PAPER G/ 
A new form of Intra- Uterine Stem Pessary, with re- 
marks upon the general use of Intra- Uterine Stems.- 
By R. A. Kinloch, M. D,, Charleston, S. C. 
The value of the intra-uterine stem in the rectifica- 
tion of versions or flexions of the uterus is perhaps not 
yet definitely fixed. Since the time when Velpeau, 
Valleix and Simpson experimented with this means of 
treatment, to say nothing of the period anterior to this, 
the opinions of the profession, as to its value and its 
danger, have greatly fluctuated. The sentiment of Dr. 
Robt. Barnes, perhaps the best modern authority upon 
the diseases of women, may be considered as approxi- 
mating the correct view to be taken of this subject, and 
should be accepted in preference to eixher the enthusi- 
astically favorable reports of modern writers, like Drs. 
Savage and Chambers, or the unqualified condemnation 
of so able a practitioner as Dr. Emmett. 
"Before using any form, of intra-uterine stem," says 
Dr. Barnes, when discussing the treatment of retro- 
flexion, "it is desirable to ascertain whether the object 
cannot be attained without using them at all. The 
cases where it is necessary to use them are exceptional." 
Now, regarding these "exceptional cases," which such 
good authority recognizes, it must be admitted that the 
kind of stem employed is an important consideration. 
The condemnation of the instruments in general use 
must naturally have arisen from prejudice or from their 
proven inefficiency or danger, as illustrated chiefly in 
the use of unyielding stems with external attachments, 2 
Kinloch on 
and the employment of these, too, without discrimina- 
tion or adequate preparatory treatment. In other words 
the adverse decision as to the use of the stem eman- 
ated from the abuse of a principle. 
We are of those who maintain that the effort to get 
rid of the evils which attach to intra-uterine stems 
should not induce us to discard them from practice. 
Rather is it incumbent upon us to develop their true 
value. As a step towards defining our position on this 
question we present the following affirmations: 
1. All stems having external attachment or support 
must be discarded. 
2. All of those rigidly fixed to vaginal frames so 
large as to restrict the movements of the stem, and thus 
prevent the proper physiological play of the uterus, are 
unsafe. 
3. All of those whose lower extremity, or vaginal 
rest, is small, whether a ball, a disk or other form, and 
easily moveable in the vagina, are inefficient, because 
not capable of insuring the proper direction of the ute- 
rine axis, and are, besides, constantly liable to escape. 
4. Those that are called "self-retaining" in virtue of 
a divaricated stem, are not always so, and we fear are 
liable to injure the uterine cavity because of their degree 
of expansive force. They are not suited to versions, for 
reasons urged in connection with the last class. 
5. The simultaneous use of the Hodge pessary and 
the intra-uterine stem has been thought to overcome 
in cases of retro-version or retro and latero-flexions, 
many of the difficulties referred to as attached to the 
previous forms. "This separate mode of using" the two 
instruments, Dr. Barnes thinks "the safest and most 
satisfactory in its results." But it must be stated that 
the "separate use" necessitates, in the view of this able 
author, the employment of a divaricated stem, to which, 
as we have said, there are objections, on account of its 
elastic expansion when in the cavity. Stem Pessary. 
3 
6. The connected use of the Hodge pessary and the 
stem has been suggested and carried out after several 
devices by Dr. Graily Hewitt and others. The 
plan of Hewitt is by a hard rubber diaphragm, 
which bridges across the branches of the Hodge pes- 
sary, and serves to support and fix the stem. The 
rigidity of the stem, in this instrument, is an objection 
which we need hardly again urge. Very recently our 
excellent American authority, Prof. T. G. Thomas, of 
New York, has suggested the combined use of the two 
instruments-(there is here no actual connection, and 
yet the use of tire instruments is not separate in the 
sense of Dr. Barnes)-without actually connecting them 
when in situ. The plan enables him to dispense with 
the self-retaining or divaricated stem. The instrument 
is figured upon pages 411 and 422 of the last edition 
of Prof. Thomas' admirable and now world-known 
treatise on the diseases of women. The Hodge pessary, 
or vaginal frame, is here bridged by a shallow vulcan- 
ite cup, which holds the ball that terminates the lower 
extremity of the uterine stem. The object is to permit 
the physiological movements of the uterus and, as said, 
to retain the stem. This instrument is complicated, 
but ingenious. We have no practical experience with 
it, but have no doubt of its efficiency in cases of flex- 
ions, for which alone, the author seems to have intended 
it. Theoretically, we believe that in cases of version, 
the shallow cup for holding the stem would be found 
inadequate to prevent the tumbling over of a heavy 
uterus. It may be said that the Hodge attachment 
would of itself prevent this in cases of retro-version. If 
so, we opine there would be no necessity for an intra- 
uterine stem, and the combination of the two instru- 
ments would be without object. We infer that Prof. 
