THE INTRA-UTERINE 
STEM ; ITS HISTORY, 
ABUSE AND USE. 
BY 
WALTER P. MANTON, M. D. 
Visiting Physician to the Woman's Hospital, Detroit; 
Consulting Gynecologist to the Eastern Asylum ; 
Sec'y of the Detroit Gynecological Society; 
Fellow of the American Society of Ob- 
stetricians and Gynecologists, and of 
the British Gynecological 
Society, Ac. 
REPRINT FROM TRANSACTIONS 
OF 
Michigan State Medical Society, 
1889. [Reprint from Proceedings of Michigan State Medical Society, 1889.] 
INTRA UTERINE STEMS-THEIR HISTORY, 
ABUSE AND USE. 
W. P. MANTO#, M. D., 
Detroit. 
The history of any invention, traced from its earliest concep- 
tion through a long line of adaptations and modifications, down 
to the completed and perfected object, cannot but present some 
points of interest to the most indifferent. Very often we find 
the crude original to be the outcome of necessity, the hasty 
creation of a desperate moment, or the result of careful, labori- 
ous thought and experiment; we see it passing through the 
hands of one and then another, twisted and changed in form 
from time to time, until at last it remains only the idea of its 
archetype. 
While undergoing these changes it lives through various 
periods of opinion and criticism; it is tried and found wanting, 
and becomes lost to sight. But if it be an invention of true 
merit, it cannot be forgotten, it crops out again to be reheralded 
and lauded until some mishap turns the scale, and we hear no 
more of it. Again and again is this little cycle repeated, until 
at last it finds its proper place and is retained, because more is 
known and appreciated, not only of the invention itself, but 
also of the conditions with which it must be surrounded in 
order to insure success. 
Perhaps no one instrument used in gynecological practice 
has had a more remarkable history than the appliance which 
forms the subject of this paper. For nearly a century this 
little invention to straighten a flexed womb, and dilate a nar- 
rowed uterine canal, has survived under the most peculiar and 
extraordinary conditions. It has been denounced, villified, and 
proscribed by the highest medical authorities and councils. It 
has been lauded and indorsed by equally well-known and dis- 
tinguished men. And yet, in spite of both condemnation and 
praise, it exemplifies the survival of the fittest, and has refused 
to be relegated to oblivion. History gives us no proof that 2 
STATE MEDICAL SOCIETY. 
the uterine stem was used before the present century, but we 
learn from the writings of the fathers of medicine that both 
Galen and yEtius recognized and replaced with their fingers 
the dislocated uterus. It is therefore difficult to believe that 
these men and their followers could have gone on with this 
digital reposition and not have discovered that a small rod of 
bone or other material, placed in the canal of the uterus, would 
keep it straight. Nor can I conceive that the brilliant intellect 
which devised and manipulated the trivalve speculum a century 
or more before the Christian era could have let so simple and 
important an addition to his armamentarium as the uterine 
stem escape him. Indeed, there are among the various imple- 
ments exhibited at the Naples museum, taken from the so-called 
house of the surgeon at Pompei, several articles which bear a 
not unsimilar appearance to the stem pessary. Does it seem at 
all probable that men so well versed in anatomy as to give the 
proper curves to a male catheter or sound, could have been in 
ignorance as to the presence and appearance of the uterine 
canal? Total darkness, however, surrounds the invention and 
application of the stem pessary up to 1803. In this year, 
according to Hohl, a certain Moller used a pliable staff in the 
uterine canal to rectify a malposition of that organ, and from 
this date we must reckon the beginning of orthopoedic interfer- 
ence in uterine displacements. 
