Keprinted from the Transactions of the AmericanAssroiation of Obstetricians and 
Gynecologists, September, 1890. 
POSTERIOR DISPLACEMENTS OF THE UTERUS. 
Remarks upon Pathology ani^'Treatment. 
By ISAAC S. STONE, M.D., 
WASHINGTON-*- LT.'T. 
The subject of displacements of the uterus has probably re- 
ceived more atteution than any other topic of interest to the gyne- 
cologist; yet there is much uncertainty in reference to the path- 
ology of such cases, aud not a little error in the recognized 
treatment of them. It occurs to the writer that very much of the 
doubt in reference to the treatment of these lesions, arises from a 
refusal on the part of the profession to accept clearly proven and 
demonstrable facts. 
There has been very much temporizing, and the climax of 
absurdity has been reached in the effort to treat the various dis- 
placements of the uterus by means of pessaries without regard to 
the cause. It has frequently occurred that patients have gone the 
round of physicians, including some specialists, vainly expecting 
relief from some vaginal support, which the attendant informed 
them might confidently be expected. It has doubtless been the 
hope that some accident might cure the patient during the treat- 
ment, and that this does occasionally occur is true. I‘ can but 
judge by observation that very much of the routine practice of 
inserting pessaries, is based upon a misunderstanding of the causes 
and complications attending cases of displacement. It is often a 
means of satisfying the mind of the patient that her disease is 
having the proper treatment, while the real fact is reserved that 
cures are indeed very rare from pessary-wearing alone. Indeed, 
it appeared at one time in the history of gynecology, that the road 
to fame might lie in the invention of a pessary, so zealously were 
they forced upon the attention of the profession. It is confidently STONE, 
to be hoped that, with the clearer light of the present pathology, 
rational methods of treatment may prevail. 
After years of experience with the theoretical treatment of these 
displacements, we can appreciate the truth and force of the state- 
ment of Bernutz: “It has been my aim to prove that deviations 
of the uterus, when simple, with the exception of prolapsus and 
procidentia, do not cause any functional disturbance; but when 
complicated with old pelvi-peritonitis or uterine catarrh, or con- 
gestion, the faulty position and the abnormal mobility are a source 
of pain, and demand treatment.” (Sydenham Transactions, etc.). 
These views should, for the most part, guide us to-day; for it 
would not be far wrong to say that those who are in the best posi- 
tion to know the truth or falsity of the remark, do not hesitate to 
endorse the great French writer. 
In opening up the abdomen for Battey’s or Tait’s reasons, it has 
been found that the parametritis or cellulitis suspected, is generally 
pelvic peritonitis or its results,—adhesions of the Fallopian tube 
and ovary to any adjoining peritoneal surface. The uterus, in 
nearly all these cases, is fixed in its position by these adhesions 
affecting its ligamentary, chiefly peritoneal, supports, and is often 
found displaced backward in version or flexion. 
It is not, therefore, surprising to find men having to do pelvic 
surgery who eschew pessaries. 
I am confident that in this year of 1890, pathological condi- 
tions should be so well understood as not to suggest a pessary 
when there are adhesions holding down a retroflexed uterus. The 
quotation from Bernutz is important from another point—that in 
reference to the symptoms caused by these displacements. When 
we take into consideration the vast number of displaced uteri 
found and treated by the profession, and add to these the addi- 
tional number not known but surely existing, we can form some 
idea of the innocuousness of any mere displacement which is 
without the symptomatic suffering. The truth cau never be ascer- 
tained as to the frequency of displacements, for we only know of 
those giving rise to symptoms. We are daily learning that a dis- 
placed uterus causes pain, discomfort, or reflexed symptoms, just so 
much as it displaces, distorts, or involves other organs and tissues 
adjacent to it. Therefore, granted a displacement backward, what 
are its causes ? POSTERIOR DISPLACEMENTS OF THE UTERUS. 
3 
First, intrapelvic disease influencing the uterine supports. 
