ON HYSTERORRHAPHY. 
By Howard A. Kelly, A. M,, M. D,, 
Gynaecologist to the Johns Hopkins Hospital and Associate Professor of Gynaecology 
and Obstetrics in the Johns Hopkins University. 
[From The Johns Hopkins Hospital Bulletin, No. 2, January, 1890.] [From The Johns Hopkins Hospital Bulletin, No. 2, January, 1890.] 
ON HYSTERORRH APR Y. 
Gynaecologist to the Johns Hopkins Hospital and Associate Professor of Gynaecology 
and Obstetrics in the Johns Hopkins University. 
Howard A. Kelly, A. M., M. D., 
Outline of Paper. 
[ Consideration of natural supports which hold the uterus in its normal position. 
These for convenience of study considered as acting at three points: (1) Pelvic 
DIAPHRAGM BELOW, (2) UtERO-SACRAL LIGAMENTS BEHIND, (3) BROAD 
LIGAMENTS IN FRONT (V. Fig. 1). 
(1) Pelvic diaphragm catches the blows of succussion and intra-abdominal 
pressure. Is in no way weakened by the clefts of rectum, vagina and urethra, as 
these are either placed exeentrically, or cleave it in an oblique direction. 
Weakening of the pelvic diaphragm throws the weight of the uterus on (2) and 
(3), which finally yield, resulting in a displacement of the uterus. 
Repair of this injury by closure of the enlarged vaginal outlet. 
(2) Relaxation of the utero-sacral ligaments involves a displacement of the cervix 
downwards in the vagina, and a consequent backward displacement of the fundus 
uteri. 
Repair of this injury not to be attained by operation; substituted by packing, 
pessary, etc. 
(3) Relaxation of the broad ligaments results in backward displacement of the 
fundus uteri—retroposition or retroflexion. 
Repaired often by simple packing or pessary in vagina, keeping cervix well back 
in the pelvis. 
Sometimes all attempts per vaginam and rectum fail. In these cases hysteror- 
rhaphy will succeed. 
Conclusions. 
All the uterine supports must be examined in every case of displacement. 
Where several factors conjoin to produce displacement, p. d. and s. u. (Fig. 1), 
must in all cases be repaired first, then if further infra-pubic treatment fails to 
remedy the remaining defect in 1.1., supra-pubic Hysterorrhaphy is called for. 
Hysterorrhaphy—defect of previous method (by Olshausen, Sanger, Kelly) is 
that the attachment of the uterus to the abdominal wall by its anterior face feathered 
it backwards, thus putting it at a mechanical disadvantage. 
New method here described is the attachment by the ovarian ligaments thus 
throwing uterus into marked anteflexion. Three cases reported.] 
Hysterorrhaphy is the operation for the correction of mal-positions of 
the uterus, by suturing it to the abdominal or pelvic walls. It is a surgical 
procedure involving first an abdominal section, low down in the median 
line, next the elevation of the corpus uteri out of the sacral hollow, with 
the separation of any adhesions binding it down, and finally its fixation by 
a series of sutures passing through the body of the uterus or close to its 
sides, and into or through the abdominal walls. These fixation sutures can be cut short and dropped within the peritoneum, or fastened outside 
on the skin and removed after the persistence of the uterus in its new pos- 
ture has been assured. 
A brief preliminary consideration of the mechanical factors concerned in 
the support of the uterus in its normal position, will greatly assist the 
appreciation of these rarer conditions, when it is necessary to resort to this 
more serious and radical method of treatment of its deviations. 
For convenience of representation the uterine sup- 
ports which preserve its equipoise in health may be 
considered as acting at three points. The body of the 
uterus is held in its position of mobile anteflexion by 
the broad ligaments in front (I. I.) at its fundus, and 
by the utero-sacral ligaments behind (s. u.) acting at 
the cervical end. 
The weight of the uterus does not fall upon either 
of these stays in health. 
Every movement of the body is communicated to 
the uterus. The succussions of coughing, sneezing, 
walking and running, and above all, the force of intra- 
abdominal pressure, increased by all exertion, espe- 
cially by one-handed lifting and the straining neces- 
sary to overcome constipation, act in the direction of 
the arrows p. i., driving the uterus down towards 
the pelvic diaphragmp. d., which is resilient, and im- 
mediately sends it up again to its former position. 