Thomas has had but little experience with this instru- 
ment. He has generally been opposed to the use of the 
intra-uterine stem, and has apparently, in this last edi- 4 
Kinloch on 
tion of his book, given it special attention in deference 
to the apparently growing favor, which it seems to have 
obtained with certain British authorities. 
Some years since, it will be remembered by members 
of this body, I called attention to and exhibited a model 
of a pessary devised by myself, in which were combined 
the Hodge lever with the intra-uterine stem. I had 
adopted this after a good deal of reflection, and some 
experience with the use of intra-uterine stems. This ex- 
perience began soon after my acquaintance with Prof. 
Simpson, made during a visit to Edinburgh, in 1855. 
Here is the original instrument of Simpson that I tested, 
as I also did the instrument of Valleix, having an exter- 
nal attachment. I cannot now fix the date of my earliest 
use of the Hodge pessary as the vaginal frame and sup- 
porter of the stem, but I am quite sure that the idea of 
combining the two instruments was independent of any 
suggestion.. After numerous experiments and devices, 
I adopted the instrument which I now, after three years, 
present again to this body, and which, up to this time, 1 
have not brought publicly before the profession, because 
preferring to test it by a larger experince. I am still 
free to admit that my experience in its use is not very 
large. The valued opinions of a few friends is my chief 
reason for here offering this paper, yet I may affirm that 
the last few years have confirmed me in my opinion re- 
garding the advantage to be derived from the judicious 
use of uterine stems in cases of flexion, in troublesome 
cases of retro-version, and in some forms of dysmenor- 
rheea. With regard to ante-version, I have had scarcely 
any experience. 
I now invite attention to my "Elastic Spring Stem Pes- 
sary,or the "Buckle Pessary" as it has been named by 
Messrs. Tieman & Co., to whom I am indebted for the finely 
executed drawings of the original instrument made by 
them. (See Figs. 2 and 3.) It is simply a union of the 
Hodge pessary, which is used as the vaginal frame and Stem Pessary. 
5 
support for the stem, and to assist, likewise, by its own 
action in supporting the uterus, with a hard rubber 
uterine stem two inches, or two inches and a quarter in 
length. The two instruments are connected by a delicate 
rubber cord, which is looped over the branches of the 
Hodge pessary, and furnishes an elastic support for the 
stem. I would here remark that any of the modifica- 
tions of the Hodge pessary, as the Albert Smith, the 
Graily Hewitt, or the "Hocker pessary" will answer 
equally well for the purpose. The plan adopted for at- 
taching the stem to tlie vaginal frame, with the rubber 
loop, is peculiar, and gives to the instrument a distinct 
and important action, from which, in some cases, it is 
thought advantageous results may be derived. The 
lower end of the stem is fashioned like a shirt stud, 
having a large and a small disk, with an intermediate 
neck. There is also a perforation in the centre of the 
lower disk. The larger disk is for the purpose of re- 
ceiving or supporting the os uteri; the lower one to 
prevent the slipping off1 of the rubber cord. 
After the rubber loop is slipped over the branches 
of the frame, the parallel cords are seized with the 
fingers and twisted to the necessary degree. The low- 
er disk of the stem is then passed between the cords, 
mid-way between the branches of the frame. The 
stem is thus at once grasped by the cord, which secures 
it at its neck. If the cords have been twisted towards 
the upper cross-bar of the frame, it is evident that the 
elastic force, produced by the effort of the cords to un- 
twist and resume their original parallelism, will tend 
to make the stem describe the arc of a circle and throw 
its upper, or free extremity, towards, or upon the lower 
cross-bar of the frame. The amount of this force will 
depend upon the size or strength of the rubber cord 
used, and the degree to which it is twisted. The advan- 
tage of this force, carefully regulated and gradually in- 
creased, I have verified in cases of retro-version where, 6 
Kinloch oh 
because of adhesions or contracted ligaments, the uterus 
at first refused to come up to its proper position. 
