UTERINE DISPLACEMENTS AND THEIR 
INFLUENCE ON THE GENERAL 
NERVOUS SYSTEM. 
By FRANCIS II. DAVENPORT, M.D. 
OK NORTON. 
Rend at the Annual Meeting of the Massachusetts Medical Society, 
June 12, 1888. UTERINE DISPLACEMENTS AND TIIEIR 
INFLUENCE ON THE GENERAL 
NERVOUS SYSTEM. 
Uterine displacements have from the earliest times about 
which we have any medical knowledge been recognized as 
existing, and as giving rise to disturbances both general and 
local. It is probable that prolapse and procidentia, as being 
malpositions which would most quickly'and surely be seen, 
were the first to be diagnosticated and treated. Later, as 
the vaginal examination became perfected, would follow 
the forward and backward displacements, reserving for 
these days of gynecological enlightenment the recognition 
of the more refined shades of departure from the normal, 
which have filled our text books with subvarieties, and for 
whose relief a legion of pessaries has been invented. 
The impetus which has been given to the study of this 
branch of medicine in the last twenty-five or thirty years has 
resulted in placing a great deal that is of value on a sound 
basis. With regard to the special branch of uterine disease 
which is the subject of this paper, the following may be 
said. We have learned to diagnosticate the various mal- 
positions to which the uterus is liable, and the tactus 
eruditus is now seeking new worlds to conquer. Tubes 
and ovaries whose recognition by a large proportion of 
practising physicians is still a matter of considerable dif- 
ficulty are palpated by the trained gynecologist, and their 
pathological changes diagnosticated with wonderful ease. 
The more remote and insignificant structures of the pelvis 
arc now trying in vain to elude the searching finger of the 4 
UTERINE DISPLACEMENTS : 
specialist; and in one of the latest text books minute and 
lengthy rules are given for finding not only the round 
ligament and ureter, but even for differentiating the various 
muscles of the pelvic floor, and palpating the pelvic arteries 
and nerves. 
The chapter on the diagnosis of displacements may in a 
certain sense be said to he closed. So too with the mechanical 
treatment of these disorders. Necessity is the mother of 
invention, and the skill and perseverance of the gynecologist 
in overcoming the difficulties he has had to contend with, have 
resulted in the multiplication of pessaries of all forms from the 
external to the intra-uterine, and of substances as various as 
ingenious, to meet all possible varieties. Slight modifications 
will continue to appear, but they will be on the lines already 
marked out, and will in all probability embody no new 
principle. It is to my mind a fair indication of the feeling 
which may be supposed to govern the question of treatment 
in the small proportion of cases which do not show them- 
selves amenable to the mechanical devices alluded to, that 
progress is in the direction of operative measures, and that 
too of a bolder character than would have been dreamed of 
twenty or even ten years ago. Who, for instance, twenty 
years ago would have thought in his wildest moments of 
performing laparotomy and suturing the fundus uteri to the 
abdominal wall to cure an obstinate retroflexion ? Yet that 
has been repeatedly done. It is an outcome to be sure of 
the feeling of security with regard to opening the abdominal 
cavity which the splendid results of our leading specialists 
have developed. Yet still other indications, less striking 
perhaps, but showing the same tendency, are the Alexander 
operation of shortening the round ligaments, Sanger’s bold 
procedure of forcibly separating adhesions of the uterus to 
adjacent parts under ether, or Byford’s proposition to 
shorten the sacro-uterine ligaments by an operation from 
the vagina. TIIEIK INFLUENCE ON THE NERVOUS SYSTEM. 
5 
While such questions ns these are, as I have said, practically 
settled, it is a beneficent law which holds good in any depart- 
ment of human knowledge that it cannot be exhausted. 
Certain outposts are taken and occupied, and the scene of 
the conflict shifts to new ground. We know the course 
which the blood takes in its rapid circulation through the 
body. We busy ourselves now with counting the millions 
and billions of white and red blood corpuscles, and noting 
their varying proportions in disease, or discussing the micro- 
scopical character of the membrane which forms the coat of 
the capillaries. So the questions concerning displacements, 
about which doubt exists to-day, and which are the subjects 
of discussion, are on entirely different lines from those we 
have mentioned above. 
