1 00:00:01,320 --> 00:00:04,240 Speaker 1: Welcome to Stuff You Missed in History Class, a production 2 00:00:04,400 --> 00:00:14,680 Speaker 1: of iHeartRadio. Hello, and welcome to the podcast. I'm Tracy V. 3 00:00:14,800 --> 00:00:18,919 Speaker 1: Wilson and I'm Holly Fry. This is one of a 4 00:00:19,079 --> 00:00:21,799 Speaker 1: number of episodes that I've done on the show that 5 00:00:22,000 --> 00:00:27,880 Speaker 1: was inspired by Internet behavior that I've been witnessing today. 6 00:00:27,960 --> 00:00:33,200 Speaker 1: It is a history of the inter uterine device. Intrauterine 7 00:00:33,200 --> 00:00:36,839 Speaker 1: device is how it's technically pronounced, but I always is 8 00:00:36,920 --> 00:00:39,239 Speaker 1: going to come out of my mouth interuterine sort of 9 00:00:39,240 --> 00:00:43,239 Speaker 1: slurred together. Probably we will be getting into the Internet 10 00:00:43,280 --> 00:00:47,680 Speaker 1: behavior inspiration at the end of the episode. IUDs are 11 00:00:47,840 --> 00:00:53,199 Speaker 1: under the umbrella of long, long acting reversible contraceptives. They 12 00:00:53,200 --> 00:00:56,240 Speaker 1: are the oldest one of those that is in use 13 00:00:56,280 --> 00:01:00,320 Speaker 1: today and an estimated one hundred and sixty million people 14 00:01:00,400 --> 00:01:04,560 Speaker 1: around the world use them, but their popularity really varies 15 00:01:04,600 --> 00:01:09,040 Speaker 1: from place to place. Some of that is connected directly 16 00:01:09,120 --> 00:01:15,080 Speaker 1: to its history. This whole episode of our podcast is 17 00:01:15,160 --> 00:01:21,560 Speaker 1: about inserting devices into the uterus to prevent pregnancy. I'm 18 00:01:21,600 --> 00:01:25,000 Speaker 1: a person who feels pretty comfortable with my body. I 19 00:01:25,080 --> 00:01:28,680 Speaker 1: have watched my share of gory medical dramas on TV. 20 00:01:29,280 --> 00:01:31,440 Speaker 1: Sometimes Patrick will walk in the room and he will 21 00:01:31,440 --> 00:01:33,959 Speaker 1: watch sort of the you know, the talking scene of 22 00:01:34,080 --> 00:01:37,240 Speaker 1: doctors happening, and then there will be blood on screen 23 00:01:37,240 --> 00:01:43,520 Speaker 1: and he goes. Nobody leaves. I keep watching. But some 24 00:01:43,600 --> 00:01:46,039 Speaker 1: of the history that we are gonna talk about is 25 00:01:46,080 --> 00:01:48,040 Speaker 1: like right on the edge of body horror to me, 26 00:01:48,560 --> 00:01:53,040 Speaker 1: even with all that context. Huh. Also, this is not 27 00:01:53,200 --> 00:01:55,400 Speaker 1: medical advice. We are not gonna be talking in any 28 00:01:55,480 --> 00:01:58,240 Speaker 1: kind of great detail about like the benefits and risks 29 00:01:58,240 --> 00:02:01,400 Speaker 1: of IUDs from today's understand It is about history, not 30 00:02:01,600 --> 00:02:06,080 Speaker 1: like current medical thought on them. There are a couple 31 00:02:06,160 --> 00:02:10,320 Speaker 1: of probably apocryphal stories about the beginnings of IUDs that 32 00:02:10,440 --> 00:02:15,119 Speaker 1: show up pretty regularly in articles about their history. One 33 00:02:15,200 --> 00:02:18,880 Speaker 1: is it hundreds or thousands of years ago, nomadic peoples 34 00:02:19,240 --> 00:02:22,240 Speaker 1: would put stones into the uteruses of camels so they 35 00:02:22,280 --> 00:02:25,720 Speaker 1: would not become pregnant during long journeys through the desert. 36 00:02:27,000 --> 00:02:29,840 Speaker 1: The origins of this factoid are pretty unclear, but it 37 00:02:29,919 --> 00:02:33,480 Speaker 1: only seems to show up in writing about IUDs. But 38 00:02:33,560 --> 00:02:38,240 Speaker 1: that's generally writing that comes from North America or Europe. Yeah, 39 00:02:38,320 --> 00:02:42,960 Speaker 1: I guess it's not completely impossible. It doesn't seem like 40 00:02:43,120 --> 00:02:48,919 Speaker 1: something that's documented outside of this. Yeah. Uh, this conversation. Also, 41 00:02:49,000 --> 00:02:52,520 Speaker 1: you can say it uteruses or uteri. Either way is fine, 42 00:02:53,760 --> 00:02:58,880 Speaker 1: It's all good. There are also vague references to Hippocrates 43 00:02:59,000 --> 00:03:04,680 Speaker 1: having written some thing about IUDs. The Hippocratic Corpus dates 44 00:03:04,720 --> 00:03:08,520 Speaker 1: back more than two thousand years. It encompasses roughly sixty 45 00:03:08,840 --> 00:03:12,239 Speaker 1: different Greek medical texts. Those were written over the course 46 00:03:12,320 --> 00:03:15,360 Speaker 1: of about two centuries. I don't want to judge anybody 47 00:03:15,400 --> 00:03:19,320 Speaker 1: too harshly for shorthanding all of that to just Hippocrates. 48 00:03:20,280 --> 00:03:23,040 Speaker 1: I'm sure we have done that at some point. But 49 00:03:23,480 --> 00:03:28,160 Speaker 1: in these IUD discussions, nobody really cites a specific source 50 00:03:28,240 --> 00:03:35,440 Speaker 1: for whatever it is that Hippocrates supposedly specifically said. Classicists 51 00:03:35,480 --> 00:03:39,280 Speaker 1: and medical historians Rebecca Philis and Helen King traced the 52 00:03:39,480 --> 00:03:43,760 Speaker 1: probable origin of this to a passage in book two 53 00:03:43,960 --> 00:03:48,760 Speaker 1: of the Hippocratic text, known as Diseases of Women that 54 00:03:48,920 --> 00:03:53,240 Speaker 1: describes a method for opening the cervix. It does not 55 00:03:53,480 --> 00:03:58,640 Speaker 1: describe placing anything in the uterus, and this also was 56 00:03:58,720 --> 00:04:01,760 Speaker 1: not something that was described is being done to prevent pregnancy. 57 00:04:01,960 --> 00:04:06,680 Speaker 1: So something else has been sort of misstated as being 58 00:04:06,760 --> 00:04:12,840 Speaker 1: Hippocrates talking about IUDs. So the most likely precursor to 59 00:04:12,840 --> 00:04:16,960 Speaker 1: the IUD is not Hippocrates or Stones in the uteruses 60 00:04:17,000 --> 00:04:19,640 Speaker 1: of camels, it's the pesseai, which is one of the 61 00:04:19,680 --> 00:04:24,000 Speaker 1: oldest medical devices still in use today. A pessai is 62 00:04:24,160 --> 00:04:28,200 Speaker 1: used in the vagina to support the uterus. Today's pessies 63 00:04:28,240 --> 00:04:32,480 Speaker 1: are typically made from soft, flexible materials like silicone or 64 00:04:32,480 --> 00:04:35,320 Speaker 1: silicone coated rubber, and they come in a variety of 65 00:04:35,320 --> 00:04:39,640 Speaker 1: shapes depending on exactly what they're intended to do. Historically, 66 00:04:40,320 --> 00:04:43,200 Speaker 1: before we had those materials, pessaries were made with a 67 00:04:43,279 --> 00:04:46,960 Speaker 1: range of other materials. In the sixteenth century, past podcast 68 00:04:47,000 --> 00:04:52,800 Speaker 1: subject Moise Pier used hammered brass and waxed cork, as 69 00:04:52,839 --> 00:04:57,760 Speaker 1: well as gold and silver. Other materials included sponges and wax. 70 00:04:58,360 --> 00:05:02,360 Speaker 1: There's apparently a disc of using half a pomegranate as 71 00:05:02,360 --> 00:05:05,760 Speaker 1: a pessary in book two of Diseases of Women. I 72 00:05:05,960 --> 00:05:08,960 Speaker 1: was not able to directly confirm that, though it's not 73 00:05:09,080 --> 00:05:12,640 Speaker 1: impossible that that's in there. That seems so problematic. That 74 00:05:12,760 --> 00:05:16,160 Speaker 1: seems large to me unless it was a very small pomegranate. 75 00:05:16,600 --> 00:05:20,159 Speaker 1: I'm also just thinking that like pomegranates have a lot 76 00:05:20,200 --> 00:05:26,400 Speaker 1: of crevicey surface area, Yeah, where like bacteria could move 77 00:05:26,440 --> 00:05:32,560 Speaker 1: in questions I have, yeah, many listen we don't know today, 78 00:05:32,680 --> 00:05:36,279 Speaker 1: and historically pessaries have primarily been used to treat a 79 00:05:36,320 --> 00:05:40,760 Speaker 1: pelvic organ prolapse. Depending on their shape, pessories can also 80 00:05:40,839 --> 00:05:44,160 Speaker 1: treat some kinds of incontinence, or they can be used 81 00:05:44,160 --> 00:05:47,640 Speaker 1: as part of the preparation for a pelvic surgery. Since 82 00:05:47,640 --> 00:05:49,919 Speaker 1: a pestery can sit at the top of the vagina, 83 00:05:50,040 --> 00:05:53,400 Speaker 1: next to the cervix, they've also been used as contraceptives, 84 00:05:53,720 --> 00:05:56,960 Speaker 1: either alone or in conjunction with some kind of spermicide. 