomas on 
Diseases of Women, as follows: “To cast them entirely 
aside when such high authority* recommends them would be 
irrational and unjustifiable ;* to use them freely* in the face of 
such evidence as we possess would be reckless and unwarranta- 
ble.” According, then, to this author, stem pessaries are too 
highly recommended by distinguished authority to put them 
aside, and yet with all the lights before us, we should not use 
them indiscriminately. This is the whole meaning of the quo- 
tation, which not only endorses the stem pessary, but bases this 
endorsement on high authority. This is singular, since my 
critic has just declared that the “ high authority ” in gynaecol- 
ogy condemns them. 
* Italics mine. INTRA-UTERINE STEM PESSARIES. 
5 
I beg pardon of my critic, but let me quote a little further 
from Dr. Thomas : “ For none could hesitate to endorse the 
sentiment expressed by Malgaigne in the discussion upon the 
subject* in the Academy of Medicine in Paris in 1852, that a 
treatment which Amussat, Velpeau, Simpson, Huguier, and 
Valleix had tried, can not, should not, be considered as repug- 
nant to common sense.” 
Again : “ During the last five years there has been evidenced, 
however, a growing inclination to return to this plan,* and the 
last year has brought forth a number of reports favorable to it.” 
Again: “ It matters not which of these three varieties of 
irreducible flexion we meet with, it is incurable, except by two 
means : The use of the intra-uterine stem or the knife.” 
Unfortunate witness for his purpose, it would certainly appear; 
selected too as the single proof among so many “leading gynae- 
cologists,.” 
A further examination into gynaecological authorities will 
still more clearly show the estimate to be put upon the state- 
ments of my critic editor. Sir James Y. Simpson, whose genius 
and name will live always, tells us in his late posthumous work 
upon Diseases of Women, that “ the chief hope that we can, I 
think, ever entertain of the cure of amenorrhcea consists in the 
use of the intra-uterine or galvanic pessary.” Detailing a case 
of obstinate amenorrhcea from undersize uterus cured by stem 
pessary, he says : “At her own suggestion and urgent solicita- 
tion, I again introduced the galvanic pessary, and she wore it 
for about three years altogether without experiencing from it 
any kind of inconvenience.” 
In treating the subject of retroversions, Prof. Simpson tells 
us: “ But the question arises, will the uterus bear the presence 
of a foreign body in its interior ? Experience has replied that 
in properly selected cases the intra-uterine pessary can be worn 
without any drawback; and for many years before I had found 
a vaginal pessary that would give relief, I had recourse to the 
use of the stem pessary for the cure of retroversions, and in 
many cases still we are forced to use them when the vaginal 
instruments have failed.” 
* Treatment by the stem pessary. 6 
INTRA-UTERINE STEM PESSARIES. 
In his work on Diseases of Women, Graily Hewitt, referring 
to a cut of the stem devised and used by himself, says : “ The 
stem pessary here recommended is half an inch shorter than 
those which have generally been employed, * * * * * 
and which is about one and a half inches in length, and I have 
very rarely found it to produce irritation.” 
In referring to his special method of retaining the stem, he 
says: “ Unless proper means are adopted, the stem is never re- 
tained in the uterus. * * * * * This method of retain- 
ing the stem in utero answers well, and in suitable cases is a 
very valuable means of permanently straightening the uterus'' 
(Italics mine.) 
Prof. By ford, in his Diseases of Women, says: “ The stem 
pessary, as it is introduced in part into the cavity of the uterus, 
if properly adapted, also corrects all sorts of deviations.” * * 
“ It is the most perfect mechanical support we can make use of, 
for if adjusted in accordance with a just knowledge of the nat- 
ural place and position of the uterus, it is certain to prevent it 
from departing from it.” 
Prof. Peasley, of New York, tells us: “ There are certain 
cases in which a stem pessary must be used, and in which no 
other instrument will supply its place." (Italics mine.) 