Curiously enough, one question which it would seem 
would naturally be the first to be settled, is only recently 
being met with any unanimity of sentiment. I refer to the 
normal position of the uterus. It is begging the question 
to affirm as some writers do that an organ, suspended in the 
pelvis between other organs liable to such temporary 
variations of size as the bladder and rectum, can have no 
normal position. On the other hand it is manifestly absurd 
to judge a freely movable organ by the same rules as we 
would a spleen or kidney, and make any deviation from an 
arbitrary fixed standard a malposition. The truth seems 
to lie between, and the most accurate observers now recog- 
nize a normal position of the uterus which varies within 
certain bounds according to the condition of the adjacent 
pelvic viscera. 
I have said that the question of the mechanical treatment 
of displacements was practically settled, meaning by that 
that where such treatment was indicated, the principles on 
which it would be carried out were essentially known. 
There still exists, however, great difference of opinion as to 
the advisability or necessity of such treatment at all. 6 
UTERINE DISPLACEMENTS : 
Some writers, a respectable minority at least, maintain that 
displacements of the uterus very seldom give rise to symp- 
toms, and that when they do general treatment is preferable 
to local. Still others claim that they are much more often 
the cause than the result of general conditions, and that not 
only is it useless to ignore mechanical treatment, but that the 
best results are obtained by such local treatment either alone 
or primarily. 
These differences of opinion are based upon the different 
views which are held with regard to the dependence of one 
upon the other in the question of causation, and their subse- 
quent reaction upon each other. Let me make this clearer 
by illustration. We find in a given case a malposition of 
the womb. With it is associated a debilitated state of the 
nervous system, which shows itself in the protean ways that 
are so familiar to us under the convenient but vague term 
of neurasthenia. There is now a problem to be solved in 
order to arrive at such a correct understanding of the case 
that we shall be able to treat it successfully. What has 
been the sequence of events in this particular instance? 
Has the general health begun to suffer, the nutrition become 
impaired, the muscular system weakened, fat absorbed, and 
as a result the natural supports of the uterus become relaxed, 
and thus allowed of a version or flexion? Or on the other 
hand has the uterus become displaced, has congestion result- 
ed, followed by a low grade of inflammation, has this begun 
to react upon the nervous system, and finally resulted in the 
more or less complete loss of tone which we find in these 
cases? If we claim that the first hypothesis is correct, our 
course is plain. Build up the nervous system by rest and 
tonics, make fat and blood by forced feeding, and as the 
body becomes better nourished, and the muscular system 
<n-<>ws stronger, the uterus will riidit itself. 
On the other hand if we take the starting point to be the 
displacement, our rational plan is to restore the uterus to its THEIR INFLUENCE ON THE NERVOUS SYSTEM. 
7 
normal position, relieve the congestion, diminish the nervous 
strain, and our patient is cured. 
There are today firm, I had almost said bigoted adherents 
of both these opinions. There are men who make light of 
the local symptoms of their neurasthenic patients, who 
claim that treatment of the genital organs rarely does good, 
and often does harm, and who concentrate all their attention 
on general treatment. So too there are others who refer all 
these complex and remote symptoms to some lesion of the 
pelvic viscera, and are content to treat those exclusively. 
As a natural and almost inevitable result of circumstances, 
it follows that those who devote themselves largely to 
gynecological practice should more often err in the last 
named direction, while those who from the character of their 
practice or from preference see few such cases should fail to 
give these symptoms their proper significance. 
That neither of these extreme views is correct is self- 
evident. It is however insufficient to state in a general 
way that the advocates of both systems go too far. Little 
has been done unless such practical considerations are urged 
and demonstrated, as will set forth in a clear light the true 
relations which prevail between disorders in the genital 
sphere, and general nervous symptoms. It will be the 
object of this paper if possible to do this. 