85 00:05:57,680 --> 00:06:01,360 Speaker 1: So today most people call these kinds of devices diaphragms 86 00:06:01,440 --> 00:06:05,039 Speaker 1: or cervical caps, but some of the earliest ones were 87 00:06:05,080 --> 00:06:10,720 Speaker 1: billed as ecclusive pessories. While pessaries are used in the vagina, 88 00:06:11,160 --> 00:06:15,479 Speaker 1: in the late nineteenth century, there were also intracervical pessaries. 89 00:06:16,120 --> 00:06:18,440 Speaker 1: They's had a flattened out part like a disc or 90 00:06:18,480 --> 00:06:22,240 Speaker 1: a button that was attached to a rounded stem. That 91 00:06:22,360 --> 00:06:26,600 Speaker 1: stem went into the cervical canal and the disc rested 92 00:06:26,680 --> 00:06:30,400 Speaker 1: against the outer surface of the cervix. And then there 93 00:06:30,400 --> 00:06:34,479 Speaker 1: were intrauterine pessaries, which had a disc connected to a 94 00:06:34,520 --> 00:06:37,640 Speaker 1: longer stem that went all the way through the cervical 95 00:06:37,680 --> 00:06:44,240 Speaker 1: canal into the uterine cavity. In the simplest intrauterine pessaries, 96 00:06:44,560 --> 00:06:47,920 Speaker 1: the stem was about five centimeters it's about two inches long, 97 00:06:48,279 --> 00:06:50,280 Speaker 1: and it was wider at the far end to keep 98 00:06:50,279 --> 00:06:54,240 Speaker 1: it from slipping back out through the cervix. More complex 99 00:06:54,320 --> 00:06:57,919 Speaker 1: intrauterine pessees had a loop that rested inside the uterus 100 00:06:58,360 --> 00:07:01,680 Speaker 1: or a pair of legs, kind of picture a wishbone. 101 00:07:01,720 --> 00:07:04,560 Speaker 1: These parts would be squeezed together and encased in a 102 00:07:04,600 --> 00:07:08,520 Speaker 1: gelatine capsule for insertion, and then that capsule would dissolve 103 00:07:08,560 --> 00:07:12,280 Speaker 1: in the uterus so those legs could expand out. We've 104 00:07:12,320 --> 00:07:14,920 Speaker 1: been assuming that everyone in the audience right now has 105 00:07:14,960 --> 00:07:18,880 Speaker 1: a basic understanding of the anatomy of the female reproductive system. 106 00:07:18,880 --> 00:07:21,920 Speaker 1: But we're gonna pause for a second here because I 107 00:07:22,000 --> 00:07:25,040 Speaker 1: realized while working on this that my mental image of 108 00:07:25,080 --> 00:07:28,600 Speaker 1: the cervix does not line up with reality, and that 109 00:07:28,760 --> 00:07:33,360 Speaker 1: made the size of these intracervical and intrauterine pessories really confusing, 110 00:07:34,080 --> 00:07:36,160 Speaker 1: because I thought that the cervix was sort of like 111 00:07:36,200 --> 00:07:40,400 Speaker 1: a dense muscular valve, maybe a centimeter or too thick, 112 00:07:41,240 --> 00:07:44,280 Speaker 1: and that meant that the stems on these pessaries seemed 113 00:07:44,280 --> 00:07:48,000 Speaker 1: like they were way too long. The cervix, though, is 114 00:07:48,040 --> 00:07:51,080 Speaker 1: really more like a tunnel. It is closer to three 115 00:07:51,120 --> 00:07:54,560 Speaker 1: centimeters or a little over an inch long, although that 116 00:07:54,720 --> 00:07:59,240 Speaker 1: changes significantly during portions of pregnancy. I mentioned by confusion 117 00:07:59,240 --> 00:08:03,680 Speaker 1: on this to some, and they were also confused. Basically, 118 00:08:03,720 --> 00:08:05,840 Speaker 1: the only person in the group chat who had a 119 00:08:05,880 --> 00:08:11,160 Speaker 1: correct understanding of the cervix was the midwife. So it 120 00:08:11,280 --> 00:08:13,280 Speaker 1: sort of seems like it might be a common enough 121 00:08:13,320 --> 00:08:18,120 Speaker 1: misconception to clear up here, since it would not otherwise 122 00:08:18,160 --> 00:08:20,920 Speaker 1: really make sense in the context of these pessories. I 123 00:08:21,040 --> 00:08:26,800 Speaker 1: blame vague illustrations that don't really differentiate between the cervix 124 00:08:26,840 --> 00:08:30,720 Speaker 1: and the lower part of the uterus like other pessories. 125 00:08:30,840 --> 00:08:35,480 Speaker 1: In the nineteenth and early twentieth centuries, intracervical and intrauterine 126 00:08:35,520 --> 00:08:39,640 Speaker 1: pessories were primarily used to support the uterus. They were 127 00:08:39,679 --> 00:08:44,600 Speaker 1: also used to treat conditions ineffectively, for things that they 128 00:08:44,640 --> 00:08:46,679 Speaker 1: just would not have had any kind of impact on, 129 00:08:46,840 --> 00:08:51,560 Speaker 1: like irregular menstruation and conditions that have no foundation in medicine, 130 00:08:52,320 --> 00:08:56,199 Speaker 1: like our good old favorite hysteria. And since they blocked 131 00:08:56,240 --> 00:08:59,800 Speaker 1: the cervix and in the case of interuterine models, occupied 132 00:08:59,840 --> 00:09:03,400 Speaker 1: the uteruss, people used them to try to prevent pregnancy 133 00:09:03,880 --> 00:09:08,400 Speaker 1: or in some cases, to try to terminate pregnancies. Gynecologist, 134 00:09:08,600 --> 00:09:12,160 Speaker 1: surgeon and pathologist Mary Halton, who was the only woman 135 00:09:12,240 --> 00:09:15,840 Speaker 1: doctor in this whole episode, was regarded as the foremost 136 00:09:15,880 --> 00:09:18,840 Speaker 1: expert on these devices for contraception in the US in 137 00:09:18,840 --> 00:09:22,520 Speaker 1: the early twentieth century. She said she had used them 138 00:09:22,559 --> 00:09:25,320 Speaker 1: on more than seven hundred patients in her practice in 139 00:09:25,400 --> 00:09:31,600 Speaker 1: New York. So whatever these were being used for, in 140 00:09:31,720 --> 00:09:35,360 Speaker 1: most cases not very effectively. They apparently weren't that great 141 00:09:35,400 --> 00:09:38,920 Speaker 1: at preventing pregnancy either. In my opinion, these sound terrible. 142 00:09:39,760 --> 00:09:43,200 Speaker 1: Most of them were made from gold, silver, aluminum, or 143 00:09:43,320 --> 00:09:46,120 Speaker 1: hard rubber, and then they sat in the cervical canal 144 00:09:46,240 --> 00:09:49,520 Speaker 1: or went all the way through it. So, having experienced 145 00:09:49,600 --> 00:09:53,520 Speaker 1: like the temporary sensation of an IUD insertion and the 146 00:09:53,600 --> 00:09:57,680 Speaker 1: discomfort of many years worth of PAP tests, I just 147 00:09:57,720 --> 00:10:00,240 Speaker 1: can't imagine that having a piece of metal going all 148 00:10:00,280 --> 00:10:03,600 Speaker 1: the way into or through my cervix would be comfortable 149 00:10:03,640 --> 00:10:06,720 Speaker 1: at all, especially since the stems on some of these 150 00:10:06,760 --> 00:10:12,920 Speaker 1: things were not smooth. They were shaped like springs or coils. Also, 151 00:10:13,160 --> 00:10:14,960 Speaker 1: a lot of these were meant to be used for 152 00:10:15,120 --> 00:10:17,520 Speaker 1: a month or two at a time, and then removed 153 00:10:17,520 --> 00:10:21,400 Speaker 1: and cleaned and reinserted. Halton talked about having to let 154 00:10:21,520 --> 00:10:27,200 Speaker 1: the cavity heal before it could be reinserted. The intracervical 155 00:10:27,240 --> 00:10:30,080 Speaker 1: model that we described here was placed by a doctor 156 00:10:30,320 --> 00:10:32,520 Speaker 1: at the end of someone's menstrul period, and then the 157 00:10:32,600 --> 00:10:35,319 Speaker 1: patient was supposed to remove it just before the start 158 00:10:35,360 --> 00:10:39,200 Speaker 1: of the next one. But the intrauterine models had to 159 00:10:39,240 --> 00:10:41,920 Speaker 1: be inserted and removed by a doctor, So there was 160 00:10:42,000 --> 00:10:45,840 Speaker 1: just like a lot of very uncomfortable seeming doctor visits 161 00:10:45,880 --> 00:10:50,720 Speaker 1: involved with this. James Frier Cooper's nineteen twenty eight technique 162 00:10:50,760 --> 00:10:55,240 Speaker 1: of Contraception The Principles and Practice of Anti Conceptional Methods, 163 00:10:55,760 --> 00:11:02,040 Speaker 1: describes the disadvantages of intracervical pessaries as including infections, irritation, 164 00:11:02,679 --> 00:11:06,760 Speaker 1: being extremely difficult to adjust except by a doctor, and 165 00:11:07,120 --> 00:11:10,880 Speaker 1: quote it does not entirely occlude the cervical canal so 166 00:11:11,000 --> 00:11:16,280 Speaker 1: that pregnancy may take place, so also ineffective. He describes 167 00:11:16,320 --> 00:11:20,400 Speaker 1: the intrauterine pessory as unreliable as a contraceptive and says 168 00:11:20,440 --> 00:11:23,839 Speaker 1: that reports from both London and New York associate them 169 00:11:23,880 --> 00:11:28,640 Speaker 1: with infections and even deaths. So quote from a health viewpoint, 170 00:11:28,679 --> 00:11:34,000 Speaker 1: this type of pessory is therefore undesirable. Even so, these 171 00:11:34,040 --> 00:11:38,079 Speaker 1: pessories were in use as contraceptives until around the nineteen thirties. 