There are three breaks in the pelvic floor, the two 
outlets the rectum and the urethra, and the out- and 
Fig. 1. 
Showing the points at 
which the normal ute- 
rine supports act to pre- 
serve its equipoise; 1.1. 
broad ligaments; s.u. 
utero-sacral ligaments; 
p. d. represents the re- 
siliency of the pelvic 
diaphragm; p. i. is in- 
tra-abdominal pressure 
tending to displace a 
uterus in which any of 
these supports are bro- 
ken down. 
inlet, the vagina (Fig. 2), but these are either placed excentrically forwards 
or cleave its layers in an oblique direction and thus in no way weaken its 
resisting power. 
If, however, the pelvic diaphragrh is broken down, or the outlet of the 
vagina becomes relaxed (commonly called rupture of the perineum), the 
mechanical factor p. d. disappears, that is there is no longer anything below 
to catch the blows of p. i. (v. Fig. 1) and the uterus unsupported at this 
point, now rests with its full weight, increased by such impacts as fall 
upon it, upon the slender stays s. u. and I. I. If it 
takes a force of say fifteen units to support the uterus 
distributed as follows; two at the broad ligaments 
to hold it forwards, three at the cervical end to hold 
it back, and ten below holding it and all the pelvic vis- 
cera up, if eight of these units are taken out of the 
pelvic floor by a relaxation, 1.1, and s. u. must at once 
do more work making up the deficiency of the eight 
units needed for its support, or the inevitable result 
will be that s. u. and I. I. will in time yield, and the 
uterus be driven down towards the weak spot by p. i. 
above (v. Fig. 3). The mechanism is as follows: the 
fundus cannot descend through the anterior vaginal 
wall to escape from the lax outlet, on account of the 
Shows the directions 
of the rectal, vaginal 
and urethral outlets 
piercing the pelvic 
floor obliquely and 
placed forwards. 
Fig. 2. 
interposed bladder, a water-cushion upon which it now rests. The arrows at p. i. represent units of The long wavy line s. u. repre- 
intra-abdominal pressure; the arrowsp. d. sents the relaxed utero-sacralliga- 
the resisting power of the pelvic dia- ment, allowing the downward dis- 
phragm; s. u. and 1.1. the forces which keep placement of the cervix, 
the poles of the uterus in position. 
Fig, 3. 
Fig. 4. 
The force of the blows p. i. falls therefore upon s. u., which yields gradu- 
ally, and the cervix begins to slide down the vaginal canal (v. Fig. 4). At 
this juncture the fundus uteri comes more directly between the lines of 
downward pressure and the vaginal outlet, and is as a consequence finally 
retro verted and driven back into the sacral hollow. 
If now on the other hand from any causes the 1.1, becomes relaxed, or 
has to bear the undue strain of an enlarged uterus, it rapidly yields to the 
strain, and a simple flexion or retroposition backwards is the immediate 
result (v. Fig. 5). 
From this brief consideration of the three factors 
concerned in producing displacements, we are pre- 
pared for a rational consideration of the treatment of 
displacements. It is at once manifest that it is not 
worth while to try to do much with the two weaker 
superior supports (s. u. and 1.1.) as long as the strong 
pelvic diaphragm is deficient, for no treatment or 
operation we can perform will enable these slender 
supports to substitute the stronger, and bear the 
brunt of all the attacks of the abdominal viscera 
The wavy line shows 1.1. 
(ligamenta lata) relaxed, 
no longer able to hold the 
fundus forward. 
Fig. 5. 
bearing down upon a corpus uteri devoid of support below. 
Thus the pelvic diaphragm (p.d.) must in all cases be restored first, and 
no device for retaining the uterus in situ is rational, which does not first 
Fig. 7. 
Shows substitution of a wedge, after 
the old method, by which the relaxed 
outlet is corked up, as it were. 
Fig. 6. 
