The air pessaries cannot remain long in the vagina, for the air escapes, they become rough and foul-smelling, irritate the vagina, and their con nection with the stems loosens. Simpson's and Martin's elastic regulators are so firmly attached to the pessary, that the stem readily irritates the uterus and prevents the normal movements of the organ.
The insertion of tampons is unquestionably the best method of retain • ing the stem in position, but this method is open to the objection that the patient must be kept under constant supervision, since the tampons must be changed every twenty-four to forty-eight hours. This applies also to tampons which are impregnated with glycerine or tannin and glycerine. Iodoform gauze, on the other hand, may remain in situ for four to six days.
To fix the stem is not, however, the only object of the procedures we have mentioned The stem straightens the flexed uterus and also causes a version, and in order to overcome this version and to maintain the organ in good position, other instruments are needed. This refers in particular to retroflexions. The pessary is then inserted so that its extra uterine end points backwards, and thus the uterus is anteverted, and the organ is steadied, as is Schultze's custom, by the insertion of a figure of eight pessary.
The indications for resort to the intra-uterine stem have not been distinctly formulated even by its partisans. Pure flexions of the uterus, forwards, backwards, laterally, are the most common indications. The best results are obtained in case of congenital flexions of high grade, and they are not so good in case of women who have borne children, or in whom the flexion is acquired. Simple, uncomplicated curvatures only exceptionally call for the ham-uterine stem, although Schultze claims that every case of retroversio-flexio in which, on account of the retroposition of the cervix, the body of the uterus flexes backward, calls for intrauterine orthopedic treatment Huguier has also used the intra-uterine stem in case of amenorrhea; Simpson aimed at the same end in the use of his electric pessary, and in this connection I would state that we often meet with tolerant uteri, which stand the irritation of the stem very well, and in many instances the use of the stem for weeks has resulted in causing the recurrence of a typical hemorrhage from the uterus. In these instances I have used •
slender, light, metal stems with concave cup. In cases of lack of sexual desire, which is often associated with amenorrhea and faulty development of the genital organs, my results from the stem have been without ex ception negative.
In addition to the above indications, intra-uterine pessaries are recom mended in case of reflex neuroses, of stenosis of the cervical canal, where the Fritsch knob-stem answers well, and finally, in case of sterility. In this latter respect Martin has had a number of good results, Amann in nine to sixteen instances, Winckel has not succeeded as well. The latter has seen conception follow once and Olshausen twice while the patients were wearing the stem. It should further be stated that Fehling, Ahlfeld and others, resort to the stem for the purpose of drainage in case of uterine catarrh.
It is not possible to state definitely the unfavorable results which have followed resort to the stem, and which have served the purpose of con demnation of the orthopedic intra-nterine treatment. The frequent severe diseases and deaths which formerly occurred (in 1870 Hueter col lected one case of Riese's, two of Rockwitz's, six from Broca and Cruveil bier, sixteen from Tilt), were certainly in part to be laid to the careless choice of patients, and in particular to the use of bad instruments. Lat terly, the advocates of the stem have produced figures which prove that the instrument is by no means such a dangerous one. In 247 cases Winckel found no death; in 393 cases collected by Warker there were in thirteen symptoms which called for removal of the stem. We occasion ally even see after the use of the simple regulator, the best of all these instruments, inflammations of the mucous membrane of the uterus, of its mnscularis, and its serosa, also of the parametrium, and further hem orrhages, abnormal sensations in different regions of the body, without any specific trouble.