172 00:11:39,160 --> 00:11:42,720 Speaker 1: At this point, these concerns about infections were well founded. 173 00:11:43,120 --> 00:11:47,040 Speaker 1: Antibiotics had not been invented yet. If one of these 174 00:11:47,160 --> 00:11:50,720 Speaker 1: pessaries was inserted in a non sterile way, or if 175 00:11:50,840 --> 00:11:54,160 Speaker 1: pathogens traveled along it from the vagina to the uterus, 176 00:11:54,240 --> 00:11:56,719 Speaker 1: or if it caused injury to one of these organs, 177 00:11:56,760 --> 00:12:00,920 Speaker 1: any infection that developed could be life threatening. But this 178 00:12:01,000 --> 00:12:06,320 Speaker 1: association with infections would continue after the development of true IUDs, 179 00:12:06,760 --> 00:12:09,920 Speaker 1: and it was initially because of their connection to these pessaries. 180 00:12:11,040 --> 00:12:14,200 Speaker 1: We will get to the first actual IUDs without a 181 00:12:14,240 --> 00:12:17,680 Speaker 1: part that stayed outside the cervix after a sponsor break. 182 00:12:27,320 --> 00:12:31,360 Speaker 1: The first published description of an IUD was by physician 183 00:12:31,559 --> 00:12:35,000 Speaker 1: Richard Richter in an article in the German Medical Weekly 184 00:12:35,120 --> 00:12:39,960 Speaker 1: magazine in nineteen oh nine. Its title translated to a 185 00:12:40,080 --> 00:12:45,319 Speaker 1: means of preventing conception. Richter described using two threads of 186 00:12:45,440 --> 00:12:48,680 Speaker 1: silkworm gut tied in a simple loop like a very 187 00:12:48,760 --> 00:12:53,440 Speaker 1: loose overhand knot. The free ends of the silkworm gut 188 00:12:53,440 --> 00:12:56,360 Speaker 1: were encased in celluloid so that they would not damage 189 00:12:56,400 --> 00:13:00,880 Speaker 1: the lining of the uterus. A bronze wire was connected 190 00:13:00,880 --> 00:13:03,320 Speaker 1: to the bottom of this loop that held the two 191 00:13:03,400 --> 00:13:06,600 Speaker 1: threads together, and it also made the device visible on 192 00:13:06,679 --> 00:13:11,400 Speaker 1: an X ray and facilitated its eventual removal. This loop 193 00:13:11,679 --> 00:13:15,400 Speaker 1: was inserted into the uterus using a hollow probe, and 194 00:13:15,520 --> 00:13:17,840 Speaker 1: the end of the wire was snipped off close to 195 00:13:17,880 --> 00:13:21,439 Speaker 1: the outer surface of the cervix. Richter said he had 196 00:13:21,440 --> 00:13:24,840 Speaker 1: been testing this for several years and that the silkworm 197 00:13:24,920 --> 00:13:28,200 Speaker 1: threads irritated the mucous membranes of the uterus enough to 198 00:13:28,280 --> 00:13:31,400 Speaker 1: keep an egg from implanting, but not so much that 199 00:13:31,480 --> 00:13:34,560 Speaker 1: the patient could feel it. He said the longest that 200 00:13:34,600 --> 00:13:36,640 Speaker 1: one of his patients had kept one in place was 201 00:13:36,800 --> 00:13:40,040 Speaker 1: four years, and that after the device was removed, his 202 00:13:40,120 --> 00:13:45,040 Speaker 1: patients were able to conceive and had uncomplicated pregnancies. He 203 00:13:45,080 --> 00:13:48,200 Speaker 1: didn't give any specific details about how many patients he 204 00:13:48,200 --> 00:13:51,240 Speaker 1: had treated this way or data on how effective this 205 00:13:51,360 --> 00:13:56,080 Speaker 1: method was. In nineteen twenty three, Carl Post published an 206 00:13:56,160 --> 00:13:59,080 Speaker 1: article in the same journal with a title that translated 207 00:13:59,120 --> 00:14:02,960 Speaker 1: to a use protection for women. He said that he 208 00:14:03,000 --> 00:14:06,040 Speaker 1: had treated more than four hundred patients with a similar 209 00:14:06,080 --> 00:14:08,560 Speaker 1: device that also had some of the traits of an 210 00:14:08,640 --> 00:14:13,600 Speaker 1: intrauterine pessari. Poost described it as a pessari in the paper. 211 00:14:14,400 --> 00:14:17,360 Speaker 1: In addition to a loop of silkworm gut that sat 212 00:14:17,440 --> 00:14:20,560 Speaker 1: inside the uterus, this device had a tail made of 213 00:14:20,600 --> 00:14:24,560 Speaker 1: silk that extended out through the cervix. The tail was 214 00:14:24,600 --> 00:14:28,920 Speaker 1: attached to a button made of borisilicate yana glass, which 215 00:14:28,960 --> 00:14:33,000 Speaker 1: is heat and shock resistant. This button rested against the 216 00:14:33,040 --> 00:14:36,680 Speaker 1: surface of the cervix. Pooste claimed that there had been 217 00:14:36,720 --> 00:14:41,320 Speaker 1: no serious complications in any of those four hundred plus patients, 218 00:14:41,760 --> 00:14:44,960 Speaker 1: and that more than twenty thousand of these devices were 219 00:14:45,000 --> 00:14:49,400 Speaker 1: in use around the same time. Also in Germany, gynecologist 220 00:14:49,560 --> 00:14:54,800 Speaker 1: Ernst Grafenberg started experimenting with intri uterine contraceptive devices in 221 00:14:54,880 --> 00:14:59,280 Speaker 1: his private medical practice. Like Richter and Poost, his first 222 00:14:59,280 --> 00:15:03,400 Speaker 1: attempts a loop of silkworm suture, although he doesn't seem 223 00:15:03,440 --> 00:15:07,040 Speaker 1: to have been aware of their earlier work. His loops 224 00:15:07,040 --> 00:15:09,760 Speaker 1: were prone to being expelled from the uterus, so he 225 00:15:09,880 --> 00:15:14,520 Speaker 1: tried wrapping the suture in silver wire, creating a flexible ring. 226 00:15:15,640 --> 00:15:19,120 Speaker 1: Pure silver was absorbed by the patient's bodies, causing them 227 00:15:19,160 --> 00:15:22,800 Speaker 1: to develop argeria or a blue tinge around their gums. 228 00:15:23,520 --> 00:15:26,560 Speaker 1: He switched to an alloy of copper, nickel, and zinc 229 00:15:26,720 --> 00:15:30,720 Speaker 1: that's known as German silver. The copper probably provided at 230 00:15:30,800 --> 00:15:33,680 Speaker 1: least some of the contraceptive effect of this ring, although 231 00:15:33,720 --> 00:15:38,720 Speaker 1: that connection wasn't discovered until much later. Grafenberg gave a 232 00:15:38,760 --> 00:15:43,000 Speaker 1: presentation on his intrauterine ring at a course presented by 233 00:15:43,040 --> 00:15:46,920 Speaker 1: birth control advocate Margaret Sanger in nineteen twenty eight, and 234 00:15:46,960 --> 00:15:50,840 Speaker 1: then at the nineteen twenty nine International Sexual Reform Congress 235 00:15:50,920 --> 00:15:53,800 Speaker 1: in London, and then at the nineteen thirty one German 236 00:15:53,880 --> 00:15:57,880 Speaker 1: Congress of Gynecology in Frankfurt. He published his work on 237 00:15:57,920 --> 00:16:00,680 Speaker 1: this device in nineteen thirty one, as well, reporting a 238 00:16:00,680 --> 00:16:04,720 Speaker 1: failure rate of only one point six percent, but other 239 00:16:04,920 --> 00:16:11,200 Speaker 1: gynecologists denounced the Grafenberg ring as unsafe. Grafenberg was using 240 00:16:11,200 --> 00:16:14,800 Speaker 1: sterile procedures when inserting these rings, and they didn't have 241 00:16:14,880 --> 00:16:18,320 Speaker 1: a portion that extended through the cervix, but they were 242 00:16:18,400 --> 00:16:22,280 Speaker 1: still associated with the infection risks of intracervical and intra 243 00:16:22,440 --> 00:16:27,880 Speaker 1: uterine pessaries. Grafenberg's work was happening alongside a movement for 244 00:16:28,000 --> 00:16:32,080 Speaker 1: birth control and sexual reform in Germany. This was during 245 00:16:32,080 --> 00:16:35,320 Speaker 1: the period that's known as the Weimar Republic. We've talked 246 00:16:35,360 --> 00:16:37,360 Speaker 1: about it a few times lately. It was a time 247 00:16:37,440 --> 00:16:42,360 Speaker 1: of both political turmoil and social and artistic freedom. This 248 00:16:42,560 --> 00:16:45,840 Speaker 1: was also when Magnus Hirschfeld was operating the Institute for 249 00:16:45,920 --> 00:16:51,360 Speaker 1: Sexual Science in Berlin, which conducted research and training on sex, sexuality, 250 00:16:51,440 --> 00:16:55,480 Speaker 1: and gender and developed a massive library on those subjects. 