Dr. Robert Barnes, of London, in a discussion of the paper 
of Dr. Routh upon the subject of stem pessaries in the Obstet- 
rical Society of London, said : “He was convinced that intra- 
uterine stems were, in properly selected eases, of the greatest 
use. He had frequently employed the galvanic pessary with 
satisfactory results in cases of amenorrhcea, the catamenia dis- 
charge appearing and the nervous symptoms passing away. In 
consequence of the zinc portion becoming rough, he advised the 
removal and cleansing of the instrument once a fortnight. In 
cases of dysmenorrhoea, he had, after incising the os, used 
Dr. Chambers’ stem with advantage, pregnancy having fre- 
quently followed the removal of the dysmenorrhceal condition.” 
Lomb Athill, in his Clinical Lectures on Diseases of Women, 
upon the subject of stem pessaries in flexions of the uterus, 
says: “ I have known much good to result in such cases as the 
foregoing from this simple treatment; it is at least worth try- 
ing before advising that an operation should be performed. INTRA-UTERINE STEM PESSARIES. 
7 
“ The use of the stem pessary is also specially indicated when 
painful menstruation exists with either retroflexion or ante- 
flexion of the uterus, for the stem not only renders the canal 
patulous, but by straightening the cervix favors the escape of 
the discharge.” 
Prof. Carl Schrceder, in his Diseases of the Female Sexual 
Organs, vol. x of Ziemssen’s Cyclopaedia, has this to say upon 
the subject of stem pessaries: “ The cases then which are 
adapted to the intra-uterine method of treatment are the pure 
flexions uncomplicated by inflammatory processes. Very good 
results sometimes attend its use in congenital ante-flexions, when 
the intolerable pain attending menstruation immediately disap- 
pears with the introduction of the stem, and conception not in- 
frequently follows years of sterility. Ketroflexion, too, as they 
occur in multiparae—though, to be sure, they are rarely seen— 
may produce much the same symptoms, and are eminently well 
suited to this method of treatment. ***** 
I am, therefore, disposed to regard the method of treatment by 
intra-uterine pessaries as very efficient in appropriate cases, and 
not particularly dangerous.” 
Prof. R. Olshaunsen, of Germany, says : “ Hence the appli- 
cation of stem pessaries in carefully selected cases is invaluable, 
and ought not to be discarded any more than numerous surgi- 
cal operations undertaken for the relief of affections not dan- 
gerous to life.” 
Lawson Tait, F. R. 0. S., Surgeon to the Birmingham Hos- 
pital for Women; Consulting Surgeon, etc., says: “The use of 
the galvanic intra-uterine stem of Simpson is the most pow- 
erful means that we possess for the treatment of uterine dys- 
menorrhcea or amenorrhcea.” 
Dr. Thomas Savage, Surgeon to the Birmingham Hospital 
for Women, etc., says: “Since Sir J. Y. Simpson introduced 
the galvanic stem for the cure of amenorrhcea, this instrument 
has been familiar to gynaecologists; but I believe that there is 
in the minds of many a very great dread of all kinds of intra- 
uterine therapeutics, and consequently by such the all but very 
occasional use of the stem is regarded with much abhorrence, on 
account of the dangerous or serious after effects which are said 8 
INTRA-UTERINE STEM PESSARIES. 
to arise. In the cases in which I have followed this treatment, 
none but the best results have occurred, and in not one case has 
there been the slightest symptom to lead me to think the case 
would have done better. I will not say as well by other courses 
of treatment. * * * * Jn reference to the after ill effects, 
parimetritis, metritis, endometritis, abscess of the broad liga- 
ment, may be spoken of as likely to arise. I have used intra- 
uterine stems for flexions, retro and ante, in forty-four women who 
have never been impregnated, and in not one has any ill effect 
followed, nearly all the cases having been attended at the least 
several times, at all events long enough to be watched and to 
discover if anything did arise at the hospital, after treatment 
had commenced. * * * The chief difficulty in the whole 
plan of treatment has been not what course to pursue, but what 
means to adopt to insure retention of the stem. * * * The 
point I wish to press is the great benefit, and almost, to me, so 
far, quite perfect safety of the intra-uterine stem.” 