Moller's deductions, whatever they may have been as to the 
feasibility of such a procedure, seem not to have found prompt 
acceptance, for within a period of twenty-five years following, 
literature furnishes us with but one example of an attempt to 
replace the uterus by mechanical means. Osiander, in 1808, 
had the temerity to imitate his unsuccessful predecessor, and 
by means of his dilator to restore the retroverted womb to its 
normal position. In 1827 or '28 Amussat began to use a small 
stem of ivory to rectify uterine displacements, and was more or 
less successful until one unfortunate young patient developed a 
peritonitis which resulted in her death, a termination so dis- 
tressing that Amussat was led to abandon this method of treat- 
ment.* 
* This statement, found in the German edition, 1864, of Tilt's Uterine 
Therapeutics, does not accord with that of Dr. Quetier, who, in his thesis on 
retroversion, published in 1828, states that Amussat was successful in many cases. W. P. MANTON. 
3 
Moreau and Velpeau took up the mechanical treatment of 
this class of cases in 1830, but for lack of satisfactory results 
soon abandoned it. Following this a period of fourteen years 
ensued, during which the stem treatment appears to have made 
little or no progress. The modern era of the intra-uterine 
stem, may be said to have dawned in 1843-44, when Sir James 
Y. Simpson introduced what he called a form of permanent 
bougie for dilating the cervical canal in dysmenorrhoea. 
This method of handling a very distressing condition was so 
satisfactory in its results that it led to the devising of the stem 
pessary. So great was Simpson's confidence in the efficacy 
of his invention to straighted a distorted womb, that he, as 
Tilt somewhat petulantly writes, "advocated his stem pessary 
in the same enthusiastic spirit with which he took chloroform; 
tallow for consumption; numismatics; or revivals." 
Such unqualified indorsement from a leading teacher was 
not long in begetting disciples and imitators, and there can be 
little doubt that to the frequent accidents and sometimes deaths 
which resulted, and which a few words of caution and sugges- 
tion from Simpson's own lips might have averted, the odium 
and distrust which has existed until recently, and even now in 
some quarters opposes the usefulness of the intra-uterine stems, 
is due. 
The success of Simpson having been noised abroad, Velleix, 
of Paris, took up the mechanical treatment of uterine displace- 
ments. In 1853 he published a collection of 117 cases, in which 
78 had been cured, 14 unrelieved, and the remainder benefited 
by the use of the stem. 
The publication by Broca, in the following year, of a case 
of death from sounding the uterus, and the statement in his 
article that he was authorized to report fatal cases from the use 
of the uterine redresseur in the practice of Aran, of Nelaton, 
and of Cruveilhier, led to an investigation of the orthopoedic 
treatment of uterine cases, by the Paris Academy of Medicine. 
The result of this investigation was that the intra-uterine stem 
was denounced, as not only useless but dangerous, and the 
opinion advanced that it should be totally abandoned in prac- 
tice. 
In Paris, as in England, however, a few wise individuals 4 
STATE MEDICAL SOCIETY. 
did not share in this wholly adverse opinion. It is related of 
Velieix, who was one of those to continue the treatment, that he 
kept on reducing the length of the instrument until it would no 
longer remain in the uterus; which gave Huguier the oppor- 
tunity to report that he had examined women by whom the 
intra-uterine pessary was said to be well borne, and found the 
stem outside the womb. 
While Simpson and his school in England, Velieix and others 
in France, were carrying out the mechanical idea, notice of 
Kiwisch and his followers in Germany must not be omitted. 
This observer was, perhaps, the first to point out certain prin- 
ciples of action, and hang up danger signals for the guidance 
of those using the stem. 
He stated that while the stem should not remain too long 
in the uterus, such minor symptoms as hemorrhage, increased 
blenorrhoea, and uterine colic, did not contra-indicate its use. 
He especially drew attention to the fact that the stem should 
not be employed in cases of retroflexion with adhesions, or in 
hypertrophy and induration of the uterus with a tendency to 
peritonitis, hemorrhage and colic. 
Although many authenticated cures by means of the intra- 
uterine support were placed on record, the occasional accident 
or death resulting from its careless and indiscriminate employ- 
ment tallied heavily against it, so that we find West, as recently 
as 1864, writing that its use was almost universally discon- 
tinued, and that probably in a few years more the uterine sup- 
porter and its uses will have become mere matters of history. 