Second, changes in the body of the uterus itself. 
It is probable that the first heading would include the second, if 
such changes are a result of intrapelvic lesions, which indeed is 
generally the case. The cause of retro-displacement is in by far 
the greatest number of cases due to intrapelvic inflammation. The 
result of such inflammation in the form of adhesions between 
peritoneal surfaces, and influencing the position and length of the 
various ligaments, constitutes the lesion which at once indicates 
with how much difficulty a cure may be accomplished by any 
vaginal support. In addition to such traction as may be exerted 
by inflammatory changes within the pelvis, there must be men- 
tioned the growth of tumors, and other changes in the uterus 
itself, or in adjacent structures, yet influencing its position. 
The second class is intended to apply to those cases where the 
uterus may be displaced by reason of organic change in its muscu- 
larity, as from fatty degeneration, subinvolution, etc., yet not due 
to those causes before mentioned, such as fibroid or other tumors. 
Treatment.—Displacements of the uterus backward involve 
two very important considerations, which the practical gynecolo- 
gist must at once determine when investigating such cases. 
First, What is the size of the organ ? 
Seoond, Is it fixed or movable, i.e., can it be easily replaced ? 
The question is thus simplified by removing all the accumulated 
verbiage surrounding it. In this connection must come the in- 
quiry, How much is the patient’s health influenced by the malposi- 
tion? This question is all-important, for no absolute relation of 
cause and effect can be formulated for these cases of disease. Very 
many women carry their wombs in the third degree of the pro- 
lapse, yet without great suffering. Others appear to suffer greatly 
from the slightest supposed abnormal position. 
To return to the treatment of mild cases or those without great 
pain, fixation, or other evidence of intrapelvic disease, it appears 
that very much of the treatment of these slight retro-displacements 
is entirely unnecessary. In looking over my own experience, I do 
not find so many cases of malposition requiring vaginal support, 
as when, earlier in practice, one was taught that very much of the 
backache and other suffering in women was due to these displace- 
ments. I can only rely upon the evidence furnished by my medical 4 
STONE, 
friends and fellow gynecologists, to support me in this opinion, 
that the pessary is slowly sinking into desuetude. I am fully 
convinced that at no distant day, medical men generally will place 
the pessary where it belongs, and not use it without positive indi- 
cations. 
The symptoms of dislocated uteri are the symptoms in a large 
number of cases of nerve tire, and demand systematic electrical, 
medicinal, and hygienic treatment. That the use of a pessary 
serves to calm the fears of a nervous woman, is no excuse for con- 
tinuing its use when the flexion, if present, cannot be cured by it, 
and perhaps other and more important treatment is being neg- 
lected. Several years ago, a married lady, aged forty-eight 
who had been suffering for some months with insomnia, was sent 
to me for examination. Her physician suspected a uterine cause, 
and I found it, as I supposed, in a retroflexed uterus, which had 
probably caused her sterility, for she had no children. She was in 
good flesh, and there appearing no other cause for her sleeplessness, 
I inserted a Hodge pessary to sustain (?) the fundus uteri. She was 
at once greatly benefited, but in a short time her insomnia returned, 
and she sought relief at a well-known water cure establishment. 
The pessary was removed, and the excellent hygienic treatment 
served to cure the insomnia. After her return, she allowed her 
curiosity to get the better of her, and insisted that I examine her 
to know if the retroflexion was cured. I unwillingly deceived 
her, and although I found the uterus just where it had doubtless 
been for years, managed to assure her that she need have no fur- 
ther fear of any uterine trouble. 1 was wrong in my estimate of 
this woman’s disease, and should not now declare a retroflexion to 
have anything to do with the health of a patient past the meno- 
pause, if it were, as in this case, uncomplicated by other organic 
change. Hr. Bantock says, in his work on Use and Abuse oj 
Pessaries, “No pessary yet invented can undo a flexion” (loc cit.). 