Dr. Thomas Chambers, M. R. C. P., F. R. C. S. Edin., Physi- 
cian to the hospital, etc., premises the report of a number of 
cases of flexion successfully treated by the stem, as follows: 
“ Leaving all theories, therefore, for the present as to the causes 
of uterine flexion, it is proposed to illustrate their effects and 
successful treatment by putting on record a few typical cases as 
they have occurred in this hospital during the last few months.” 
In a discussion in the Obstetrical Society of London, Dr. 
Chambers said: “He had not found it necessary to adopt the 
prolonged preliminary treatment urged by Dr. Routh. He 
thought all dislocations should be reduced at once, and this 
method of treatment had, in his hands, proved most satisfac- 
tory. He thought it dangerous to introduce a stem in the con- 
sulting-room, or out-door department of a hospital, and then 
allow the patient to go home. She should be kept in bed after 
its introduction at least a week.” 
The length of time Dr. Chambers keeps his patient in bed 
after introducing the stem will be better appreciated when 
it is remembered that he rejects the usual precautionary 
measures. He reduces at once the displacement and introduces 
his stem under the influence of ether if necessary. Inflamma- INTRA-UTERINE STEM PESSARIES. 
9 
tory troubles, which must occasionally arise, are promptly met 
by appropriate measures, the stem in the meantime remaining 
in the uterus. 
The instrument of Dr. Chambers, as seen in 
the wood cut, is retained in position in the 
uterus by expanding arms, and is a modifica- 
tion of the excellent stem of Dr. Wright. This 
form of stem pessary is very popular in Great 
Britain, and the type of those most highly 
recommended. 
Dr. Meadows, in the Obstetrical Society of 
London, upon the subject of flexions, said: “Of 
mechanical means, the intra-uterine stem was 
far the most efficacious, and not mischievous 
if of the proper kind. He often used it, and 
rarely saw any mischief from it even in retro* 
flexion.” 
Dr. Horatio Storer, in the Gynsecological So- 
ciety of Boston, upon the subject of amenor- 
rhoea and sterility from undersize uterus, said: 
“ He had of late years, as formerly, placed 
much reliance upon galvanic metal stems, or 
intra-uterine batteries, discussed by the Society 
at a former meeting.” 
At the former meeting alluded to upon this 
subject, Dr. Storer stated: “That there were 
gentlemen who, from non-familiarity with the 
instrument, were skeptical as to the possibility 
of any direct results ensuing from its use, and 
Fig. 1 
A represents the handle, with terminal slit, by which the stem is intro- 
duced into the uterus. 
B, the stem itself, as left in the uterine cavity when the handle is with- 
drawn. 
C, the head of the stem, which alone remains in the vagina, the central 
facet fitting into the slit of the handle, the central cavity admitting of the 
free discharge of the uterine secretions. 
D gives a side view of the stem when fixed in the handle ready for intro- 
duction. It has the general outline of a sound, being a size larger. When 
the handle is withdrawn, the arms of the stem expand; their spring force being 
equal to its weight, it is retained in the uterus without difficulty. 
The instruments are represented in the engraving of half size. 10 
INTRA-UTERINE STEM PESSARIES. 
if this were granted, as to the way in which it was effected. 
* * * As to the benefits of this application in practice, he 
had constantly employed the batteries for more than a dozen 
years, and in many instances of functional amenorrhoea they 
produced a cure where all other means failed.” 
In the same discussion, “ Dr. Cutter stated that he had used 
galvanic stem pessaries for many years, and with the same re- 
sults described by Dr. Storer. He had never seen any evil 
from their use, and considered them a valuable means for in- 
ducing or increasing the menstrual flow.” 
I might continue these favorable comments upon the use of 
the stem from such men as Wright, Bantock, Gadson, Routh, 
Greenhalough, etc., but for the present it seems unnecessary for 
my purpose. 