Since West's time many and able have been the warfares 
of words waged pro and con the medical treatment of uterine 
displacements. 
If we pause here for a moment and consider the mile-posts 
marking gynecological advancement during the present century, 
we may perhaps understand why the use of the uterine stem 
in the hands of the earlier profession was attended with such 
disastrous results, and why some were so hot in urging or 
denouncing its employment. 
In the first place we must remember that the normal and 
abnormal position of the uterus were shrouded with a veil of 
uncertainty. While marked deviations were perhaps recognized, W. P. MANTON. 
5 
minor displacements were overlooked, and the pathological 
conditions effecting them were almost wholly unknown, or 
ignored. A glance through the periodical literature of the 
past twenty-five years, will convince one how greatly adrift in 
this matter gynecologists have been ; nor can we say to-day 
that the question is no longer sub Judice. 
Many and varied have been the theories and demonstrations 
advanced in regard to the normal position of the uterus, and I 
have but to mention the names of Cusco, Kohlrausch, Klob, 
Crede, Schroeder, Schultze, Bennet, Braxton, Hicks, Van de 
Warker, Foster, and a score of others, who have written on 
this subject, to indicate the character of the men who have 
thrown their knowledge and ability into the controversy. 
Prof. B. F. Schultze, of Jena, whose work on the pathology 
and treatment of displacements of the uterus, originally pub- 
lished in 1881, has recently been translated into the English 
language, has done more, perhaps, than any other one observer 
toward settling this vexed question. And yet, clear and 
demonstrable as Schultze's arguments are, he has many op- 
ponents. 
In regard to the pathology of displacements I have to call 
your attention to the admirable treatise of Dr. Grailey Hewitt, 
of London, who presents the subject in a comprehensive and 
convincing manner, the result of years of careful observation; 
and yet, nevertheless, Dr. Hewitt's views are not acceptable 
to all. 
I do not, however, intend to even touch upon these moot 
points, which would of necessity involve an almost endless 
discussion. I simply mention them to show that, if to-day, 
after all the careful work which has been put into this depart- 
ment of medicine, we are not entirely settled in our own minds 
in regard to certain factors which enter into the reasonable 
discussion of the treatment of uterine displacements, it is not 
to be wondered at that the earlier observers so often failed in 
the successful fulfillment of their undertakings. 
Another reason why disastrous results so often followed the 
the use of the intra-uterine stem is traceable to the clumsiness 
of the instruments employed. A glance at the redresseurs of 
Velleix, Kiwisch, Kilian, Detschy, the earlier form of Simp- 6 
STATE MEDICAL SOCIETY. 
son's stem, and many others, will show to what abusive 
treatment the long-suffering uterus was subjected. 
To ignorance of uterine pathology, and the inappropriate- 
ness of the instruments employed, a third element contributing 
to unsuccess, namely the absence of antiseptic precautions, 
must be added. It is now pretty well established that certain 
germs may exist in the human body in a state of health, 
inocuous and harmless; but given a pathological soil, these 
same germs develop into mischievous and death-producing 
organisms. 
Taking, therefore, an unsuitable case, a clumsy instrument, 
and a total disregard for cleanliness, could a better bid for 
untoward results be imagined ? 
In the foregoing remarks I have briefly summed up the 
history of the intra-uterine stem, from its first application to 
the present time, and there now remains for me only to con- 
sider in few words the status and application of the instrument 
of to-day. 
Now, as formerly, this method of treating uterine displace- 
ments has its adherents as well as its opponents, but the former, 
and among them the leading men of this country, are gradually 
but surely out numbering the latter. And it is safe to say that 
the time is not far distant when the opposition will be silenced 
and the stem will be allotted its legitimate place in gynecological 
treatment. 
If we are to account for the mishaps, which even now we 
often hear said, follow the use of the stem pessary, we must begin 
by taking into consideration the suitableness of cases. The 
large majority of uterine displacements seen in practice can be 
corrected by means of a proper, well-fitting vaginal pessary, 
alone, or in combination with general treatment and local ap- 
plications. It is therefore an error to make use of the stem 
until all these other means have been tried and found inefficient; 
for it is to the indiscriminate use of the instrument to-day, as in 
the past, that the failures following its employment are to be 
attributed. 
