THE TREATMENT 
OF 
ANTEFLEXIOXS OF THE UTERUS. 
BY 
ELY YAR DE WARKER, M.D., 
SYRACUSE, N. T. 
[REPRINTED FROM THE NEW TORE MEDICAL JOURNAL, JUNE\ 18T6.] 
NEWYORK: 
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1876. THE POPULAR SCIENCE MONTHLY. 
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549 & 551 Broadway, New York. THE TREATMENT 
OF 
ANTEFLEXIOXS OE THE UTERES. 
BY 
ELY VAN DE WALKER, M. LI., 
SYRACUSE, N. Y. 
[REPRINTED FROM THE NEWYORK MEDICAL JOURNAL, JUNE, 18T6.] 
NEXT YORK: 
D. APPLETON & COMPANY, 
54 9 & 55 1 BROADWAY. 
1876. THE TREATMENT OF ANTEFLEXIONS OF 
THE UTERUS. 
In medicine, as in law, the influence of precedent and well- 
established authority often obstructs the way of truth ; and, 
when they are finally set aside, yields only to the pressure of 
accumulated facts. It requires a firmer array of facts to stem 
the current of opinion, which is the outcome of authority, 
than to establish a natural law. This is about the relation 
that intra-uterine mechanical support bears to standard au- 
thority in gynecic surgery. This force of authority is ren- 
dered still stronger in this relation by the fact that the his- 
tory of intra-uterine stem-treatment is one of repeated fail- 
ures up to the year 1870; and many of the recent works 
upon diseases of Avomen speak either doubtingly of it, or 
condemn it in unmeasured terms. Importance, therefore, 
attaches to all additional experience that tends to prove 
the value of the intra-uterine stem in practice. This be- 
comes all the more important in view of the difficulties 
which surround the treatment of the various degrees of ante- 
r? 
flexion and -version. I speak for myself only when I say that 4 
all the instruments, other than the intra-uterine stem, devised 
for the correction of these errors of position, have failed to 
amend the fault; and, judging from the number of cases that 
have come into mj hands from other physicians—some of them 
experts—I have not been solitary in my failures. 
The causes of these failures are purely mechanical. There 
are no means, aside from intra-uterine support, that act so di- 
rectly in restoring the displaced organ. The cause of this in- 
direct action is the anterior vaginal wall intervening between 
the means of support and the part to be supported; a vaginal 
wall, moreover, that participates in the displacement, and is a 
part of the error. It is this changed relation of the vagina, 
and the want of a fixed point of support anteriorly, which 
render the forward displacements so much more difficult to 
deal with than the backward; the inner surface of the pubes 
is available as a point of intra-vaginal support in the latter, 
wdiile in the former this point is directly under the part to be 
sustained, without any point of counter force. These are the 
main difficulties in the way of simply intra-vaginal mechani- 
cal treatment. 
I shall refer briefly to those instruments which exert their 
sustaining force from a point external to the vagina. In 
order to illustrate this order of mechanical support, I shall se- 
lect one, the type of all others not intra-uterine, and ideally the 
most perfect—Cutter’s anteversion pessary, with Dr. Thomas’s 
modification. In order to understand what this pessary really 
does when properly adjusted, let us examine the position of 
the anterior vaginal wall as implicated in the displacement. 
Anteriorly and below, the vagina has an unyielding point of 
origin in its osseous attachments; above, it is subject to the 
varying positions of the uterus. In forward displacements, 
particularly of extreme degree, the anterior vaginal wall 
passes obliquely upward and backward across the vaginal vault 
to its insertion in the cervix, stretching it more and more as 
the cervix is forced backward and upward ; so that, in the ex- 
treme limit of malposition, the finger may detect the tension 
of the vagina and the nearly obliterated condition of the an- 
terior transverse plicae. Whatever the amount of deviation of 
the organ, the difference in effect upon the vaginal column is simply that of degree in tension. Now, the transverse bar of 
the pessary, impinging upon this tense anterior wall of the 
vagina, is supposed to lift the fundus of the uterus; but it 
can only do so as it indents and uplifts the vaginal wall. 