251 00:16:56,320 --> 00:17:00,800 Speaker 1: Many of Hirschfeld's patients would be described as gay, lesbian, bisexual, 252 00:17:01,080 --> 00:17:04,960 Speaker 1: or transgender today, although most of those terms were not 253 00:17:05,040 --> 00:17:07,520 Speaker 1: in use or they were not used quite the same 254 00:17:07,520 --> 00:17:11,000 Speaker 1: way at the time. Our episode on Hirschfeld and the 255 00:17:11,000 --> 00:17:14,080 Speaker 1: Institute ran as a Saturday Classic in April of twenty 256 00:17:14,119 --> 00:17:18,600 Speaker 1: twenty three. The Weimar era ended with the rise of 257 00:17:18,680 --> 00:17:23,240 Speaker 1: Nazi Germany. In nineteen thirty three, Nazis raided the Institute 258 00:17:23,240 --> 00:17:26,760 Speaker 1: of Sexual Science and burned its entire library of an 259 00:17:26,840 --> 00:17:31,600 Speaker 1: estimated twenty thousand books. Hirschfeld was both gay and Jewish, 260 00:17:31,640 --> 00:17:34,600 Speaker 1: although he had not been observant since his childhood, and 261 00:17:34,880 --> 00:17:40,639 Speaker 1: Nazi propagandists used him as an example of degeneracy. Ernst 262 00:17:40,680 --> 00:17:44,080 Speaker 1: Grafenberg was also Jewish, and he was fired from his 263 00:17:44,160 --> 00:17:47,280 Speaker 1: position at a hospital in Berlin for that reason in 264 00:17:47,359 --> 00:17:52,320 Speaker 1: nineteen thirty three. He remained in Berlin though, until he 265 00:17:52,400 --> 00:17:56,480 Speaker 1: was arrested in nineteen thirty seven. He was eventually released 266 00:17:56,480 --> 00:17:58,679 Speaker 1: with the help of Margaret Sanger, and he fled to 267 00:17:58,680 --> 00:18:02,480 Speaker 1: the United States in late nineteen forty If you have 268 00:18:02,600 --> 00:18:05,960 Speaker 1: been wondering, this is the same Grafenberg that the g 269 00:18:06,119 --> 00:18:08,840 Speaker 1: spot is named for that was based on a publication 270 00:18:08,920 --> 00:18:12,600 Speaker 1: of his from nineteen forty four. Gravenberg continued to work 271 00:18:12,640 --> 00:18:16,360 Speaker 1: as a gynecologist in the US, although because of perceptions 272 00:18:16,400 --> 00:18:21,399 Speaker 1: of iud's as dangerous, he shifted his contraceptive focus to 273 00:18:21,600 --> 00:18:26,560 Speaker 1: diaphragms and cervical caps. A somewhat similar trajectory took place 274 00:18:26,600 --> 00:18:30,720 Speaker 1: in Japan starting in the nineteen twenties. Birth control advocate 275 00:18:30,800 --> 00:18:33,840 Speaker 1: Margaret Sanger made her first of several visits to Japan 276 00:18:34,200 --> 00:18:39,480 Speaker 1: in nineteen twenty two. Contraception was both illegal and culturally 277 00:18:39,600 --> 00:18:44,000 Speaker 1: taboo in Japan, and initially the Japanese government barred Sanger 278 00:18:44,040 --> 00:18:48,080 Speaker 1: from visiting. When it did happen, that visit was tightly 279 00:18:48,119 --> 00:18:53,280 Speaker 1: controlled and Sanger was banned from discussing contraception, but afterward 280 00:18:53,520 --> 00:18:57,639 Speaker 1: Japanese women started their own birth control movement. One of 281 00:18:57,680 --> 00:19:00,800 Speaker 1: its key figures was Shizuei Kato, who had met Sanger 282 00:19:00,880 --> 00:19:03,560 Speaker 1: in the United States in nineteen twenty and who had 283 00:19:03,560 --> 00:19:06,359 Speaker 1: acted as her guide during that nineteen twenty two visit. 284 00:19:07,160 --> 00:19:12,480 Speaker 1: In nineteen thirty three, Japanese gynecologist tenrai Ota introduced an 285 00:19:12,520 --> 00:19:16,240 Speaker 1: iud he called the Preshia ring. This was an English 286 00:19:16,320 --> 00:19:21,240 Speaker 1: Japanese neologism meaning pressure. He had experimented with a range 287 00:19:21,240 --> 00:19:25,200 Speaker 1: of contraceptive techniques starting in the late nineteen twenties. His 288 00:19:25,240 --> 00:19:29,600 Speaker 1: first attempts at an intrauterine device were gold balls. Having 289 00:19:29,680 --> 00:19:32,720 Speaker 1: heard a similar story to the one about the stones 290 00:19:32,760 --> 00:19:35,720 Speaker 1: and the camels, he had heard that cows would not 291 00:19:35,800 --> 00:19:39,400 Speaker 1: become pregnant if a gold ball was placed in their uterus, 292 00:19:40,160 --> 00:19:42,840 Speaker 1: but he found that these gold balls did not stay 293 00:19:43,040 --> 00:19:46,719 Speaker 1: in the human uterus well. When he learned about the 294 00:19:46,720 --> 00:19:50,240 Speaker 1: Grafenberg ring. He combined these two ideas and to what 295 00:19:50,400 --> 00:19:53,600 Speaker 1: looked kind of like a stylized wheel with an outer 296 00:19:53,760 --> 00:19:57,760 Speaker 1: rim made of suture wrapped in wire and three spokes 297 00:19:57,800 --> 00:20:00,600 Speaker 1: connecting the rim to a gold ball in the center. 298 00:20:01,520 --> 00:20:04,520 Speaker 1: He tried to market this as a contraceptive, which also 299 00:20:04,560 --> 00:20:08,120 Speaker 1: became known as the Ota ring. And had some initial success, 300 00:20:08,880 --> 00:20:11,840 Speaker 1: but not long after he developed the device, the Japanese 301 00:20:11,840 --> 00:20:17,480 Speaker 1: government started reimposing restrictions on contraceptives. We have talked about 302 00:20:17,640 --> 00:20:20,920 Speaker 1: connections between the eugenics movement and the birth control movement 303 00:20:20,960 --> 00:20:26,520 Speaker 1: on the show. Before eugenicists, including Margaret Sanger, thought contraceptives 304 00:20:26,560 --> 00:20:30,320 Speaker 1: could keep the so called wrong people from reproducing for 305 00:20:30,400 --> 00:20:34,639 Speaker 1: the betterment of the human race. Japan's eugenics movement had 306 00:20:34,680 --> 00:20:39,000 Speaker 1: a slightly different nuance. The easy access to contraception might 307 00:20:39,119 --> 00:20:43,879 Speaker 1: mean the purportedly right people would not reproduce enough. There 308 00:20:43,880 --> 00:20:48,160 Speaker 1: were also concerns about ID specifically, including worries about negative 309 00:20:48,160 --> 00:20:51,960 Speaker 1: health effects and claims that they terminated pregnancies rather than 310 00:20:52,000 --> 00:20:57,959 Speaker 1: preventing them. Japan defined the IUD as a harmful contraceptive 311 00:20:58,080 --> 00:21:02,680 Speaker 1: in nineteen thirty six and banned contraception outright. After allying 312 00:21:02,760 --> 00:21:06,960 Speaker 1: with Fascist Italy and Nazi Germany, Outa had to take 313 00:21:07,000 --> 00:21:10,320 Speaker 1: on a new name and go into hiding. He returned 314 00:21:10,320 --> 00:21:12,879 Speaker 1: to his work and opened a birth control clinic after 315 00:21:12,920 --> 00:21:15,200 Speaker 1: the end of World War Two, at which point the 316 00:21:15,280 --> 00:21:20,200 Speaker 1: Japanese government started to promote contraceptives due to fears of overpopulation. 317 00:21:21,200 --> 00:21:24,880 Speaker 1: Iud's were not licensed in Japan until the nineteen seventies, 318 00:21:24,920 --> 00:21:29,040 Speaker 1: though although there were individual doctors who worked with IUDs 319 00:21:29,240 --> 00:21:32,280 Speaker 1: at this point, the medical community as a whole did 320 00:21:32,320 --> 00:21:36,360 Speaker 1: not trust them. They were still associated with, and sometimes 321 00:21:36,440 --> 00:21:40,480 Speaker 1: confused with, the intr uterine pessaries that we talked about earlier. 322 00:21:41,480 --> 00:21:45,679 Speaker 1: Only one paper on IUDs was published in Western medical 323 00:21:45,680 --> 00:21:49,040 Speaker 1: literature between nineteen thirty four, after the fall of the 324 00:21:49,080 --> 00:21:53,920 Speaker 1: Weimar Republic and nineteen fifty nine, after developments in plastics 325 00:21:54,000 --> 00:21:57,920 Speaker 1: led to innovations in the field. That nineteen forty eight 326 00:21:57,960 --> 00:22:02,480 Speaker 1: paper was by Mary Halton, Robert L. Dickinson, and Christopher Titza. 327 00:22:03,200 --> 00:22:06,280 Speaker 1: It described the use of a gelatine capsule to insert 328 00:22:06,320 --> 00:22:09,800 Speaker 1: a device made of sterilized silkworm gut into the uterus. 329 00:22:10,600 --> 00:22:13,399 Speaker 1: According to the paper, only one point one percent of 330 00:22:13,440 --> 00:22:18,160 Speaker 1: patients using this device became pregnant. Later on, Titsa described 331 00:22:18,160 --> 00:22:21,399 Speaker 1: the paper's content as so subversive at the time that 332 00:22:21,480 --> 00:22:23,520 Speaker 1: he would not have put his name on it without 333 00:22:23,520 --> 00:22:28,080 Speaker 1: Dickinson's encouragement. Dickinson had written numerous books and served as 334 00:22:28,119 --> 00:22:31,840 Speaker 1: president or director of a whole collection of medical societies, 335 00:22:32,200 --> 00:22:36,080 Speaker 1: so he had some safety to his credentials that TITSA, 336 00:22:36,119 --> 00:22:39,679 Speaker 1: maybe didn't. Yeah, there were some new developments in the 337 00:22:39,680 --> 00:22:42,399 Speaker 1: world of IUDs in the post World War two years, 338 00:22:42,400 --> 00:22:53,960 Speaker 1: and we will get to those after a sponsor break. 