It may indeed be stated as an axiom that the cases where 
the stem can be used with benefit are extremely few. But, we 
must not overlook the fact that there still remain a few W. P. MANTON. 
7 
undoubted instances where nothing that we can do will relieve 
the patient, and we are finally forced to the stem. Now just at 
this point another serious mistake often occurs,-it is too often 
forgotten that the uterus is an organ rich in lymphatics, nerves, 
and blood vessels, and that unless the parts are put in a healthy 
condition, and tolerance to a foreign body in the uterine canal 
established, we are apt to do more harm than good by our 
interference. Too often a stem is used to straighten a uterus, 
inflamed, sensitive, engorged and enlarged, and the result is 
that pain, hemorrhage, and perhaps a localized peritonitis 
supervene and almost irreparable injury is done. 
But granted that these points have been well considered, 
the careful disinfecting of the vagina and the stem before its 
introduction are often neglected. This I believe to be, not 
only good practice, but absolutely essential if we expect to 
give our patient every chance for relief or cure. 
It was Spiegelburg, 1 think, who said that some uteri were 
like leather bags,-you could do anything with them, and put 
anything into them without creating a disturbance. Most of 
the cases which come under observation, however, are not 
constructed on this plan, and we cannot exercise too great 
precautions or prepare the way too thoroughly for our proposed 
treatment. 
One of the most important points to attain in this method is 
the establishment of uterine tolerance. Formerly this caused 
no end of anxiety, time, and the exhibition of patience, but 
since the introduction of the soft stem by Dr. A. Reeves 
Jackson, of Chicago, this end is accomplished more quickly and 
with less annoyance to both patient and physician. When the 
uterus can bear the presence of the sound in its cavity for the 
space of a few minutes, one of Dr. Jackson's stems may be 
introduced, and the patient allowed to wear it for a week, or a 
month if necessary, observing of course the usual precautions. 
When the soft stem can be tolerated for this length of time, it 
is quite certain that the hard rubber instrument will be worn 
without danger. 
It is unnecessary for me here to go into the details of 
manipulating the stem, the selection of cases, or the watchful 
care and surveillance under which the patient must be, while 8 
STATE MEDICAL SOCIETY. 
wearing a stem pessary, for these may be found in the modern 
text books on gynecology. 
But I desire to call to your especial notice: 
i. That the history of the stem pessary furnishes conclus- 
ive proof that it is destined to a permanent place in the 
gynecological armamentarium, and that opposition to its use 
in the future, as in the past, will prove futile. 
2. But, that its indiscriminate and careless use is to be 
strongly deprecated. 
3. That the cases where its actual application can be ex- 
pected to be followed by beneficial results are very few. 
4. But that in the few, well-chosen, carefully-prepared 
individuals, under antiseptic precautions and with a proper instru- 
ment, the intra-uterine stem pessary accomplishes great good, 
affords immense relief to the patient, and in a small percentage 
of cases, undoubtedly leads to a permanent cure of the con- 
ditions for which it is applied. 
In concluding this paper on the uterine stem, gentlemen of 
the gynecological section, I feel almost like apologizing for 
bringing so trite a subject to your attention. 
I do so, however, with less hesitation for the reason, as it 
seems to me, that the medical profession, like the Athenians of 
old, are too much given to the telling or hearing of new things, 
to the exclusion, and greatly to the detriment, of subjects 
which are more intimately connected with our daily practice. 1 
trust that the little that I have had to offer on the subject of my 
paper, may serve to bring out a discussion which will be of 
much interest and value to us all. 
BIBLIOGRAPHY. 
In the preparation of the historical portion of the above 
paper, I have consulted Winckle's Die Behandlung der Flexionen 
des Uterus, mit intrauterinen Elevatoren, Berlin, 1872, and the 
text-books and the periodical literature of the past fifty years 
or more.