There are several questions to be discussed. In the first 
place we are met at the outset by the inquiry which suggests 
itself always in considering this subject, is the relation 
between the genital organs and the whole nervous system 
so peculiar, that disorders of the latter more often follow 
disease of the former, than is the case with other organs of 
the body? The ancients believed it to be so when they 
attributed to the influence of the womb, those nervous 
manifestations which under the name of hysteria we recog- 
nize as a common symptom of a debilitated nervous 
condition. We now know that hysteria is not necessarily 8 
UTERINE DISPLACEMENTS : 
associated with uterine disease, that in fact it occurs in men, 
yet its preponderance in woman is a suggestive fact. Grant- 
ed that a woman’s nervous system is naturally weaker than 
a man’s, may the cause not lie in the fact that her generative 
organs during their period of functional activity call for a 
greater expenditure of nervous force even when in health 
than any other organ or set of organs? If this is so in 
health, how much more potent must be their influence when 
diseased. That such nervous phenomena as we generally 
call hysteria or the more pronounced condition of nervous 
debility known as neurasthenia almost exclusively occur 
between the years of puberty and the menopause, confirms 
the opinion that there is in the majority of cases a more than 
chance relation between the disorders of the genital functions 
and the general nervous disturbance. 
The clinical experience of those who have had the largest 
opportunities of observing these cases, will, I am confident, 
be confirmatory of this opinion. 
There are undoubtedly certain classes of pelvic disease 
which more than others predispose to coincident nervous 
wear and tear. The amount of pain which accompanies the 
lesion is one of the criteria by which we judge of the probable 
effect upon the nervous system. We therefore find certain 
forms of ovarian disease accompanied by dysmenorrhoea 
very frequently associated with nervous debility. This rule 
is not absolute, however, for cancer with its gnawing pain 
does not affect the nervous system in the way that I am 
describing. It saps the strength and diminishes the vital 
powers, but it does not make the whole nervous organization 
bypeiaesthetic, if I may so express it. Under this latter 
condition the nerves respond to the slightest stimulus, even 
that of a lively imagination, until it needs but a suggestion 
of discomfort in one part of the body to start reflex symp- 
toms of the most acute type in another. There are certain 
affections of the female genitals which seem particularly THEIR INFLUENCE ON THE NERVOUS SYSTEM. 
9 
li.ible to exert this baleful effect upon the whole nervous 
economy. Some of these have been recognized. Emmet 
long ago, and many others since then have pointed out the 
marked results in this direction of a neglected laceration of 
the cervix. After the primary symptoms of leucorrhcea, 
backache, dyspareunia, and a feeling of weight in the pelvis 
have persisted for a longer or shorter time, there are very 
apt to follow those phenomena which begin as nervous debil- 
ity and end as nervous prostration, and these latter symptoms 
may soon entirely predominate over the former. 
This result is more apt to follow if in addition to the 
cervix the perineum is also lacerated. 
Chronic pelvic cellulitis, of which we are hearing less and 
less, inasmuch as many cases which we formerly classed 
under this head are now known to be affections of the 
tubes and ovaries, chronic metritis, and its result areolar 
hyperplasia, and even chronic endometritis, all furnish their 
contingent of neurasthenic cases. 
Eess however has been said about displacements as a 
cause, and yet I conceive that they not infrequently are the 
starting point of grave nervous trouble, and serve to keep it 
up. This cannot be Said of all forms of displacement alike, 
and some consideration of the various malpositions of the 
uterus with reference to their significance in this respect, is 
of importance here. 
Backward displacements of the uterus are by all means 
more serious than forward ones. The retroHexions and 
versions occur oftencr, admit of a much greater decree of 
malposition, and with themselves dislocate other organs 
more than do the anteversions and flexions. The resulting 
disturbance to the blood and nerve supply is much more 
profound. Anteversions pure and simple are in my experi- 
ence rare, and do not as a rule give rise to symptoms. 