I have shown beyond question the error of my critic in 
assuming that the leading gynaecologists of the world condemn 
stem pessaries. Instead of such condemnation, it is seen that 
quite the reverse is true. 
Scanzoni, whose work upon diseases of women was written 
some twenty years ago, is an avowed opponent of the stem pes- 
sary, and evidently rests his opposition upon the uncertain 
results obtained from the instruments of Valleix, Kiwisch, and 
Detschy. 
When it is remembered that these instruments, by their 
extra-uterine and extra-vaginal attachments, disregard and in- 
terrupt the physiological movements of the uterus, hence sub- 
jecting the organ to the dangers of friction and concussion, it 
can not be wondered that he uses the following language: “For 
our part we have never cured a flexion.” 
An examination of the mechanism of the respective instru- 
ments of Simpson, Valleix, etc., will explain why those who 
followed the one had good results, while those who adopted the 
other had troubles continually. It will be seen that the instru- 
ment of Valleix virtually impales the uterus, destroying abso- 
lutely its freedom of mobility and subjecting it with the adja- 
cent structures to the constant danger of serious injury. The 
stem of Simpson, with its small exta-uterine bulb, rides so freely 
on the vaginal walls as certainly not to endanger the organ from 
concussion. INTRA-UTERINE STEM PESSARIES. 
11 
The synchronous movements of the uterus with the respira- 
tory act must be of the most delicate nature, and should always 
be borne in mind in the adjustment of a pessary, whether intra- 
uterine or vaginal. 
Fig. 2. 
It may be justly said that a pessary approaches perfection 
in proportion to its non-interruption with the- physiological 
mobility of the uterus, and vice versa. 
“ The uterine restorer of Valleix consists of a staff, A, intended to pene- 
trate into the uterine cavity. At its base is a metallic disc four-fifths of an 
inch in diameter, and terminated below by two circular protuberances, be- 
tween which should be placed the hollow disc of rubber, B. The first part of 
the apparatus is united by a spring joint with another staff made of metal, 
which, being intended to remain in the vagina, has received the name of the 
vaginal staff D. The spring G, situated at the joint of the disc with the vag- 
inal staff, is arranged in such a manner that it seems to maintain these two 
parts bent at a right angle. The vaginal staff is hollow to receive a solid 
staff, which is firmly fixed at a right angle to a plate destined to be placed 
upon the abdomen. The two distinct parts of which this apparatus is com- 
posed are maintained united by the aid of a thread passed through a hole, F> 
made in the vaginal staff near the joint. The thread C 0 is attached to the 
plate E, which is to be fixed along the abdomen by means of two bands 
fastened to its superior portion and forming a girdle; two other bands run- 
ning under the thighs are attached to the lower part, near the point where 
the thread ought to be tied that unites the two portions of the instrument, 
H H." (Scanzoni.) 12 
INTRA-UTERINE STEM PESSARIES. 
The objectionable features of Simpson’s stem and its modifi- 
cations are the difficulty in its retention and the friction conse- 
quent upon its independent upward and downward motion in 
the uterus. It was to meet these diffi- 
culties that the delicate stem, with its 
silver suture attachment, was devised, 
and for which I have been so roughly 
handled. 
My critic proceeds: “But the indis- 
criminate* use of stem pessaries is unqual- 
ifiedly condemned.” This would imply 
that the indiscriminate use of vaginal pes- 
saries, or perhaps many other things, are 
approved. How ridiculous! The indiscriminate use of no 
appliance in medicine, surgery or gynaecology is allowable, but 
unqualifiedly condemned. It is the discriminate use of all 
medical and surgical appliances that distinguishes the empiric 
and pretender from the educated and skillful physician. 
This effort upon the part of my critic to make the impression 
that I have recommended the indiscriminate use of stem pes- 
saries is simply absurd. That he makes this effort appears the 
more palpable, as he says further on: “ And the only other 
additional precautions which he adopts are those of dress.” 