Shows by the loops the restoration of the 
relaxed vaginal outlet, giving the levator 
ani a new hold on the tissues torn away 
and dropped back out of its grasp. 
assure the integrity of this, its inferior support. This can be accomplished, 
when the pelvic diaphragm is broken down, by a closure of the outlet, either 
by the old-fashioned denudation methods on the posterior wall, narrowing 
the outlet by the substitution of a wedge, apex upwards (v. Fig. 6), or by Emmet’s or Martin’s operations, which closely imitate nature in the res- 
toration of the pelvic diaphragm {v. Fig. 7). 
We have unfortunately no good surgical procedure for restoring the utero- 
sacral ligaments, but we can form a substitute by packing the vagina, or 
inserting a pessary, which keeps the cervix back in the sacral hollow by 
means of its posterior bar. 
With s. u. and p. d. thus rendered functionally active, 
we still have the problem of restoring 1.1, to a state of 
efficiency. Sometimes but little more is necessary than a 
simple elevation of the fundus, after which it remains in situ 
naturali, or is easily retained by a pessary. 
In other cases it is simply impossible to keep the fun- 
dus forward by any treatment through the vagina; and 
where strong adhesions exist binding it down in retro- 
flexion, it is manifestly impossible to accomplish anything 
Keeping the cer- 
vix up by cotton 
when s. u. is weak. 
Fig. 8. 
by treatment through the inferior strait of the pelvis. If there be no 
relaxation at the vaginal outlet, and the cervix be held well back in the 
pelvis, it is clear that when we bring the uterus into such a position, that the 
blows of the intra-abdominal pressure fall upon its posterior surface, the degree of 
its anteflexion will he constantly increased, and the gentlest force applied at its 
anterior pole will be sufficient to detain it in its new position. 
In this way in simple retroflexion the operation of shortening the round 
ligaments by cutting down over the inguinal canals, and pulling them out 
to such a degree as to draw the uterus well forwards, and cutting off the 
excess and stitching the stumps into the wound, has proved very successful 
in some hands. 
On the other hand there are a number of operators who prefer the more 
direct plan of making a small abdominal incision, which allows at the same 
time a thorough examination of all the pelvic organs, and enables the 
operator to deal directly with the displaced uterus, elevating it, and even 
breaking up any bands of adhesions binding it down to the pelvic floor. 
One of these direct intra-pelvic plans is hysterorrhaphy—the attachment by 
suture of the displaced uterus by corpus or broad ligaments close to its body, to an- 
terior abdominal or pelvic wall. 
As originally devised and practiced by Olshausen, Sanger, Werth, Bren- 
necke and myself, the procedure consists in catching the broad ligaments on 
their anterior face (through the round ligament, Olshausen) elevation and 
attachment by suture to the lower part of the anterior abdominal wall. 
(Fig. 10.) 
Fig. 9. 
Fig. 10. 
Showing the suspension of the uterus to Showing the suspension by 
the anterior abdominal wall by suture about ligature through the fundus, 
the round ligament. 
Boldt and Leopold have hung the uterus directly by sutures passed through 
the fundus, (Fig. 10). This is not unlike the original device of Prof. Koeberle who was the first 
to open the abdomen for the simple purpose of correcting a retroflexion. He 
removed the left ovary, and by means of its stump and the left tube 
clamped into the lower angle of the wound, thus fixed the uterus in ante- 
position, where it was found six years later.* 
The advantages of Hysterorrhaphy are that it has unquestionably both 
cured many cases of misplacement, and relieved the distress of a large 
number of patients upon whom it has been performed. 
The disadvantage has been a percentage of failures in which the uterus 
has slipped back into its old position. I attribute these disadvantages to a 
fault in the mechanism of the operation as hitherto performed, for by the 
method catching the uterus by the broad ligament on its anterior face and 
suturing it to the abdominal wall it is necessarily left in such a position 
that it must hang upon the sutures, and such adhesions as are formed at 
this point, and at the central incision. This hanging is a disadvantage, 
and is by no means a satisfactory substitute for the natural condition of 
mobile equipoise. It is also coupled with another mechanical disadvantage 
in that it is by this means feathered backwards. 