W hen however with the anteversion there is some descent 
of the uterus as a whole, a combination which is by no 10 
UTERINE DISPLACEMENTS : 
means rare, the resulting effect upon the whole system is 
much more marked. The same may be said of anteflexion, 
though here symptoms referable to the bladder and back, and 
disorders of menstruation are much more common. 
Retroversion of the uterus is the most common form of 
malposition that we meet with, and when of the first or 
second degree, that is if the version is not more than one of 
90°, it may often exist without symptoms. If the organ 
however is deflected from its normal position in which the 
long axis of the uterine body makes a right angle with the 
axis of the vagina, more than 90°, we have symptoms aris- 
ing from pressure on the rectum, and are apt to have 
dislocation of other organs. The danger of neglecting the 
treatment of even the slighter degrees of this displacement 
lies as I conceive it in the fact, that as the axis of the uterus 
approaches that of the vagina the weight of the abdominal 
viscera comes directly upon the fundus, and the resistance 
to descent of the uterus being lessened, slight degrees of 
prolapse are likely to follow. 
Retroflexion adds to the symptoms which it causes in 
common with the version, those due to the uterus itself being 
bent, either from a loss of tone of the muscular structure of 
the organ, or from being drawn over by adhesions. This 
flexion of the uterus is an exceedingly grave symptom, and 
productive of the most marked general disturbance. Roth 
for this reason, and because its treatment is often difficult, 
requiring even severe operative measures for its relief, it is 
commonly regarded as perhaps the most serious displace- 
ment in the category. 
Prolapse and procidentia follow closely on retroversion in 
frequency, and equal if not exceed it in importance. The 
severer forms of falling, especially when complicated with a 
rolling out of the anterior and posterior vaginal, walls, 
cystocele and rectocele, are so easily recognized by both 
patient and physician, that their true value as a cause of TIIEIR INFLUENCE ON THE NERVOUS SYSTEM. 
11 
local and general symptoms is accorded them. Not so 
however with the milder forms, where either from increased 
weight, or a slight giving way of the natural supports, the 
uterus sinks a little lower in the pelvis. These relatively 
minor grades of displacements are very often passed bv 
unheeded, when they in reality are a cause of constant and 
distressing symptoms. They are not recognized for the 
reason that in the ordinary method of examination they 
cannot be detected. With the patient in the dorsal position 
the uterus, unless fixed, recedes from the vulvar orifice, and 
the examining finger fails to detect its abnormal mobility. 
Even if the patient is requested to strain, the action of the 
abdominal muscles is not sufficient to force the uterus as low 
as it descends when the patient is standing and the force of 
gravity is added. The proper method of examining in these 
cases is with the patient standing in the erect position. 
Then if she is requested to contract the abdominal muscles 
as if to relieve the bowels, the finger in the vagina will 
appreciate the full amount of descent. 
In the same category though of less relative importance 
are the displacements of the vaginal wall which may occur 
without any prolapse of the uterus, though their tendency is to 
produce such in time. They have only recently begun to 
receive the attention which they deserve. 
Lateral displacements are merely subvarieties and minor 
complications of the forward and backward malpositions which 
we have spoken of, and do not need any special mention. 
From the foregoing it will be seen that the displacements, 
which most often give rise to serious symptoms and demand 
treatment, are of the third degree or of lesser degrees when 
complicated with prolapse, retroflexion especially when 
bound down by adhesions, and prolapse; less frequently 
anteflexion, anteversion with prolapse, and least frequently 
of all simple anteversion, and retroversion of the first two 
degrees. 12 
UTERINE DISPLACEMENTS : 
If we study this order of relative frequency closely it will 
be seen that there are three conditions upon which the 
gravity of the symptoms depends. First prolapse, second 
adhesions, and third flexion. I have named them in this 
order because it seems to me that both as regards severity 
of local symptoms, and secondary effect upon the whole 
system, especially the nerves, that is the proper order of 
relative frequency and importance. 