The caution previously given to which he refers being the few 
days rest which I advised should follow the introduction of 
the stem. Now this is unpardonable, and only to be explained 
upon the ground of carelessness or the willful corruption of 
facts. The precautionary measures in the paper criticised are 
carefully and concisely given, and in order to make them espe- 
cially prominent, are enumerated: 1st, 2d, 3d, 4th, 5th, 6th, 
and 7th, under the following head: “ The special points to be 
observed in the use of the intra-uterine stem are.” 
I must beg pardon of the reader for repeating here these 
Fig. 3. 
“ Intra-uterine stem pessary, for the cure of retroflexion. A, lower or vag- 
inal aspect of the bulb; B, upper surface of the bulb, on which the cervix 
rests; D, intra-uterine portion, or stem; C, point of the staff used to facilitate 
the introduction." 
* Italics mine. INTRA-UTERINE STEM PESSARIES. 
13 
special precautionary points as given in the paper criticised, 
and which are as follows: 
“1st. A fit sufficiently loose to make no undue pressure at any 
point, and which at the same time is sufficiently close and secure 
in position to prevent any free motion of the instrument. 
“2d. It should be perfectly secured in its position in the cer- 
vix, so that no slipping up and down is allowable. 
“3d. It should cause no pain or uneasiness either in its intro- 
duction or its continued use. 
“4th. The point of the instrument, when introduced, should 
extend but little beyond the internal os. 
“5th. The uterus should be free from any marked tenderness 
or congestion. 
“6th. The peri-uterine structures should be soft and elastic, 
and free from tenderness. (The italics are mine.) 
“7th. The instrument should be light and simple in construc- 
tion, flat in shape, and preferably of zinc and copper, or copper 
alone.” 
In the face of these facts, my critic states positively that I 
have given but two precautions: 1. In regard to dress. 2. A 
few days rest immediately following the application of the stem, 
when in fact ten are given, including the two he mentions, and 
the last sentence in the paper, viz.: “ The vaginal douche of 
hot water should be daily used while the pessary is worn.” 
Nowhere in the entire array of distinguished authorities I 
have quoted will be found the precautionary measures in the 
use of stem pessaries so carefully and precisely detailed, and 
yet notwithstanding this and their prominence in a short paper 
of a little more than three small pages, their existence is not 
only ignored, but positively denied. 
My critic further writes: “All gynaecologists who attempt to 
employ intra-uterine pessaries provide a ready method by which 
they may be removed, and every precaution is adopted to guard 
the wearer of the instrument; but the author of this the latest 
novelty absolutely rejects such precautions.” 
It has just been shown that the benefit of every available 
precautionary measure is given the patient subjected to the 
stem pessary; and if he means by ready method a means by 14 
INTRA-UTERINE STEM PESSARIES. 
which the patient herself may remove the instrument, his state- 
ment is equally as unfortunate in point of fact. I know of 
no stem pessary provided with a ready method of removal by 
the patient unless it be the old and awkward instrument of 
Valleix and Detschy and their modifications, discarded more 
than twenty years ago; or the comparatively recent and inge- 
nious instrument of Cutter, of Boston. These having vaginal 
attachments are readily removable, but as I have shown repre- 
hensible. The stem in most common use has a small vaginal 
bulb, which rests, with the uterus replaced, upon the posterior 
vaginal wall and looking backward toward the coccyx. In such 
relative position of the parts, few women without the most care- 
ful education would remove readily the stem, and hence such 
instruments can not be said to be susceptible of ready removal 
by the patient; the popular instruments of Great Britain with 
intra-uterine expanding arms are entirely beyond the patient’s 
control. 
If my critic means ready removal by the surgeon, then the 
simple instrument with a vaginal bulb is certainly most readily 
removed as it is readily introduced; next the stem secured by 
silver suture; lastly the most difficult, the deservedly popular 
instruments of Wright, Chambers, Bantock, etc. 