I have succeeded in remedying this difficulty by the simple plan of reaching 
over the tops of the broad ligaments, and lifting the uterus by the ovarian ligaments 
(v. Pig. 11), thus necessarily throwing it into anteflexion just as the body of 
a man would be bent forwards if he were caught by the shoulder-blades, 
and drawn up against the ceiling. Three of these cases have been operated 
upon in this Hospital. The results attained have thus far surpassed my 
expectations, and seem about to realize the ideal method of hysterorrha- 
phy after which I have been striving since my first original work in this iine.f 
Ten days after thus raising the uterus by the ovarian ligaments I have 
in each case found the cervix well back in the vagina and the body of the 
uterus lying upon the anterior vaginal wall, no longer hugging the abdom- 
inal wall, from which it is separated by a distinct interval. Its posture is 
thus one of marked anteflexion, from which all moderate efforts fail to dis- 
lodge it. Any efforts to displace it backwards simply results in carrying 
the corpus uteri up against the abdominal wall. 
The technique of the improved operation is as follows: 
Careful preparation of the patient for laparotomy. As 
thorough an aseptic regime on the part of the operator, 
assistants, instruments and field of operation as for the 
greatest abdominal operation. As soon as the patient is 
placed upon the table all genital hairs must be shaved off 
and the urine drawn. The incision is made 1 \ inches in 
length, nearer to the symphysis pubis than in case of 
abdominal section for diseased tubes. 
OV. is the right 
ovary; between this 
and the abdominal 
wall lies the ovari- 
an ligament which 
is sutured to the ab- 
dominal wall by s. 
Fig. 11. 
The next step is the insertion of six sutures into the 
abdominal parietal peritoneum, three on either side of the 
lower angle of the wound (v. Fig. 12). These are brought 
out on either side and grasped by two pairs of forceps. 
*Gastrotomie dans un cas de Retroversion uterine. Gastrotomie avec ovariotomie, 
dans le but de fixer I’uterus d’une maniere permanente a la paroi abdominale. E. 
Koeberle, Strassbourg, 1877. 
tAmer. Jour. Obs,, Jan., 1887, and Amor. Jour. Obs., May, 1888. The index and middle fingers then go down into the pelvis to seek and 
raise the uterus from its retroflexion. Before the fingers are withdrawn, 
the ovary and tube of one side are caught and drawn out through the incision. 
In this way the ovarian ligament is brought into plain view and within 
easy reach, and the three ligatures on the same side, already passed through 
Showing the six liga- 
tures passed through 
the parietal peritoneum 
and temporarily grasp- 
ed by forceps on either 
side. 
Fig. 12. 
Showing the fallopian tube and ovary grasped in the right 
hand while the needle with a leader is passed under the ova- 
rian ligament, ready to carry through one of the parietal 
sutures already in place (Fig. 12). 
Fig. 13. 
the parietal peritoneum, are conducted by means of a carrier (Fig. 13), in 
the order in which they lie from within outward, around the ovarian liga- 
ment, midway between corpus uteri and ovary. 
These are not to be pulled up and tied at once. The ovary and tube are 
dropped back into the peritoneal cavity and the ligatures left untied 
in the grasp of the forceps until the three ligatures of the opposite side are 
in the same way passed 
around the other ovarian 
ligament. Both ovarian 
ligaments are thus caught 
by ligatures connecting 
them to the abdominal 
wall. Before tying these 
ligatures it is necessary 
to slip the index finger The sutures embrace the ovarian ligaments, perito- 
, ~ , , neum and some of the muscle in the abdominal wall, 
around the uterus on both The uterus hangs anteflexed in the middle and ovaries 
sides, making sure that and tutes at the sidcs- 
neither intestines nor mesentary have become entangled in any of the liga- 
tures, or in front of the uterus. If all is clear the ligatures may then be 
Pig. 14. 
drawn up one by one, tied firmly, cut short, dropped, and the abdominal 
wound closed. The result is seen in Fig. 14. 
Adhesions form at once (Fig. 15), but these soon stretch by the simple 
weight of the uterus (Fig. 16), so that within two weeks the corpus uteri 
sinks on to the level of the anterior vaginal wall, to the position it now 
occupies in all my cases. 