339 00:22:54,560 --> 00:22:58,199 Speaker 1: In nineteen fifty nine, two papers helped lift some of 340 00:22:58,240 --> 00:23:03,280 Speaker 1: the stigma around IUD. Doctor Villi Oppenheimer, who worked at 341 00:23:03,280 --> 00:23:06,600 Speaker 1: a hospital in Israel, published an article in the American 342 00:23:06,760 --> 00:23:11,280 Speaker 1: Journal of Obstetrics and Gynecology saying that he had used 343 00:23:11,359 --> 00:23:14,600 Speaker 1: variants of the Grafenberg ring in three hundred and twenty 344 00:23:14,680 --> 00:23:18,520 Speaker 1: nine patients, changing those rings out every nine to twelve 345 00:23:18,640 --> 00:23:22,399 Speaker 1: months for a total of eight hundred sixty six rings. 346 00:23:23,160 --> 00:23:25,879 Speaker 1: He said one of his patients had used rings for 347 00:23:26,000 --> 00:23:30,200 Speaker 1: twenty years and another for twenty seven. He had seen 348 00:23:30,520 --> 00:23:34,280 Speaker 1: no pelvic inflammation of any kind among any of his patients, 349 00:23:34,320 --> 00:23:38,640 Speaker 1: and no cancer or endometriosis. The devices had also been 350 00:23:38,800 --> 00:23:41,720 Speaker 1: very effective, with a failure rate of one point three 351 00:23:41,760 --> 00:23:44,879 Speaker 1: percent for silver rings versus two point four percent in 352 00:23:44,880 --> 00:23:49,720 Speaker 1: the original silkworm design. The other paper was by Atsumi 353 00:23:49,760 --> 00:23:54,840 Speaker 1: Ishihama in the Yokohama Medical Bulletin. He reported his observations 354 00:23:54,880 --> 00:23:58,080 Speaker 1: of nine hundred seventy three patients that he had personally 355 00:23:58,160 --> 00:24:02,520 Speaker 1: seen and more than eighteen thousand other patients across almost 356 00:24:02,520 --> 00:24:07,080 Speaker 1: one hundred and fifty hospitals in Japan. His results were 357 00:24:07,119 --> 00:24:10,679 Speaker 1: similar to Oppenheimer's. Only one point four percent of his 358 00:24:10,760 --> 00:24:14,320 Speaker 1: own patients became pregnant and about two point three percent 359 00:24:14,400 --> 00:24:17,679 Speaker 1: of patients across the other hospitals, and there had been 360 00:24:17,720 --> 00:24:21,680 Speaker 1: no pattern of serious side effects. These two papers did 361 00:24:21,720 --> 00:24:25,040 Speaker 1: not flip some kind of light switch going from Iud's 362 00:24:25,160 --> 00:24:29,240 Speaker 1: being condemned to being accepted, but they did spark some 363 00:24:29,440 --> 00:24:32,399 Speaker 1: researcher's interest, and they made it a little easier for 364 00:24:32,480 --> 00:24:36,800 Speaker 1: people to publish new research without it just immediately being dismissed. 365 00:24:37,640 --> 00:24:41,680 Speaker 1: In nineteen fifty nine, doctor Lazar Marghulis, a Polish immigrant 366 00:24:41,720 --> 00:24:45,560 Speaker 1: to the United States, started experimenting with loops of silkworm 367 00:24:45,640 --> 00:24:49,960 Speaker 1: gut inserted using a gelatine capsule, similar to what had 368 00:24:49,960 --> 00:24:53,240 Speaker 1: been described in that paper that Mary Halton had co authored. 369 00:24:54,040 --> 00:24:57,480 Speaker 1: But he was disappointed and how often this was expelled 370 00:24:57,680 --> 00:25:01,359 Speaker 1: from the uterus and how painfu full the insertion was 371 00:25:01,400 --> 00:25:05,760 Speaker 1: for his patients. So he developed a spiral made from 372 00:25:05,880 --> 00:25:09,000 Speaker 1: polyethylene tubing, filled with a solution that would make it 373 00:25:09,080 --> 00:25:13,320 Speaker 1: visible on an X ray and sealed this spiral could 374 00:25:13,320 --> 00:25:17,239 Speaker 1: be straightened out and inserted through a narrow tube and 375 00:25:17,280 --> 00:25:20,760 Speaker 1: it would return to its spiral shape in the uterus, 376 00:25:20,800 --> 00:25:23,600 Speaker 1: so what needed to be inserted was a lot smaller. 377 00:25:24,680 --> 00:25:28,440 Speaker 1: In nineteen sixty two, gynecologist Jack Lippies of New York 378 00:25:28,560 --> 00:25:32,719 Speaker 1: developed a polyethylene IUD shaped like a double s, larger 379 00:25:32,720 --> 00:25:35,119 Speaker 1: at the top than at the bottom, and this was 380 00:25:35,160 --> 00:25:40,560 Speaker 1: similarly straightened out for insertion. This shape approximately filled the 381 00:25:40,680 --> 00:25:43,960 Speaker 1: uterine cavity, which reduced the likelihood that the uterus would 382 00:25:43,960 --> 00:25:48,000 Speaker 1: expel it. It also had nylon strings that exited through 383 00:25:48,000 --> 00:25:50,280 Speaker 1: the cervix, which could be felt to make sure that 384 00:25:50,320 --> 00:25:52,920 Speaker 1: the IUD was still in place, and they could also 385 00:25:52,960 --> 00:25:57,359 Speaker 1: be used to remove it. The first International Conference on 386 00:25:57,520 --> 00:26:03,480 Speaker 1: Intrauterine Contraceptive Devices, sponsored by the Population Council, was held 387 00:26:03,480 --> 00:26:07,000 Speaker 1: from April thirty first to May first of nineteen sixty two. 388 00:26:07,760 --> 00:26:11,640 Speaker 1: As that name suggests, at the time, the Population Council 389 00:26:12,040 --> 00:26:16,240 Speaker 1: was focused on the purported dangers of over population in 390 00:26:16,280 --> 00:26:18,840 Speaker 1: the wake of the post World War two baby boom. 391 00:26:19,480 --> 00:26:23,080 Speaker 1: The book Population Bomb would be published later on in 392 00:26:23,119 --> 00:26:26,640 Speaker 1: the decade. This was one of the driving forces behind 393 00:26:26,760 --> 00:26:31,240 Speaker 1: research into iud's At the time, there were multiple papers 394 00:26:31,280 --> 00:26:34,840 Speaker 1: about the Grafenberg ring, the Marguley spiral, and the Lippy 395 00:26:34,920 --> 00:26:44,320 Speaker 1: sloop presented at this conference. Participants included doctors from Japan, China, England, Israel, Pakistan, Egypt, Mexico, India, Chile, 396 00:26:44,520 --> 00:26:48,919 Speaker 1: and the United States, including Puerto Rico, including several of 397 00:26:48,960 --> 00:26:53,120 Speaker 1: the IUD developers that we have mentioned. In nineteen sixty nine, 398 00:26:53,200 --> 00:26:55,880 Speaker 1: doctor Howard Tatum, who had a medical degree as well 399 00:26:55,920 --> 00:27:00,280 Speaker 1: as other multiple degrees related to medicine like chemistry, tried 400 00:27:00,320 --> 00:27:03,320 Speaker 1: to develop a smaller IUD with the hope of resolving 401 00:27:03,400 --> 00:27:07,080 Speaker 1: issues with pain and cramping after the device was inserted. 402 00:27:07,920 --> 00:27:10,800 Speaker 1: The general idea was that an IUD had to occupy 403 00:27:10,840 --> 00:27:14,200 Speaker 1: the uterus to prevent pregnancy and to reduce the likelihood 404 00:27:14,240 --> 00:27:17,560 Speaker 1: of it being expelled, but an IUD that was too 405 00:27:17,640 --> 00:27:21,600 Speaker 1: big could cause ongoing discomfort or even injury to the uterus. 406 00:27:22,480 --> 00:27:25,760 Speaker 1: Tatum thought that a t shaped IUD with arms that 407 00:27:25,800 --> 00:27:29,080 Speaker 1: could be folded flat for insertion and then spring back 408 00:27:29,200 --> 00:27:34,080 Speaker 1: out inside the uterus might be more comfortable. Tatum's first 409 00:27:34,080 --> 00:27:37,200 Speaker 1: designs did seem to be more comfortable, but they were 410 00:27:37,280 --> 00:27:42,120 Speaker 1: also less effective than other IUDs. Then he met physician 411 00:27:42,200 --> 00:27:45,600 Speaker 1: and scientist Jamie Zipper while on a sabbatical in Chile 412 00:27:46,560 --> 00:27:49,280 Speaker 1: in nineteen sixty eight. Zipper had discovered that a copper 413 00:27:49,320 --> 00:27:52,760 Speaker 1: wire had a contraceptive effect when placed in the uterus 414 00:27:52,800 --> 00:27:57,720 Speaker 1: of rabbits. Tatum and Zipper developed the Copper T two hundred, 415 00:27:58,200 --> 00:28:01,800 Speaker 1: a T shaped plastic device with copper wound around the 416 00:28:01,880 --> 00:28:07,880 Speaker 1: central stem. This was the first copper IUD. In nineteen seventy, 417 00:28:08,000 --> 00:28:12,040 Speaker 1: doctor Antonio Scomegna, who was born in Italy and first 418 00:28:12,040 --> 00:28:14,760 Speaker 1: came to the US as a Fulbright scholar in nineteen 419 00:28:14,840 --> 00:28:18,400 Speaker 1: fifty four, developed progest Assert, which was a T shaped 420 00:28:18,440 --> 00:28:22,840 Speaker 1: IUD with a capsule that released progesterone. One of the 421 00:28:22,960 --> 00:28:27,560 Speaker 1: unwanted side effects of IUDs was increased menstrual bleeding, and 422 00:28:27,640 --> 00:28:32,080 Speaker 1: he thought the progesterone would reduce that bleeding. This was 423 00:28:32,119 --> 00:28:36,720 Speaker 1: the first hormone releasing IUD, although its popularity was limited 424 00:28:36,760 --> 00:28:38,760 Speaker 1: by the fact that it was only approved to be 425 00:28:38,920 --> 00:28:42,320 Speaker 1: used for a year at a time. So we're not 426 00:28:42,360 --> 00:28:45,040 Speaker 1: going to mention all of the specific IUDs that were 427 00:28:45,080 --> 00:28:48,360 Speaker 1: developed at this point because they fall into those two 428 00:28:48,400 --> 00:28:53,000 Speaker 1: broad categories copper or hormonal. At least in the US, 429 00:28:53,120 --> 00:28:57,520 Speaker 1: some hormonal IUDs are FDA approved to treat heavy menstrual bleeding. 