By twisting the cords in the opposite way, towards 
the lower cross-bar, the direction of the force is so 
changed as to serve our purpose of treatment, in cases of 
ante-version. To prevent any tendency of the loop to 
slip up or down along the branches of the frame, the 
hard rubber or metal, constituting this, may be easily 
notched with a file, at the point desired. It is always 
within the power of the operator to adjust the force to 
a nicety, in accordance with the indication to be fulfilled, 
and also to fix the loop at any required portion of the 
branches of the vaginal frame. A very moderate force 
is what is advised, in most cases, generally only the de- 
gree sufficient to keep the stem in the direction of the 
proper uterine axis, and offer a minimum resistance to the 
tendency to displacement of the organ in the noted di- 
rection. The uterine sound, or repositor, must be used 
from time to time, to assist in the restoration of the or- 
gan. 
To introduce the pessary, after due preparation of the 
patient, as explained below, it is best to employ Sims' 
speculum and to have the assistance of a competent 
nurse or physician. This is, however, not always ne- 
cessary. With a narrow vaginal frame/the introduction 
can be effected by the operator alonef through an ordi- 
nary Nott's, or Smith's even without a 
speculum, provided the operator is accustomed to this 
kind of manipulation. 
To illustrate the introduction of the pessary, in a case 
of retro-version: First, seize the anterior lip of the uterus 
with a long tenaculum to steady the organ. Then pass 
a uterine sound to get a correct idea of the size and di- 
rection of the canal. The stem, which is now secured 
and kept down upon the upper cross-bar of the frame 
by a sound or stout wire, introduced into the perforation 
of the lower disk (See fig. 3)-is now advanced along Stem Pessary. 
7 
the vagina (as is also the frame, but to a less extent), 
made to traverse the os, and to securely engage in the 
uterine canal. The wire is now withdrawn, as the 
pressed up higher and higher by the other hand of the 
operators finally adjusted with the cross-bar,' occupy- 
ing the;posterior vaginal cul de sac. 
While it is desirable, for facility of introduction, to 
have the vaginal frame as narrow as practicable, care 
must be taken that the length of. this be well adapted to 
the particular vaginal canal. It should not be long 
enough to act, as a brace or prop, and thus endanger 
the integrity of the tissues of the vaginal cul de sac, 
and yet it should have sufficient length to prevent much 
to and fro movement. 
In cases of anteversion, certain modifications of the 
manner of introducing the pessary will occur to any 
one familiar with uterine surgery, and need not be dwelt 
upon here. 
In every case, but in flexions more particularly than 
in versions, preliminary treatment has to be instituted, 
and this I will now allude to in a few remarks upon 
The General Use of the Intra- Uterine Stem. 
After completing a rough sketch of this paper, my 
attention was called to extracts from an article by Dr. 
C. H. F. Routh, read before the Obstetrical Society of 
London, December 4th, 1874. The views of this au- 
thor I find so nearly related to my own that it would 
be superfluous for me to dwell at length upon this sub- 
ject. But as all the members of this body may not be 
familiar with these views, as expressed by the very 
able gynaecologist referred to, I may venture a succinct 
statement of the principles of the preparatory treatment 
I have commonly adhered to. 
As already intimated, in the use of the stem I have 
endeavored to confine myself to such cases as could not, 
in my judgment, be managed by the more common 
means. 8 
Kinloch on 
I have ever appreciated the necessity of getting rid 
of all inflammatory complications, and of at least mod- 
erating the more prominent nervous symptoms. All 
the functions of the female are looked to with the view 
of improving those that are faulty. 
The frequent preliminary use of seatangle tents I 
insist upon, to inure the cavity to the presence of a 
foreign body. Often it is necessary to open the os by 
bilateral or other incisions. In flexions the canal must 
at times be straightened by preliminary incisions. The 
use of glycerine, cotton tampons, hot water vaginal in- 
jections, the frequent introduction of the uterine sound 
and uterine repositor, to aid in bringing the organ to a 
better position, applications of iodine or crude carbolic 
acid to the uterine cavity, are some of the means com- 
monly resorted to. 
When ready to try the stem in cases of obstinate 
version, I first use a simple stem that can be easily in- 
troduced and removed. This is not expected to be cer- 
tainly self-retaining, but its position is maintained by 
tamponing the vagina, and keeping the patient at rest. 