Fig. 15. 
Fig. 16. These delicate filaments of drawn out adhesions serve effectually to pre- 
vent any backward rotation of the uterus. If the cervix tends to descend 
in the vagina a pessary must be worn. 
The three cases which follow were operated upon in this Hospital, and 
present results similar to those obtained in each of the cases in which this 
method has been employed, I present them therefore as typical. 
Case I.—Mrs.W.,age 28, mar., 3-Par, youngest fouryears old, had puerperal 
fever after her last confinement, and has ever since been a constant sufferer 
with distress in head and back, making her at times so nervous that she “ fears 
she will become crazy.” When she first came into my office she was in a 
wild, excited condition. She had for a long time been almost constantly 
confined to bed. I found a large relaxed vaginal outlet associated with a 
sharp retroflexion of a large infiltrated fundus uteri. In the spring of this 
year the outlet was repaired, and at the same sitting I raised the fundus up 
against the abdominal wall, and passed a suture through the abdominal pari- 
etes and corpus uteri, by means of a large curved needle, without opening the 
abdomen. The perineum healed rapidly, and gave strong support at the outlet, 
but the single stitch, which was removed in the second week, had been insuffi- 
cient to cure the displacement permanently, as 
the uterus soon rolled back into the sacral 
hollow. 
On Oct. 16, 1889, I made an abdominal in- 
cision close to the pubes 1J in. long, raised 
the uterus into anteflexion and attached it by 
its ovarian ligaments to the anterior abdomi- 
nal wall. Two silk sutures were used on each 
side. Drainage tube used. She rose from 
bed in three weeks, and left the hospital after 
four weeks. The outlet was tight, the cervix 
well back, and the anterior face of the uterus 
lay upon the anterior vaginal wall in easy 
anteflexion, quite mobile and not touching 
the scar in the abdomen, but I could not 
throw it back beyond the abdominal scar. 
Figure showing method of liga- 
ting ovarian veins in the angle 
between the ovarian hilum and 
the round ligament. 
Fig. 17. 
Case ll.—Mrs. H., age 21, 3-Par. Extensive relaxation of the vaginal 
outlet with a sharp retroflexion of the body of the uterus which lay with 
fundus lower than cervix in Douglass’ pouch. 
I restored the pelvic floor in April, at the same time catching up the 
uterus by a suture passed through the body, and through the abdominal 
walls. The vaginal operation healed perfectly, but the uterus soon dropped 
back, in spite of a repetition of the suspensary operation without anaesthe- 
sia, and no local treatment or pessary served to keep it even for a short 
time in place. 
Oct. 17, 1889, I performed hysterorrhaphy by the new method described, 
tying at the same time the enormous varicose ovarian veins on each side. 
(Fig. 17). 
No drainage tube was used. 
She made a rapid and perfect recovery, leaving the hospital Nov. 15. 
She was examined by Dr. Neal of this city, and several others interested in the new operation, who verified the apparently perfectly natural position 
of the uterus. 
Case 111. Mrs. S., a patient of Dr. Radcliffe Cheston, of Philadelphia, 
is 41, and has had eight children, the last 5J years ago. 
Last spring I repaired a large open vaginal outlet and at the same time 
lifted the uterus and fixed it to the abdominal wall without incision as in 
the other cases. 
This soon dropped back and I performed hysterorrhaphy Oct. 29th, 1889. 
The uterus was easily raised and two sutures passed under the ovarian liga- 
ments of each side raising it to the abdominal wall. No drain. 
She has made a rapid recovery, and the uterus is in a position of ante- 
flexion, the body lying on the vaginal wall and the cervix well back in the 
pelvis, a position from which no ordinary moderate efforts can dislodge it. 
She has since returned home. 
In conclusion I wish to state that my effort thus far has been to discover an 
operative method which will cure certain obstinate retroflexions. Whether 
the cure of the retroflexion will, in all cases, relieve the patients of their suf- 
erings is yet to be determined, and is of course the more important question. 
[Note, January 26, 1890. I have seen these three patients within a few 
days, and their condition remains as reported.]