To remove the stem secured by silver suture, we need simply 
a pair of long-handled scissors, which being introduced along 
the palmar surface of one or two fingers in the vagina, is car- 
ried up to the wire, which is clipped inside the compressed shot, 
when the stem easily slips out. It is done quickly and easily. 
A Sims’ speculum may or may not be used for the removal. It 
is done more quickly with the patient on her back without the 
speculum. 
It is of course well understood by all gynaecologists that a 
patient with a stem pessary is not to go beyond the observation 
of her physician, unless by transfer from one doctor to another, 
with instructions as to her condition and requirements. My 
critic proceeds: “We would not willingly cause the author a 
fraction of the pain that his pessary must occasion some unof- 
fending woman; but it has evidently not occurred to the gen- 
tleman that he has conceived and brought forth a dangerous INTRA-UTERINE STEM PESSARIES. 
15 
and mischievous instrument, for his delicate pessary, 'made in a 
little while in any doctor’s shop,’ when handled by a bungler, 
will be nothing less.” 
What ridiculous twaddle ! Dangerous and mischievous when 
handled by a bungler! Accordingly, then, nothing in medi- 
cine or surgery should be in use but what can be handled safely 
by a bungler. If I comprehend the import of words, this is 
the meaning of my critic. 
In this remarkable criticism the following curious reasons are 
given why the stem pessary is dangerous and should not be 
used: 
1st. “ It may be handled by a bungler. 
2d. “ If adopted at all, it will be by inexperienced men. 
3d. " Because its employment will undoubtedly make work 
for some country coroners. 
4th. “ The author presents his instrument and its novel at- 
tachment clad in verbiage which is all ‘couleur du rose.’ ” 
(If any of the readers are incredulous, they are respectfully 
referred to the “ Louisville Medical News,” leading editorial 
of May 26th, 1877.) 
It can not be denied that a large amount of ignorance per- 
vades the profession upon the subject of pessaries, nor can it be 
denied that they are unprofitable and oftentimes dangerous in 
the hands of “ bunglers but must we abandon valued resources 
because forsooth the ignorant may do damage with them? 
The proposition is too silly for respectful consideration. 
No pessary, and especially the intra-uterine stem, should be 
used without a thorough and skillful understanding of its 
mechanism and the objects to be attained; the "tactus eruditus” 
and a thorough appreciation of the contra-indications are abso- 
lute prerequisites. The medical man who from ignorance or 
blind prejudice rejects these instruments is clearly not in accord 
with the advanced teachings of the day. It is true that only a 
limited number of cases are suitable for stem pessaries, but these 
are not remediable by other resources, unless it be to a certain 
extent by the knife. 
There are certain propositions to be considered always in the 
use of stem pessaries. 16 
INTEA-UTERINE STEM PESSARIES. 
1st. Precautionary measures to precede the use of the stem. 
2d. Precautionary measures necessary during the use of the 
stem. 
3d. Diseases calling for the stem. 
4th. Length of time the stem may be worn. 
5th. Kind of stem preferable. 
The precautionary measures necessary to precede the use of 
the stem apply particularly to the uterus and the peri-uterine 
structures. If the uterus is congested and excessively tender, 
it is best to remove or at least modify these before using the 
stem. If the peri-uterine structures are tender, and if in addi- 
tion they be not soft and elastic, or the uterus fixed by adhe- 
sions, the stem is not admissible until these are removed. 
The failure of appreciation and recognization of these con- 
gestions and inflammatory conditions accounts for very much 
of the disfavor in which the stem was held some fifteen or 
twenty years ago, as also the present opposition of those un- 
skilled in its use. 
We should be careful that the beginning of treatment by the 
stem in no way conflicts with the menstrual epoch; hence it is 
well to introduce the stem some six or seven days after the 
cessation of menstruation, which, in addition, gives full time for 
the establishment of tolerance in the organ to the foreign body 
before the next period. 