430 00:28:58,240 --> 00:29:02,120 Speaker 1: By the nineteen sixties, IUDs becoming more widely accepted, although 431 00:29:02,120 --> 00:29:06,040 Speaker 1: there were still some questions about safety, especially about whether 432 00:29:06,080 --> 00:29:11,000 Speaker 1: IUDs carried an increased risk of infections or pelvic inflammatory disease. 433 00:29:12,040 --> 00:29:16,720 Speaker 1: In the United States, IUDs really surged in popularity after 434 00:29:16,760 --> 00:29:20,480 Speaker 1: the Senate held hearings on the safety of oral contraceptives 435 00:29:20,520 --> 00:29:24,280 Speaker 1: in nineteen seventy. We covered the Nelson Pill hearings on 436 00:29:24,360 --> 00:29:28,520 Speaker 1: the Show on May fifth, twenty twenty one. The first 437 00:29:28,600 --> 00:29:31,960 Speaker 1: oral contraceptive had been approved in nineteen sixty and those 438 00:29:32,120 --> 00:29:37,080 Speaker 1: early pills had much much higher levels of hormones than 439 00:29:37,080 --> 00:29:40,400 Speaker 1: they do today. There were reports of blood clots and 440 00:29:40,400 --> 00:29:44,840 Speaker 1: other potential health concerns, and reporting around these hearings led 441 00:29:44,880 --> 00:29:49,440 Speaker 1: to increased fears of birth control pills among the general public. 442 00:29:50,240 --> 00:29:52,800 Speaker 1: One of the speakers at the Nelson Pill hearings was 443 00:29:52,840 --> 00:29:57,080 Speaker 1: Obguin Hugh Davis, who developed an IUD called the Dalkon 444 00:29:57,200 --> 00:30:01,320 Speaker 1: Shield with engineer Irwin Lerner. The Dalkon Shield had been 445 00:30:01,360 --> 00:30:05,000 Speaker 1: introduced in nineteen sixty eight, and by nineteen seventy more 446 00:30:05,040 --> 00:30:07,760 Speaker 1: than six hundred thousand had been sold in the US. 447 00:30:08,640 --> 00:30:11,840 Speaker 1: The ah Robins Company bought the design from Davis and 448 00:30:11,920 --> 00:30:15,320 Speaker 1: Lerner in nineteen seventy one, and by nineteen seventy four 449 00:30:15,480 --> 00:30:18,520 Speaker 1: more than two point two million of them had been sold. 450 00:30:19,400 --> 00:30:22,480 Speaker 1: The Dalkon shield was made of flexible plastic with a 451 00:30:22,600 --> 00:30:26,120 Speaker 1: membrane across the middle, so if you're looking at a picture, 452 00:30:26,160 --> 00:30:29,400 Speaker 1: it looks almost like a solid thing. It was flexible, 453 00:30:29,440 --> 00:30:34,440 Speaker 1: though it had five downward pointing prongs along the edge, 454 00:30:34,480 --> 00:30:37,640 Speaker 1: meant to reduce the likelihood of it being expelled by 455 00:30:37,680 --> 00:30:41,480 Speaker 1: the uterus. Looked a little bit like a horseshoe crab. 456 00:30:42,360 --> 00:30:44,680 Speaker 1: By this point, it was common for IUDs to have 457 00:30:44,760 --> 00:30:48,040 Speaker 1: some kind of strings that exited through the cervix, both 458 00:30:48,280 --> 00:30:50,880 Speaker 1: for a person to be able to confirm that it 459 00:30:50,920 --> 00:30:53,880 Speaker 1: was still in place and to eventually allow it to 460 00:30:53,920 --> 00:30:58,640 Speaker 1: be removed. Because the Dalkon shield was designed to be 461 00:30:58,800 --> 00:31:03,760 Speaker 1: more difficult to lodge, it needed a stronger string. That 462 00:31:03,840 --> 00:31:07,560 Speaker 1: stronger string was made up of multiple filaments within a sheath. 463 00:31:08,360 --> 00:31:12,560 Speaker 1: There were reports of health problems associated with the Dalkon shield. 464 00:31:13,040 --> 00:31:16,880 Speaker 1: It came preloaded in a sterile inserter that extended past 465 00:31:16,880 --> 00:31:20,000 Speaker 1: the top edge of the IUD, and there were reports 466 00:31:20,040 --> 00:31:25,080 Speaker 1: of this protruding bit perforating the uterus during insertion. There 467 00:31:25,080 --> 00:31:28,880 Speaker 1: were also reports of infections and pelvic inflammatory disease, which 468 00:31:28,920 --> 00:31:34,160 Speaker 1: were blamed on the unsealed multifilament strings. The Dalkon shield 469 00:31:34,240 --> 00:31:37,200 Speaker 1: was blamed for at least eighteen deaths, and more than 470 00:31:37,240 --> 00:31:41,840 Speaker 1: three hundred thousand lawsuits were filed against ah Robins. The 471 00:31:41,880 --> 00:31:44,520 Speaker 1: company pulled the Dalkon Shield off the market in the 472 00:31:44,640 --> 00:31:48,760 Speaker 1: US in nineteen seventy four and suspended sales worldwide in 473 00:31:48,880 --> 00:31:54,920 Speaker 1: nineteen seventy five. Ah Robins ultimately filed for bankruptcy in 474 00:31:55,000 --> 00:31:59,080 Speaker 1: nineteen eighty four. There was a widespread ad campaign encouraging 475 00:31:59,120 --> 00:32:02,400 Speaker 1: anyone who still had a Dalcon shield to have it removed, 476 00:32:02,800 --> 00:32:05,360 Speaker 1: and then there was a nineteen eighty nine legal settlement 477 00:32:05,440 --> 00:32:08,520 Speaker 1: that created a two point five billion dollar trust to 478 00:32:08,640 --> 00:32:13,640 Speaker 1: pay off claims against the company. Multiple case control and 479 00:32:13,720 --> 00:32:17,760 Speaker 1: cohort studies suggested that Dalkon shield users had a much 480 00:32:18,040 --> 00:32:22,520 Speaker 1: higher rate of pelvic inflammatory disease than other ied users, 481 00:32:22,960 --> 00:32:27,320 Speaker 1: but clinical trials weren't quite as definitive. Researchers also found 482 00:32:27,360 --> 00:32:30,360 Speaker 1: that the Dalkon shield had a higher failure rate than 483 00:32:30,400 --> 00:32:34,400 Speaker 1: what the manufacturer had claimed, and those pregnancies had a 484 00:32:34,480 --> 00:32:38,600 Speaker 1: higher risk of complications. All of this had an immense 485 00:32:38,680 --> 00:32:42,040 Speaker 1: impact on the acceptance of IUDs in the United States. 486 00:32:43,000 --> 00:32:46,040 Speaker 1: Multiple other IUDs were pulled off the market in the 487 00:32:46,080 --> 00:32:50,800 Speaker 1: face of the Dalkon shield's bad publicity. In nineteen seventy six, 488 00:32:50,960 --> 00:32:54,479 Speaker 1: Congress passed the Medical Device Amendments, which gave the FDA 489 00:32:54,560 --> 00:32:59,840 Speaker 1: authority to regulate medical devices and established three risk categories 490 00:33:00,240 --> 00:33:04,360 Speaker 1: those devices. IUDs were placed in Class three, which was 491 00:33:04,400 --> 00:33:09,680 Speaker 1: the highest risk category. In nineteen seventy about ten percent 492 00:33:09,720 --> 00:33:12,640 Speaker 1: of women in the US who were using contraception were 493 00:33:12,720 --> 00:33:16,400 Speaker 1: using an IUD. I have some questions about exactly how 494 00:33:16,400 --> 00:33:19,640 Speaker 1: that number was derived. That's just how it was described 495 00:33:19,640 --> 00:33:22,480 Speaker 1: in the paper that I was reading. In the year 496 00:33:22,520 --> 00:33:25,360 Speaker 1: two thousand, that number had plummeted. It was less than 497 00:33:25,440 --> 00:33:29,200 Speaker 1: one percent. But in other parts of the world not 498 00:33:29,360 --> 00:33:33,640 Speaker 1: affected by the Dalkon shield, IDs became a popular form 499 00:33:33,680 --> 00:33:38,480 Speaker 1: of contraception. By nineteen eighty five, an estimated sixty million 500 00:33:38,520 --> 00:33:42,120 Speaker 1: people around the world were using IUDs, and forty million 501 00:33:42,160 --> 00:33:46,280 Speaker 1: of them, or about two thirds, were in China. That 502 00:33:46,360 --> 00:33:50,880 Speaker 1: brings us to one of the contradictions around IUDs. If 503 00:33:50,880 --> 00:33:53,440 Speaker 