This indentation cannot occur except by drawing the cervix 
toward the pubes. . It is evident that all force which draws 
the cervix forward, without lifting the fundus to a correspond- 
ing degree, converts a version into a flexion, and, where the 
latter already exists, simply aggravates the deformity. The 
effect of the instrument upon the cervix is always in excess of 
its effect upon the depressed fundus. The operation of this 
pessary is complicated by another condition. By the altered 
position of the anterior vaginal wall, the lifting force of the 
instrument is deflected backward behind the point of avail- 
able lifting force under the fundus. Its force is therefore ex- 
pended, not under the depressed summit of the organ, but at 
the junction of the uterine body with the uterine neck. Any 
one can satisfy himself of the truth of this by examining 
the position of the transverse bar of the pessary after it has 
been worn for a few hours. What is really accomplished by 
the instrument is this : The cervix is drawn forward, and the 
entire uterus lifted in the pelvic space. It often relieves 
symptoms, not by the correction of the deformity, but by lift- 
ing the organ entire, its relative position of displacement re- 
maining unchanged. 
Hewitt’s anteflexion pessary in extreme cases cannot bo 
worn. The tense vaginal roof forces the anterior portion of 
the instrument downward from Its point of support upon the 
pubes, and tends to partially expel the lower part of the in- 
strument. 
The intra-uterine stem with, extra-vaginal support I shall 
not consider. Gynecic surgery has passed beyond such crude 
ideas. Notwithstanding the great name of Simpson and the 
ingenuity of Yalleix, these instruments have been driven out 
of use by the general good sense of the profession. They vio- 
late every law of normal uterine movement, the complicated 
and important character of which I have already demonstrated.1 
1 “ A Study of the Normal Movements of the Unimpregnated Uterus,” 
this Joxexal for April, 1875. 6 
It is, in brief, a method of impalement reduced to its possible 
minimum of danger to life. 
In this criticism of some very popular instrumental appli- 
ances for the correction of anteflexion or version of the uterus, 
I speak from my own experience only, by which I feel myself 
justified in saying that I believe that the only road to cer- 
tainty in the treatment of these deformities lies in the direc- 
tion of greater perfection in intra-uterine stem-instruments 
with adjustable intra-vaginal support. But Ido not wish the 
reader to draw the possibly too natural inference that the in- 
struments figured in this paper avoid all the objections raised 
against the instruments named; but rather to show that we 
have many reasons to seek for improvements in the mechani- 
cal treatment of these deformities, and that we are yet far 
from the goal of a perfect pessary. 
An instrument designed to correct the forward displace- 
ments must undergo a peculiar modification. This requires a 
vaginal attachment, so constructed as to bring the posterior 
vaginal wall into play as the point of counter-pressure to the 
force of anterior displacement. 
An instrument of this character has been devised by Dr. 
Eklund, of Stockholm.1 The reader can gain a good idea'of 
this stem by imagining the flange, Fig, 3, to be rigidly fixed 
to the stem, Fig. 1. It is a broad expansion of the stem, its 
surface parallel with the axis of the stem. This pessary is 
used in either ante- or retroflexion or version, and the vaginal 
expansion is not designed to bring the posterior wall into 
action as a point of pressure, but to offer a broad surface to a 
tamping of cotton, which is placed in front of the flange in 
posterior displacements, thus crowding it backward against 
the posterior wall of the passage, and lifting the fundus ac- 
cordingly ; or, in the opposite form of dislocation, the cotton 
is placed posterior to the flange, thus pushing it forward 
against, the bladder. So long as the cotton tamping is in 
place, of course the instrument answers its purpose ; but those 
of us who have tried it know how difficult it is to keep a mass 
of cotton in one position in the vagina, especially any mass 
designed to be kept in the anterior cul-de-sac. An instru- 
1 Obstetrical Journal of Great Britain and Ireland, yol. ii., p. 561. 7 
ment of this kind, with cotton tamping, is unnecessary in the 
treatment of retroflexions or versions. Accepting Dr, Eklund’s 
pessary as the basis, I designed the flange figured in cut 3, 
and which expresses its average size. Its introduction is an 
easy matter. This stem, Fig. 1, is first placed in position, and 
the flange is then pushed up upon the wire until it rests against 
the shoulder aof the stem; the same manipulation as in the 
introduction of my retroflexion stern-pessary, now some time 
before the public.1 
This pessary is intended for the correction of forward dis- 
placements, and its principle of action is very simple. The 
portion h of the flange, a smooth and rounded surface, is 
pressed backward by the tendency of the uterus to anterior 
displacement against the posterior vaginal wall ; the fundus 
is, therefore, maintained in an erect position. These instru- 
ments are made of hard rubber. 