In this position, he is sustained by Hart and Barbour, beside 
other recent writers. I am fully confirmed in this view person- 
ally, but can endorse the evidence furnished by Dr. Bantock in 
the work above mentioned—although he does not pointedly allude 
to it—that pregnancy may happen while the pessary is worn, and 
in this way permanent cures not infrequently occur. In fact, the 
only cures I am aware of in my own experience have resulted 
in this way. posterior displacements of the uterus. 
5 
It is probable that the cases cured by pregnancy are those in 
which adhesive peritonitis has caused the malposition, and the 
gentle traction and pressure of the expanding uterus have caused 
the liberation of these retaining bands, while in the process of 
normal involution they do not reform. I will conclude this por- 
tion of my subject with this remark : I would use a pessary in the 
variety of displacement under consideration only as a temporary 
expedieut, and never to the exclusion of frequent replacements or 
adjustment with a repositor, if necessary, and suitable position for 
the patient. 
It is probable that some of the electricians may have treated 
these cases successfully, or that massage may prove satisfactory in 
the readjustment of versions and flexions, but I leave these methods 
to those having experience with them. I have elsewhere stated 
my great objection to the use of massage when, in our endeavor to 
do good, we may rupture a pus tube, and do infinite harm. (See 
Gaillard’s Journal, November, 1889.) 
The only pessary capable of supporting a retroflexed uterus is the 
intra-uterine stem. Great diversity of opinion prevails as to the 
propriety of using so dangerous an instrument. We may dislike 
their use, and fear bad results, but they give real support to the 
fundus, aud there may be cases in which they can be used with 
signal benefit. I should prefer the intra-uterine stem to any of the 
proposed abdominal operations, such as suspension or fixation, pro- 
vided the stem would sustain the body of the uterus, and that no 
other disease required abdominal section. Operative measures upon 
the neck of the uterus have been resorted to by Marion Sims and 
others, hoping to influence the position of the fundus, or at least to 
straighten the canal, but these have either failed to accomplish the 
intention of their inventor, or have not attracted general attention. 
Besides, they are not philosophically correct. The methods of sur- 
gical relief of posterior displacemeuts are Alexander’s operation, 
or shortening the round ligaments. 
Ventro-fixation and Suspension; Operation upon the 
Broad and Round Ligaments Inside the Abdomen, and 
Shortening of the Utero sacral Ligaments. 
It is now evident that Alexander’s operation has not been well 
received by the profession, and surgeons generally agree with 6 
STONE, 
Winckel that it will soon become obsolete. It has been the expe- 
rience of most surgeons to find the round ligaments unfit for ser- 
vice as a means of support, and other operations are generally 
required to assist in sustaining the uterus. The methods of sus- 
pension or fixation are now being tried by some surgeons, but I 
have space to mention only one case in my own practice : 
Mrs. Gr., aged fifty years, came to me in 1888, suffering from retroflexion 
and prolapse of the uterus. She had worn pessaries for years, and was suf- 
fering from severe ulceration of the vagina as a result. I resorted to Alex- 
ander’s operation after first amputating a very large cervix. The ligament 
was found on the left side, and secured as is usually done. That on the 
right was a mere thread, having undergone elongation until it was practi- 
cally of no value. The incision in this case was extended upward and 
through the abdominal walls, until about three inches in length. The broad 
ligament and Fallopian tube, with the cornua of the uterus, was then stitched 
with catgut to the abdominal walls and within the lips of the wound. 
(Modification of Hanger’s operation.) The woman has remained well of the 
malposition, although she is still a sufferer from neurasthenia. 
Other cases of posterior displacement have occurred in practice 
requiring surgical treatment, but were generally brought to my 
notice for other reasons, notably in complication with diseased 
appendages. 