1: you live in a place where you have autonomy over 504 00:33:53,480 --> 00:33:56,160 Speaker 1: your own body and your fertility, and access to a 505 00:33:56,240 --> 00:34:00,240 Speaker 1: doctor and money or health insurance or universal health care, 506 00:34:00,560 --> 00:34:03,920 Speaker 1: and you want to get an IUD, you probably can, 507 00:34:04,280 --> 00:34:08,280 Speaker 1: and that might feel liberating, a long lasting contraceptive method 508 00:34:08,400 --> 00:34:10,760 Speaker 1: that you don't have to think about and a partner 509 00:34:10,800 --> 00:34:13,640 Speaker 1: doesn't even have to know about. But if you live 510 00:34:13,719 --> 00:34:16,160 Speaker 1: somewhere where that is not true, or if you are 511 00:34:16,200 --> 00:34:20,080 Speaker 1: in an abusive or a controlling relationship, an IUD is 512 00:34:20,120 --> 00:34:23,839 Speaker 1: something that can be imposed on you or refused to you. 513 00:34:24,719 --> 00:34:27,640 Speaker 1: While it's at least theoretically possible for a person to 514 00:34:27,760 --> 00:34:32,120 Speaker 1: remove their own IUD, most arts do not recommend doing that, 515 00:34:32,360 --> 00:34:36,640 Speaker 1: and not everyone is actually even able to. China is 516 00:34:36,719 --> 00:34:39,879 Speaker 1: one of the most populous countries in the world, which 517 00:34:39,920 --> 00:34:42,680 Speaker 1: is part of the explanation for these numbers of how 518 00:34:42,719 --> 00:34:46,360 Speaker 1: many IUD users are in China, but it's also because 519 00:34:46,360 --> 00:34:50,000 Speaker 1: of the Chinese government's One Child policy, which was announced 520 00:34:50,000 --> 00:34:54,160 Speaker 1: in nineteen seventy nine. Under this policy, couples who had 521 00:34:54,200 --> 00:34:58,440 Speaker 1: more than one child faced fines and other penalties. After 522 00:34:58,480 --> 00:35:01,480 Speaker 1: having a child, Chinese women were expected to get an 523 00:35:01,520 --> 00:35:05,520 Speaker 1: IUD or to be permanently sterilized, unless their husband got 524 00:35:05,560 --> 00:35:10,280 Speaker 1: a asectomy. China changed that to a two child policy 525 00:35:10,400 --> 00:35:13,280 Speaker 1: in twenty sixteen, and in twenty twenty one that number 526 00:35:13,320 --> 00:35:17,080 Speaker 1: was increased to three children. This kind of coercion can 527 00:35:17,120 --> 00:35:21,560 Speaker 1: happen on both a societal and an individual level. Another 528 00:35:21,680 --> 00:35:26,480 Speaker 1: recent example is the Britney Spears conservatorship case. In twenty 529 00:35:26,520 --> 00:35:29,160 Speaker 1: twenty one, she gave a statement to a probate judge 530 00:35:29,200 --> 00:35:32,200 Speaker 1: in which she said she had an IUD that her 531 00:35:32,320 --> 00:35:37,360 Speaker 1: team would not allow her to have removed. As for 532 00:35:37,440 --> 00:35:41,920 Speaker 1: the Internet behavior that inspired this episode, it is the 533 00:35:41,960 --> 00:35:46,320 Speaker 1: way that pain during IUD insertion has been reduced almost 534 00:35:46,480 --> 00:35:51,080 Speaker 1: to a meme that pain is absolutely real. A twenty 535 00:35:51,080 --> 00:35:54,560 Speaker 1: twenty three study in the European Journal of Contraception and 536 00:35:54,600 --> 00:35:58,239 Speaker 1: Reproductive health Care assessed more than a thousand patients and 537 00:35:58,320 --> 00:36:00,680 Speaker 1: reported the two point five percent of them had no 538 00:36:00,880 --> 00:36:05,840 Speaker 1: pain with IUD insertion, but forty nine point seven percent, 539 00:36:06,080 --> 00:36:11,480 Speaker 1: or almost half, had intense pain. The highest pain scores 540 00:36:11,800 --> 00:36:14,600 Speaker 1: were among people who had never given birth or whose 541 00:36:14,680 --> 00:36:19,840 Speaker 1: children had been born via cesarean section. But this reality 542 00:36:20,040 --> 00:36:24,440 Speaker 1: of pain has gotten kind of condensed into a weird shorthand, 543 00:36:24,560 --> 00:36:27,880 Speaker 1: like they don't even do pain management for IUD insertion. 544 00:36:28,080 --> 00:36:30,680 Speaker 1: What do you expect? And this is thrown around in 545 00:36:30,719 --> 00:36:36,600 Speaker 1: conversations about someone's actual painful IUD experience, or about endometriosis 546 00:36:36,800 --> 00:36:40,000 Speaker 1: or PAP tests or uterine fibroids or menstrual cramps, all 547 00:36:40,040 --> 00:36:42,960 Speaker 1: kinds of other things that can also be painful. And 548 00:36:43,000 --> 00:36:45,680 Speaker 1: then the comments also fill up with people saying that 549 00:36:45,719 --> 00:36:48,279 Speaker 1: they are afraid to get an IUD, or to get 550 00:36:48,320 --> 00:36:51,040 Speaker 1: their existing IUD replaced, or maybe to go to the 551 00:36:51,120 --> 00:36:54,799 Speaker 1: doctor at all because of this. So here is a 552 00:36:54,800 --> 00:36:58,880 Speaker 1: PSA to say, at least in the United States, doctors 553 00:36:58,920 --> 00:37:02,160 Speaker 1: who are not discussing pain management with their patients beyond 554 00:37:02,239 --> 00:37:05,880 Speaker 1: recommending over the counter pain relievers for an IUD insertion 555 00:37:06,440 --> 00:37:10,840 Speaker 1: are not following the current guidelines. In twenty sixteen, the 556 00:37:11,000 --> 00:37:14,719 Speaker 1: US Centers for Disease Control published an updated version of 557 00:37:14,760 --> 00:37:20,080 Speaker 1: its Selected Practice Recommendations for contraceptive use. That update included 558 00:37:20,080 --> 00:37:24,840 Speaker 1: this statement quote paraservical block with lytakane might reduce patient 559 00:37:24,920 --> 00:37:29,800 Speaker 1: pain during IUD insertion. The World Health Organization's most recent 560 00:37:29,920 --> 00:37:34,520 Speaker 1: Selected Practice Recommendations for Contraceptive Use, published in twenty twenty five, 561 00:37:35,160 --> 00:37:39,280 Speaker 1: say that paraservical blocks can be routinely offered for IUD placement, 562 00:37:39,800 --> 00:37:44,360 Speaker 1: as can topical anesthetics like lytacane gels, sprays, and creams. 563 00:37:45,080 --> 00:37:49,200 Speaker 1: That's in addition to recommendations for over the counter pain relievers. 564 00:37:49,960 --> 00:37:53,600 Speaker 1: The most recent US recommendations are adapted from these and 565 00:37:53,640 --> 00:37:57,560 Speaker 1: they have the same basic language. The current World Health 566 00:37:57,640 --> 00:38:03,760 Speaker 1: Organization recommendations also say this quote. Before IUD placement, all 567 00:38:03,840 --> 00:38:07,640 Speaker 1: patients should be counseled on potential pain during placement, as 568 00:38:07,640 --> 00:38:11,200 Speaker 1: well as the risks, benefits, and alternatives of different options 569 00:38:11,200 --> 00:38:15,800 Speaker 1: for pain management. A person centered plan for id placement 570 00:38:15,920 --> 00:38:19,600 Speaker 1: and pain management should be made based on patient preference. 571 00:38:20,400 --> 00:38:25,040 Speaker 1: Barriers to IUD use include patient concerns about anticipated pain 572 00:38:25,440 --> 00:38:29,719 Speaker 1: with placement and provider concerns about ease of placement, especially 573 00:38:29,880 --> 00:38:34,400 Speaker 1: among noliparis patients that means somebody that hasn't had a baby. 574 00:38:35,440 --> 00:38:39,400 Speaker 1: When considering patient pain, it is important to recognize that 575 00:38:39,480 --> 00:38:43,520 Speaker 1: the experience of pain is individualized and might be influenced 576 00:38:43,560 --> 00:38:47,680 Speaker 1: by previous experiences, including trauma and mental health conditions such 577 00:38:47,680 --> 00:38:52,640 Speaker 1: as depression or anxiety. Although these recommendations for provision of 578 00:38:52,760 --> 00:38:57,240 Speaker 1: medications for IUD placement are based on the best available evidence, 579 00:38:57,680 --> 00:39:02,080 Speaker 1: not all populations or patient excit experiences are represented in 580 00:39:02,200 --> 00:39:07,640 Speaker 1: the literature. Additionally, the American College of Obstetricians and Gynecologists 581 00:39:07,719 --> 00:39:11,320 Speaker 1: issued a new clinical consensus for pain relief in twenty 582 00:39:11,360 --> 00:39:15,040 Speaker 1: twenty five, which covers IUD insertion and a range of 583 00:39:15,080 --> 00:39:21,040 Speaker 1: other procedures involving the cervix and uterus. They include anesthetic sprays, creams, 584 00:39:21,080 --> 00:39:26,240 Speaker 1: and paraservical blocks. Various medical bodies have also recommended anti 585 00:39:26,360 --> 00:39:30,640 Speaker 1: anxiety medications or sedation if patients are anxious about the 586 00:39:30,680 --> 00:39:35,480 Speaker 1: procedure or have other factors that might necessitate that. The 587 00:39:35,719 --> 00:39:38,560 Speaker 1: shorthand of like they don't even do pain management for 588 00:39:38,600 --> 00:39:44,120 Speaker 1: IUD insertion absolutely grew out of medical sexism and decades 589 00:39:44,160 --> 00:39:48,600 Speaker 1: of reports about pain not being taken seriously enough, not 590 00:39:48,880 --> 00:39:52,759 Speaker 1: just with ID insertions. Some of the slow evolution of 591 00:39:52,800 --> 00:39:55,560 Speaker 1: these guidelines is because of a lack of clear evidence 592 00:39:55,600 --> 00:39:59,239 Speaker 1: about what actually helps, But in my opinion, it took 593 00:39:59,360 --> 00:40:02,879 Speaker 1: way way, way too long to get guidelines that very 594 00:40:02,880 --> 00:40:06,440 Speaker 1: clearly reference pain relief. While I was researching this episode, 595 00:40:06,480 --> 00:40:09,640 Speaker 1: I found papers on the use of topical lydokane and 596 00:40:09,760 --> 00:40:14,439 Speaker 1: paraservical blocks to make IUD insertion more comfortable. Going back 597 00:40:14,480 --> 00:40:19,840 Speaker 1: to the nineteen eighties, forty something years ago. The frustration 598 00:40:19,960 --> 00:40:22,879 Speaker 1: around this is all incredibly valid, but I do personally 599 00:40:23,000 --> 00:40:26,160 Speaker 1: wish that we had landed on an expression for that 600 00:40:26,280 --> 00:40:32,440 Speaker 1: frustration that was empowering instead of scaring one another. And 601 00:40:32,480 --> 00:40:35,520 Speaker 1: I will also talk about my own personal experience with 602 00:40:35,640 --> 00:40:39,680 Speaker 1: IUD insertion in our Friday Behind the Scenes. Do you 603 00:40:39,680 --> 00:40:42,880 Speaker 1: have listener mail in the meantime, I do. I have 604 00:40:43,000 --> 00:40:48,359 Speaker 1: listener mail from Hannah, and Hannah wrote hey y'all, which 605 00:40:48,400 --> 00:40:51,080 Speaker 1: is honestly one of my favorite ways to open an email. 606 00:40:51,600 --> 00:40:53,960 Speaker 1: I hollered with joy when I saw you release an 607 00:40:53,960 --> 00:40:57,400 Speaker 1: episode about Francisco Menendez and Fort Mose. I was so 608 00:40:57,520 --> 00:41:01,160 Speaker 1: excited I almost started writing this email before actually listening 609 00:41:01,160 --> 00:41:04,320 Speaker 1: to the episode. I'm a lifelong Florida resident who visited 610 00:41:04,360 --> 00:41:07,319 Speaker 1: Fort Mose a few years ago after hearing about it 611 00:41:07,360 --> 00:41:11,160 Speaker 1: on Florida Frontiers, the podcast of the Florida Historical Society. 612 00:41:11,520 --> 00:41:13,759 Speaker 1: The museum has a small footprint, but it's one of 613 00:41:13,760 --> 00:41:16,920 Speaker 1: the most well designed and accessible exhibits I've ever seen. 614 00:41:17,400 --> 00:41:20,759 Speaker 1: I remember how incredible Francisco's story was just from the 615 00:41:20,800 --> 00:41:24,960 Speaker 1: brief overview given by an informational plaque. I highly recommend 616 00:41:24,960 --> 00:41:27,960 Speaker 1: any Saint Augustine visitors to stop by, especially since it's 617 00:41:28,400 --> 00:41:31,799 Speaker 1: only a ten minute drive from the Castillo. On a 618 00:41:31,840 --> 00:41:34,640 Speaker 1: completely unrelated note, this email gives me a chance to 619 00:41:34,719 --> 00:41:38,000 Speaker 1: share a stuffy miess in history class Easter egg of sorts. 620 00:41:38,000 --> 00:41:40,160 Speaker 1: In February of twenty twenty three, I got a free 621 00:41:40,239 --> 00:41:43,759 Speaker 1: tote bag at a local festival. The artist included a 622 00:41:43,760 --> 00:41:48,040 Speaker 1: small eighteen seventy four Kitty Knox button on the subject's backpack. 623 00:41:48,840 --> 00:41:51,719 Speaker 1: This was only a month after you released Kitty's episode. 624 00:41:51,840 --> 00:41:55,280 Speaker 1: This little edition adds so many layers to the scene 625 00:41:55,280 --> 00:41:58,880 Speaker 1: depicting a black woman using public transit while watching a 626 00:41:59,040 --> 00:42:02,279 Speaker 1: rocket launch over the mangroves of the Inner coastal. I 627 00:42:02,400 --> 00:42:05,680 Speaker 1: like to think she's an astronaut continuing Kitty's legacy on 628 00:42:05,800 --> 00:42:09,000 Speaker 1: her way to Cape Canaveral in lieu of pet tax, 629 00:42:09,000 --> 00:42:12,480 Speaker 1: I'm adding photos that represent the wildlife residence of Fort Mosee. 630 00:42:12,480 --> 00:42:17,400 Speaker 1: May have encountered a wrinkly baby manatee, two river otters, 631 00:42:17,760 --> 00:42:20,680 Speaker 1: and the only bird endemic to Florida, the endangered Florida 632 00:42:20,719 --> 00:42:24,200 Speaker 1: scrub jay. Scrub days are highly specialized, intelligent birds with 633 00:42:24,239 --> 00:42:27,160 Speaker 1: big personalities. Hence why one landed on my head during 634 00:42:27,200 --> 00:42:30,239 Speaker 1: an annual population survey. There's so much more to my 635 00:42:30,280 --> 00:42:33,239 Speaker 1: home state than theme parks, wacky headlines, and beaches. I 636 00:42:33,320 --> 00:42:36,600 Speaker 1: encourage anyone who visits to explore our natural and cultural 637 00:42:36,600 --> 00:42:40,000 Speaker 1: heritage beyond the tourist hotspots. If y'all ever want outing 638 00:42:40,040 --> 00:42:43,239 Speaker 1: recommendations around the Orlando area, let me know. Thank you 639 00:42:43,280 --> 00:42:45,200 Speaker 1: so much for the work you do. It is truly 640 00:42:45,239 --> 00:42:48,360 Speaker 1: an invaluable public service and has enriched my life for 641 00:42:48,440 --> 00:42:51,240 Speaker 1: well over a decade. I wish you both nothing but peace, 642 00:42:51,280 --> 00:42:55,040 Speaker 1: good food, and laughter. Warmest regards. And then there's also 643 00:42:55,200 --> 00:42:58,239 Speaker 1: a final episode request, thank you so much Hannah for 644 00:42:58,320 --> 00:43:03,880 Speaker 1: this email. We have a picture of a bird just 645 00:43:04,040 --> 00:43:07,360 Speaker 1: hanging out on Hannah's head. I love it. We also 646 00:43:07,480 --> 00:43:12,400 Speaker 1: have a picture of this tote bag which is decorated 647 00:43:12,480 --> 00:43:16,680 Speaker 1: with an illustration that says, rethink your commute, and the 648 00:43:16,800 --> 00:43:19,880 Speaker 1: commuting person has this backpack with the Kiddie Knocks button 649 00:43:19,920 --> 00:43:25,520 Speaker 1: on it. A baby manatee also very cute. And then 650 00:43:26,120 --> 00:43:28,839 Speaker 1: River otters so favorite, and a picture from Fort Moose. 651 00:43:29,120 --> 00:43:32,680 Speaker 1: So thank you, so so so much for sending this 652 00:43:34,239 --> 00:43:37,040 Speaker 1: and all of these pictures and this great email. I 653 00:43:37,080 --> 00:43:39,040 Speaker 1: loved it and that's all I have to say about it. 654 00:43:39,280 --> 00:43:41,920 Speaker 1: We love a river otter. Yeah, I would look at 655 00:43:42,000 --> 00:43:46,520 Speaker 1: river otters all day long, every day. They're funny. I 656 00:43:46,560 --> 00:43:49,040 Speaker 1: have many great stories of the ones at the aquarium 657 00:43:49,040 --> 00:43:51,799 Speaker 1: here because I used to do animal husbandry, and some 658 00:43:51,880 --> 00:43:56,280 Speaker 1: of those stories are not suitable for this podcast. Yeah. Anytime, 659 00:43:57,280 --> 00:44:00,560 Speaker 1: anytime I'm anywhere that I know that they live, I'm 660 00:44:00,600 --> 00:44:02,600 Speaker 1: on the lookout for them. What if I get to 661 00:44:02,640 --> 00:44:06,400 Speaker 1: see one? So thank you again Hannah for this email. 662 00:44:06,440 --> 00:44:07,960 Speaker 1: If you would like to send us a note where 663 00:44:07,960 --> 00:44:11,640 Speaker 1: at history podcast at iHeartRadio dot com. You can find 664 00:44:11,760 --> 00:44:13,799 Speaker 1: our show notes with all our source lists on them 665 00:44:13,840 --> 00:44:16,840 Speaker 1: at our website, which is Missed Inhistory dot com, and 666 00:44:17,000 --> 00:44:19,640 Speaker 1: you can subscribe to our show on the iHeartRadio app 667 00:44:19,760 --> 00:44:27,840 Speaker 1: and anywhere else you'd like to get your podcasts. Stuff 668 00:44:27,880 --> 00:44:30,640 Speaker 1: You Missed in History Class is a production of iHeartRadio. 669 00:44:31,000 --> 00:44:35,600 Speaker 1: For more podcasts from iHeartRadio, visit the iHeartRadio app, Apple Podcasts, 670 00:44:35,719 --> 00:44:39,160 Speaker 1: or wherever you listen to your favorite shows.