I can better illustrate the treatment of anteflexion of the 
uterus by the history of three cases : 
Case I.—Mrs. 8., a spare brunette, aged thirty-one years ; 
married; no children ; two miscarriages, the last six years 
ago ; occupied in the care of her house. The leading symp- 
tom in this case was ceaseless and tormenting vesical tenes- 
mus, and which has been present nearly five years. She has 
been under the care of various physicians, and among them 
was a general practitioner with gynaecological proclivities, of 
considerable skill and experience, and who treated her locally, 
but without benefit. The last was an irregular German phy- 
sician, who informed her that the urinary symptom was a sign 
of the last stage of syphilis. This information, with her bil- 
ious, gloomy temperament, produced a most unhappy men- 
tal condition, which, in connection with the domestic trou- 
ble that resulted, drove her nearly to the verge of insanity. 
During this period of mental excitement the vesical tenesmus 
was aggravated, often driving her from her bed two and three 
times an hour during the night. There was never at any time 
much leucorrhoea, and menstruation was normal, or but little 
deranged. Inspection showed the urinary meatus tumefied 
1 Buffalo Medical and Surgical Journal, April, 1874; and Southern 
Medical Record, November, 1874. 8 
and inflamed, with slight eversion of the edges. On examina- 
tion, the uterus was found in a complete state of anteflexion. 
It could be easily carried back into place by the sound; but 
on the withdrawal of the instrument quickly recoiled to its 
dislocated position. lat once expressed the opinion that the 
vesical irritation was due to the anteflexion; but, as the ure- 
thra had a suspicious appearance, I thought best to eliminate 
all other probable sources of the symptoms by a careful explo- 
ration of the urethra and bladder. With this in view, assisted 
by Dr. Frank H. Butler, of this city, who gave the anaesthetic, 
on the 24th of April, 1875, the urethra was rapidly dilated by 
the finger, so as to permit the index-finger to be swept round 
the neck of the bladder just beyond its urethral contraction, 
but without detecting any diseased condition. A small bi- 
valve anal speculum was then introduced, and through its 
slightly-expanded blades a fair view could be had of the lining 
of the urethra, which appeared congested and thickened. 
Aside from this, nothing abnormal appeared. As this condition 
may have been the source of the vesical symptoms, I thought 
it better to treat it. By means of cotton wound upon a probe 
I applied chemically pure nitric acid to the entire extent of the 
urethra. The treatment, however, amounted to nothing, in a 
curative sense, but was well borne, and was unattended by 
incontinence of urine. Two weeks after the above date the 
stem represented in Fig. 1 was introduced, and secured in 
position by the flange, Fig. 3. The instrument was well 
borne, and the night following its introduction my patient 
was obliged to rise to void urine but twice, instead of as often 
every hour. The pessary was worn nearly constantly until 9 
October, with complete relief of the symptoms. In that 
month Mrs. B. left Syracuse for Chicago, where, upon going 
to a physician to have the stem replaced, she was surprised to 
learn of the fearful risk she had been exposed to by wearing 
such a dangerous instrument. As she could not have the 
pessary introduced, she concluded, if possible, to do without 
it. I saw Mrs. B. in January last, and she informed me that 
she was free from her vesical tenesmus, and had been so with- 
out interruption since October. She declined an examina- 
tion, as she believed herself to be well. 
Case ll.—Mrs. W., aged forty-three years; has been a 
widow two years ; three children, the youngest six years old; 
occupation tailoress. In this case the morbid action of the 
uterine displacement seemed to expend its force upon the 
nervous system. There were an endless variety of subjective 
sensations, and a morbid craving for sympathy. Much of her 
time was passed upon a couch, or in bed. An examination 
proved that the uterus was in an extreme degree of ante ver- 
sion. The os was forced backward and upward to such an 
extent that it was reached with difficulty by the finger. As 
usual, in version, it did not recoil so quickly to its faulty posi- 
tion after being replaced by the sound as in flexion. An effort 
was made to correct the version by means of the flange, Fig. 