The precautionary points to be looked for in the use of the 
stem are: Pain, soreness, or persistent discomfort in the region 
of the uterine organs. Should these occur, the instrument 
should be removed for the time being. For three or four days 
longer if there be the least discomfort) immediately follow- 
ing the application of the stem, the patient should be quietly in 
doors, and preferably in bed. Vaginal douches of hot water, 
with a Davidson syringe, twice or three times daily, should be 
used during the patient’s confinement, and subsequently twice a 
day while the stem is worn. The position of the patient on the 
back, with the hips a little elevated, is a matter of some conse- 
quence in the use of the syringe. Should the patient complain, 
as some do, of this position, she may use the douche effectively 
in the sitting posture, by grasping the labia firmly around the INTRA-UTERINE STEM PESSARIES. 
17 
nozzle of the syringe and pumping the vagina full to distension; 
this will require some four or five pumps when the hold is re- 
laxed and the vagina emptied. The process is again and again 
repeated, until the whole quantity of water is consumed. 
Habitual constipation should be guarded against by appro- 
priate measures. 
The patient should be thoroughly acquainted with the nature 
of the instrument she is using and the necessity of giving 
prompt notice of any untoward symptoms. 
After a few days from its introduction, when the uterus has 
become tolerant of its presence, no pain, soreness, or discom- 
fort arising, she may take her usual exercise on foot, horseback, 
in the ball-room; or as house-wife, cook, laundress, etc. 
In this freedom of exercise an absolute prerequisite is that 
the free motion of the viscera should be unimpaired by dress. 
Hence corsets, tight clothes, and heavy skirts suspended from 
the waist, should be positively interdicted. 
The pathological conditions amenable to the stem pessary 
cover a much broader scope than formerly considered. 
In flexions of the uterus, amenorrhcea from infantile uterus or 
superinvolution, dysmenorrhcea from whatever cause, sterility, 
endometritis with atrophy and thinning of the uterine walls, 
and indeed any condition in which we need constant and pro- 
tracted stimulation of the uterus, the stem is appropriate and 
invaluable. An experience extending over a number of years 
with different varieties of stem pessaries justifies the opinion, 
that with any reasonable care in the selection of cases they are 
perfectly safe. 
In reference to the length of time the stem may be worn, I 
can not do better than quote the language of Prof. Olshaunsen : 
“ The instrument must be worn as long as it is well borne, and 
as it seems necessary for a cure (a year or more) or relief of 
the trouble.” 
If a stem with vaginal bulb is used, the one represented in 
Fig. 4 is, on some accounts, to be preferred. It is very light, 
flat, with quite a small bulb, which enables it to move freely 
and easily over the vaginal walls. It is made of zinc and cop- 
per if galvanic action is desired, otherwise of the copper 18 
INTRA-UTERINE STEM PESSARIES. 
alone. Copper always keeps bright and clean when in use, and 
is, in my opinion, the very best material for a stem pessary. 
The vaginal bulb is made of gutta percha, or the dentist’s 
celluloid, shaped and secured to the stem while softened by 
heat. If the flexion is of such a nature 
that the cervix looks in the axis of the 
vagina, the stem will most likely not be re- 
tained. 
A Hodge pessary, or some of its modifi- 
cations, may be used to secure the cervix in 
its proper position, so that the stem can not 
escape by reason of its lodgment upon the 
posterior vaginal wall. 
Many devices have been adopted to keep 
this variety of stem in position. All vaginal 
attachments are objectionable, because they 
impair the mobility of the uterus. Where 
the stem is used in conjunction with a vaginal pessary, they 
should be entirely independent each of the other, and without 
diaphragms or cross-bars for fixing the stem, as found both in 
the arrangements of Thomas and Graily Hewitt. 
A stem pessary should rarely be over two inches in length. 
It should extend but little above the internal os, the usual site 
of flexion. The cavity of the body of the uterus is not as tol- 
erant of foreign substances as is the neck, a fact not to be lost 
sight of in the application of the stem. Very much of the un- 
popularity of the old instruments came doubtless from this 
cause and the too great length of the stem. 