Figure 1 represents one that is convenient. The stein 
isof hard rubber, like the one used in connection with the 
Hodge pessary; its base, a soft rubber ball. The ball 
is perforated by the lower end of the stem, from which 
the lower disk has been temporarily removed. After 
perforation, the upper and lower parts of the sphere 
are pressed together, and the lower disk of hard rubber 
again screwed on to the stem. The ball is thus con- 
verted into a hemisphere, so that it will be better retained 
by the vaginal walls. The stem is introduced by seizing 
the soft rubber hemisphere with a pair of long forceps, 
and carrying the whole instrument up through a spec- 
ulum. 
In dealing with flexions, I first use an elastic stem, 
made of a coil of fine wire covered with rubber, or a 
beaded self-retaining stem of soft rubber cord, perfor- 
ated below to carry a wire (stem here shown as made Stem Pessary. 
9 
by Tiernan & Co). Thus, there is no effort to straight- 
en the canal too suddenly. Sometimes a seatangle 
tent precludes the necessity of using these flexible stems, 
or its use is a step preliminary to their introduction. 
After two or three days, if the uterus tolerates the 
flexible stem, it is removed, and the uterine and vaginal 
canals cleansed with a weak solution of carbolic acid in 
glycerine. Now the. elastic stem pessary is intro- 
duced, and kept in so long as it gives no discomfort or 
develops no alarming symptoms. The symptoms call- 
ing for removal of the stem are usually uterine pain, 
abdominal tenderness, bloody discharge, and sometimes 
gastric irritation. These I have met with only in ex- 
ceptional cases. ' 
The patient is constantly supervised and warned to 
give notice of any unusual occurence; she is allowed 
only moderate exercise within doors, upon one floor. 
The stem is retained in situ for one week, if there be 
no urgent reason to the contrary. In cases of dysmenor- 
rhoea, with or without flexion, the stem is kept in during 
the menstrual period. Upon its withdrawal, in cases of 
version, or version with flexion, the Hodge lever is used 
alone for one week or longer, if it seems in part to meet 
the indication, and then the stem is again introduced. 
The Hodge will not always keep the organ in position, 
but it will sufficiently elevate and support it so as to 
prevent us from losing, for the time, much that we have 
gained by the use of the stem. 
The modification of the Hodge, or of the Albert Smith 
pessary, that I have derived most satisfaction from, is 
one similar to that figured upon page 419 of Prof. T. G. 
Thomas' excellent treatise before referred to. The Al- 
bert Smith form of instrument is used, but the upper 
cross bar is bulbous, or of double thickness, so as not to 
cut the tissues of the vaginal cul de sac. It acts as a 
kind of crutch head for supporting the body of the 
uterus, disposed to retroversion. A heavy organ will 
often fall over the upper bar of the ordinary pessary, 10 
Kinloch on Stem Pessary. 
while it will be well supported by the modified instru- 
ment referred to. This modification of the instrument, 
so far as the bulbous character of the upper bar is con- 
cerned, I imagined original with myself. The instru- 
ment was perfected for me by Messrs. Tieman & Co., 
some years since, after many endeavors, and sold as my 
pessary. Since the issue of Prof. Thomas' late edition, 
I have noticed a similar instrument figured, and called 
his "retroflexion pessary." The principle of the thick 
or bulbous cross bar is the same as my own. Regarding 
the other points, of length, breadth, curve, and theory of 
action of the instrument of Prof. Thomas, I am not pre- 
pared to express an opinion. Having very recently 
learned from my distinguished friend, that he had sug- 
gested the bulbous cross bar, and devised and used such 
an instrument long anterior to the beginning of my own 
experiments in this direction, it affords me pleasure to 
yield to him any credit for originality or priority that 
heretofore I might have been disposed to claim. 
If upon withdrawing the internal stem, it is found 
that the Hodge pessary as modified will not support the 
uterus satisfactorily, it may, for a time, be dispensed 
with, and the vagina simply tamponned with cotton 
saturated with glycerine, or with a solution of per sul- 
phate of iron. Rest is enjoined, and after a few days, 
the stem is again introduced. Perseverance is essential 
to success. In few cases of disease will we find it so 
necessary, during the application of our therapeutical 
resources, to bear in mind the old and safe motto-fes- 
tina lente. 
In conclusion, permit me to say that in a field limited 
to a private practice, experience is necessarily restricted, 
and while I have thought it not egotistical or improper 
thus briefly to give my views regarding a subject of 
great practical importance, it will be a source of no 
humiliation or disappointment if, upon a thorough trial 
of the means here suggested, a sound professional j udg- 
ment should fail to sustain me. Fig. 1. 
Fig. 2 
Fig. 3. 
Dr. R. A. Kinloch's Stem Pessary