3 ; but it was found that, on account of the great capacity of 
the vagina and the strong tendency to version, the organ set- 
tled forward gradually, driving the flange upward and back- 
ward into the posterior vaginal cul-de-sac. An effort was 
made to correct this fault in the flange by making its flat ver- 
tical surface broader in the direction of h, Fig. 3. But this 
was found to bring its lower edge too near the ostium vaginae, 
resting nearly upon the perineal body, so that it was being 
constantly expelled. Of course, while in place it kept the 
uterus in its correct position ; nevertheless it was not practical. 
Being somewhat discouraged by my failure, it was some time 
before I made another attempt. The next effort was to devise 
a flange which would secure a larger posterior vaginal surface 
for it to rest against; a counterpoise, as it were, to the strong 
tendency to anteversion. There remained but one way in 
which this could be done ; and that was, to enlarge the flange 10 
laterally in the direction of b, Fig. 4. In order to render its 
introduction easy, a slot was cut upon opposite sides of the 
opening for the stem, which is not shown in the cut. These 
slots permitted the flange to be turned very obliquely upon 
the wire which carried the stem, so that it might be presented 
by its edge at the ostium vaginae. Fig. 4 represents the act- 
ual size, and by means of the slots it was not more difficult 
of insertion than the flange, Fig. 3 ; and, as may be seen by a 
comparison with that cut, in its transverse diameter it is no 
larger. Taking into consideration the great capacity of the 
vagina, and the extreme degree and force of the version, the 
instrument worked remarkably well. It very seldom was ex- 
pelled or got out of adjustment. Mrs. W. gradually improved 
in general health, spent less and less of her time in bed, and 
showed more of her former spirit of industry, although her 
mental tone revealed the severe shock to which it had been 
exposed. It now appears, at this writing (April 10th), that, 
while the prospect of a “ cure ” for Mrs. W. is very remote, 
she is still wearing her instrument with comfort most of the 
time, and is earning her living as a tailoress, which she had 
been unable to do for two years previous to the treatment. 
Case lll.—Mrs. S., aged thirty-four years; has been mar- 
ried eighteen months; no children; previous to her marriage 
had taught school many years ; since her marriage her occu- 
pation is that of a farmer’s wife. In physique she is a tall, 
colorless blonde. Mrs. S. wTas brought to me by her family 
physician, Dr. S. M. Higgins of Memphis, FT. Y. It is need- 
less for the purpose for which her case is cited here to detail 
the symptoms; they were of such a nature as led her phy- 
sician, an energetic and accomplished medical man, to arrive 
at their origin an examination of the pelvic organs. On 
examining for myself I found a discouraging state of things. 11 
The vaginal cavity was very much contracted, but normally 
so, the uterus low, the cervix slightly elongated and conical, 
the finger meeting it about an inch and a half from the osti- 
um vaginae, and the uterus was sharply anteflexed, the seat 
of the flexure being at the junction of the uterine body with 
the uterine neck. The flexed organ possessed great resilience. 
From its small size and the general condition of the parts, I 
was induced to believe that the flexion was either congenital, 
or dated from early menstrual life. It was an excellent case 
for division of the cervix anteriorly; but to any thing in the 
nature of a surgical operation the patient or her husband 
would not listen. The first difficulty that presented itself in 
the way of a mechanical correction of the deformity was the 
shortness of the vagina, which prevented elevation of the or- 
gan so as to admit the smallest flange in ray possession. A 
flange the size of Fig. 3, when in position, presented its lower 
edge just within the labia, and caused so much pain that I 
at once removed it. It was evident that I would have to 
construct a vaginal attachment smaller than any I had ever 
yet devised ; and at the same time with a surface sufficiently 
large to secure a due amount of counter-force by pressure 
against the posterior vaginal wall. From a wax model Dr. 
A. J. Dallas, Jr,, a dentist, constructed out of hard rubber 
the flange represented in Fig. 2, and which is slightly larger 
than the original. This instrument was introduced without 
difficulty and was worn with comfort. Unfortunately I can 
only allude to this case as one in which many obstacles in the 
wTay of mechanically treating a severe form of anteflexion 
were overcome by a simple device, and as one eminently 
calculated to illustrate the purpose of this paper. Mrs. S. in 
February last, after a severe day’s work about her house, was 
suddenly attacked by some form of cerebral disease, and, be- 
coming rapidly unconscious, she died in about twenty four hours. No post-mortem examination was allowed. She had 
completed menstruation—still wearing the stem—about ten 
days previously to her fatal sickness, the function being per- 
formed with less general disturbance to the system than usual. 