It is only in conditions of the uterus as found sometimes in 
superinvolution, infantile uterus, etc., where the organ is not 
sensitive, and where a powerful stimulation is desired, that the 
length of the stem may be such as to approach and even to 
touch the fundus. 
Where the length of the stem is such that the cavity is much 
Small flat stem, made of strips of copper and zinc riveted together, with 
gutta percha or dentist’s celluloid, vaginal bulb. It is made of copper alone 
when mechanical action only is desired. It is from one and a half to two 
inches or more in length. 
Fig. 4. INTRA-UTERINE STEM PESSARIES. 
19 
encroached upon, or the fundus is reached, we can readily un- 
derstand the advantages of securing and fixing the stem, as 
described, by silver suture. 
The advantages of a stem pessary, which has not the slight- 
est independent motion, over those with a constant jogging 
motion, occasioned by the incessant upward and downward play 
of the uterus, must be apparent to every thoughtful mind. 
It has been suggested by medical gentlemen that the pres- 
ence in the tissues of the silver wire used for securing the stem 
was objectionable, as it might prove to be a source of constant 
irritation, and possibly inflammation. The innocuous character 
of the silver wire in living tissues is well known to surgeons, 
and is least of all things to be feared. 
The 21st of June, 1849, Dr. J. Marion Sims performed his 
first operation for vesico-vaginal fistula, in which silver suture 
was used. 
In the anniversary address of the New York Academy of 
Medicine by Dr. Sims, upon silver sutures in surgery, on the 
18th of November, 1857, alluding to his first cases of vesico* 
vaginal fistula, said: “After nearly four years of fruitless labor, 
silver wire was fortunately substituted for silk as a suture, and 
lo ! a new era dawns upon surgery.” 
The experience of twenty-eight years by renowned surgeons 
of the world has verified this statement and put beyond cavil 
the innocuous nature of silver wire in the living tissues. For 
the past three years I have used this delicate stem, with its novel 
method of attachment, in very many cases, and in one only has 
the uterus absolutely rejected the instrument; the presence of 
the wire had no agency in this. This case was reported to the 
Atlanta Academy of Medicine some two years ago, and is the 
one doubtless referred to by my amiable critic when he writes: 
“And he says nothing at all of his experience in cases where 
the uterus absolutely rejects his instrument with its novel attach- 
ment,” etc. The effort to make the impression here that I have 
attempted to cover up my unsuccessful cases is too contempti- 
ble. The only unsuccessful case occurring in my hands was 
promptly published, and through such publication only was the 
information accessible. 20 
INTRA-UTERINE STEM PESSARIES. 
The objections to the stem with silver suture are applicable to 
all stem pessaries; acting as a foreign body in the cavity of the 
uterus, they may under favorable circumstances set up inflam- 
matory action, with the result of pelvic abscess, pelvic periton- 
itis or general peritonitis. 
Such accidents, however, have not occurred in my hands with 
this stem, or indeed any other variety (several of which I have 
used), and I believe will not occur in properly selected cases. 
These inflammatory complications may and do occur from 
the indiscriminate or bungling use of any pessary, whether 
intra-uterine or vaginal, and the fact that they may fall into the 
hands of “ bunglers ” is a silly argument for putting them aside. 
I must apologize for the scope of this communication. It 
has been made necessary by the character of the criticism re- 
ferred to. I have had to write many things which the intel- 
ligent reader up with the literature of gynaecology already 
knew, in order to expose misstatements and false premises. 
In conclusion, I must beg the liberty of suggesting to my 
critic the wisdom of adhering to his legitimate domain, and 
treading other fields than gynaecology and journalism; lest his 
condition be likened to one Milo of ancient history, who after 
vanquishing all the athletes of his day, and performing many 
other marvellous feats, attempted in his plenitude of power to 
crown all by rifting open a knotty tree. The effort was too 
much for him; his strength gave out, and his hands becoming 
inextricably pinched in the cleft, he miserably perished. PERIODICAL MEDICAL LITERATURE. 
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