One case worthy of mention was called lateroflexion. In the 
left side was found a hydrosalpinx, a large cystic ovary the size of 
an orange, and a band of adherent omentum two inches broad, 
fastening the tube to the ovary and broad ligament at its outer in- 
sertion to the pelvis. Another very interesting case was sent to 
me for Battey’s operation. The uterus was fixed in the first degree 
of descent, the patient, a virgin, having been an invalid for 
many years, and having tried all sorts of treatment, including 
pessaries and dilatation of the uterus by a specialist (for what I 
have never learned). The adhesions suspected were found on the 
right side, holding down the uterus—a result of pelvic peritonitis. 
The appendages were removed, hoping to cure a menorrhagia and 
other symptoms, the right ovary looking like a beautiful cluster of 
grapes, from its cystic nature. The uterus was freely movable 
after the liberation of the adhesions, which was ascertained at the 
time of the operation, and it has since remained so; the patient is 
apparently well. These cases are not unfamiliar to those who do 
pelvic surgery, and could be greatly multiplied. I can endorse POSTERIOR DISPLACEMENTS OF THE UTERUS. 
7 
the opinion, which I think was first suggested by Mr. Tait, that 
those cases requiring pelvic surgery for diseased appendages are 
thereafter cured of any preexisting malposition. I prefer, so far 
as my own limited experience goes, to add the word “ symptom- 
atically.” 
Tait’s operation of reefing the broad ligaments is therefore prac- 
tical, and, moreover, not attended by additional danger, as the 
abdomen is generally opened in these cases for other disease than a 
mere displacement. 
The same may be said of the measures advocated by Dr. Polk 
and others, who tie the broad and round ligaments in front of the 
uterus. 
In addition to the operations already announced there are two 
methods which I have to suggest. The first, to sustain the lower 
segment of the uterus, and is a support to the utero-sacral liga- 
ments. While the abdomen is open insert through the vagina both 
ends of a suture, an inch between, into and through Douglas’s cul- 
de-sac. These sutures should be fastened to the round and broad 
ligaments, and can then be brought out separately two or more 
inches apart on the abdominal wall. By traction upon these ends 
the uterus and appendages are lifted well upward, and if denuda- 
tion has been practised upon the superior and anterior wall of the 
uterus, there can be no doubt of the fixation being complete. This 
method has the advantage of holding the uterus and broad liga- 
ment entirely away from any raw surface made by the liberation of 
adhesions. It of course supposes an aseptic and well-packed vagina 
to prevent contamination from the uterus or lower vagina. The 
other plan proposed is to insert a double wire or other reliable 
material through the uterus and out at the fundus, a roll of gauze 
at either end of the suture, one to prevent the wire slipping into 
the uterine cavity, another on the abdomen to prevent cutting into 
the skin. This method is probably the same as that suggested by 
Dr. Sims, and mentioned by Dr. Emmet in 1889. (See Trans. 
Amer. Gynecol. Soc., p. 267.) I have tried it on the cadaver, 
first placing the body in Trendelenburg’s position. There was 
no transfixion of intestine. I should regard this the safest of all 
methods of suspension or fixation when the cavity of the abdomen 
is not to be opened. But it is beyond doubt safer to know just 
what one is doing, and hence there must indeed be but few cases 8 
POSTERIOR DISPLACEMENTS OF THE UTERUS. 
demanding these operations done in the dark. These operations 
last mentioned should be, as other methods of suspension, rarely 
resorted to, and only when they supplement other work. 
Conclusions.—1. Displacements of the uterus backward may 
not give rise to symptoms, and do not require treatment unless 
other organs and tissues are involved. 
2. If symptoms are present they are often due to neurasthenia, 
and demand appropriate treatment. 
3. Those cases of posterior displacement which cause pain and 
give rise to dysmenorrhea and other symptoms, have generally a 
cause requiring other than mere treatment by pessaries, which is of 
temporary value only, and often prevents proper treatment of the 
real cause of disease. 
4. Operations recently suggested, such as fixation, suspension, 
etc., are rarely required uuless in connection with other operations, 
when the abdomen is opeu for other reasons, the treatment of which 
may set aside the necessity for the new methods.