The point in the mechanical treatment of anteversions or 
flexion, or, in fact, the opposite form of uterine dislocations, 
which these cases are designed to illustrate, is that we cannot 
place our reliance upon any one form of instrument. The sim- 
ple difference in size, which constitutes the variety in any one 
form of pessary, is not sufficient to meet the requirements of 
particular cases. It is safe to say that no two vaginae are alike,, 
and the extent to which they differ in capacity is but a minor 
difference. If we were to fail in correcting a flexion with one 
size of pessary for sale by the makers, it would not follow 
that the size larger or smaller, as the case might be, should 
succeed where the other failed ; but we ought rather to con- 
sider that the case may be one that demands some other form 
of mechanical correction. Contrast the two Cases 11. and 111., 
and the reader will perceive at once that a simple difference 
in size in the form of flange I usually employed (Fig, 3), 
would not enable a physician to treat either of these eases. 
In order to apply the same principle to the treatment of the 
three cases, it was necessary to essentially modify it in the 
management of the last two. Now, the usual method is too 
mechanical. A physician, if he relies upon the instrument- 
makers, has only a choice of a difference in size in any one in- 
strument he may select. The more complicated the instru- 
ment the greater the reason, oftentimes, for changes in form 
other than that of size. In using Dr. Thomas’s anteversion 
pessary, as sold by the makers, I have several times been 
obliged to shorten the bow ; this may not be the fault of the 
idea of the instrument, but rather of the maker, for my own 
brief experience teaches me that a pessary is one thing after it 
comes from the hands of the inventor, and another thing com- 
ing from the hands of the maker. The gynaecologist is not 
altogether blameless in the matter. If he possesses any inge- 
nuity at all, he invents an instrument, usually a pessary; and, 
because it succeeds well in one case, he places it at once in 
the hands of an instrument-maker, who advertises it accord- 13 
ngly as an instrument designed to correct a certain form of 
•uterine dislocation, and both the inventor and the maker 
seem to believe that by producing two or three sizes they are 
providing for every probable variation of condition in any case. 
AVe have a class of gynaecologists, both in this country and in 
England, who seem to devote a large amount of their time to 
mechanical inventions, if we are entitled to judge by the fact 
that they rarely come before the professional public except 
in connection with some new gynecic device. I cannot avoid 
the belief that this multiplicity of instruments is working 
harm, rather than good, to the aause of special medicine or sur- 
gery, as it is constantly leading to disappointment on the part 
of the general practitioner, who is obliged oftentimes to rely 
upon himself, and thus causing a distrust of those who profess 
special training in one department. It may be objected that 
the surgeon cannot be constantly inventing modifications or 
new appliances for his clients; but, if he is to treat cases of 
this nature successfully, he must be an inventor, not once, but 
all the time. Nor is it so much a matter of pure invention as 
may be supposed. It is the case before one, and not one’s 
originality, that suggests the new instrument or the modifica- 
tion of the old one. The surgeon has but to receive the hint 
and act upon it. 
A very convenient way for physicians who cannot take 
their orders personally to the special manufacturer of these 
instruments is, to establish relations with some dentist who 
makes rubber dental plates, and is therefore able to make 
small vulcanite instruments, such as are figured in this article. 
From a careful study of his case, the physician may prepare a 
model in wax which the dentist can easily copy in hard rub- 
ber. In this way changes in form and size may be made until 
the particular case under observation is fitted with its proper 
form of instrument. This method of procuring ante- or retro- 
flexion instruments may be more costly than ordering through 
the regular channels of the trade, but the certainty of perfectly 
adapting the mechanical treatment to the particular require- 
ments of the case counterbalances the increased expense. In 
the slighter forms of version, the block-tin rings or copper-wire 
rings covered with pure gum, which may be procured in a great 14 
variety of sizes, can be bent or moulded into any form tbe case 
may require. lam satisfied that the stem-pessary ought to be 
made specially for each case. Ido not believe that they can 
be manufactured for the trade in three or more sizes and give 
satisfaction. Success depends upon the flange being accu- 
rately fitted, and, if the physician does not succeed in his first 
model, further trial is sure to reward him with a perfect 
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