I am convinced that prolapse of the uterus especially in 
its minor forms has been much neglected or underestimated 
as a factor in the pathological significance of uterine dis- 
placements. A large proportion of anteversions give rise to 
no symptoms unless complicated with prolapse ; the same is 
true of many cases of retroversion, and the symptoms com- 
plained of in these cases are those characteristic of a descent 
of the womb, and are relieved by the treatment appropriate 
to that malposition. A slight amount of prolapse will 
cause more disturbance with the circulation than a very 
marked version, and the constant dra<™;in£ and bearing 
down, which is the almost universal complaint, is excessively 
wearing upon the nerves. 
The detrimental effects of the presence of adhesions are 
shown in two ways: first, from the impairment of the 
mobility of the uterus which ensues; and second, the 
production of pain due primarily to the inflammation of 
the peritoneum, and secondarily to the implication of nerve 
filaments in the contracting bands of adhesions. 
A bending of the uterus upon itself is of importance 
pathologically for several reasons. The two chief causes 
however to which its effects upon the general health are due, 
are the interference with the circulation in the organ itself, 
as a result of which alterations of tissue occur in time, and 
the displacement of other organs, notably the tubes and 
ovaries. 
Having thus considered in a general way the various THEIR INFLUENCE ON THE NERVOUS SYSTEM. 
13 
malpositions to which the uterus is liable, and the special 
circumstances connected with the different forms to which 
their pathological importance is due, it remains briefly to 
refer to their effect upon the system at large, and to insist 
upon the necessity of treating them. 
I do not by any means claim that uterine displacements 
are always the primary occurrence, and that they invariably 
cause grave nervous symptoms. On the contrary there is 
that large class of cases of displacement from loss of tone of 
the uterine supports where muscular debility is the first 
factor, and the uterine condition is merely one mode of 
expression of it. But even in these cases the continued 
presence of the pelvic trouble tends to keep up the condition 
of nervous debility of which it may be originally only a 
symptom. 
Of the three principal factors in these cases of displace- 
ment to which I have referred—flexions, adhesions, and 
prolapse—the importance of the first two is I think sufficiently 
recognized by the profession. The role they play in induc- 
ing and keeping up a state of nervous exhaustion is well 
known. The difficulty here is not that the necessity of 
treatment is not fully appreciated, but that they rank among 
the affections of the genital organs which are the most 
obstinate to yield to the ordinary methods. 
Cases of flexions with adhesions were for a long time, and 
still are by some authorities, considered incurable, and it is 
the exceedingly unsatisfactory results of the methods of 
treatment which have been hitherto tried, in a class of cases 
which entails so much local suffering, and exercises such a 
deleterious effect upon the whole nervous system, which has 
led to such severe operative measures being proposed and 
tried for their relief, as laparotomy, forcibly breaking up 
the adhesions, and stitching the fundus to the abdominal wall. 
It is however different with prolapse, especially in the 
earlier stages. The importance of this has I am confident 14 
UTERINE DISPLACEMENTS: 
been underestimated. I claim that it is the one element 
which makes versions, which would otherwise give rise to no 
symptoms, of any pathological significance. The constant 
feeling of weight in the pelvis, to which is soon added weak- 
ness of the muscles of the back and thighs, making locomo- 
tion painful, and standing even more difficult, is generally 
due either to the yielding of the muscular and ligamentous 
supports of the uterus, or the loss of the integrity of the 
pelvic floor as a result of parturition. 
I would therefore urge in all cases where the loss of nervous 
tone is a prominent symptom, where headache, dyspepsia, 
inability to walk, sleeplessness following the least excitement, 
loss of mental power, as shown by the inability to concen- 
trate the mind on any subject, loss of ability to control the 
emotions, evidenced by fits of crying, depression, or tem- 
porary exaltation qf spirits followed by a corresponding 
reaction, where some or all of these symptoms are found, 
the careful consideration of the accompanying pelvic symp- 
toms, and if such exist, even though to a mild degree, 
would recommend a vaginal examination. 
If any of the various malpositions be found which have 
been described in this paper, the important question has to 
be decided whether it should be treated and when. If the 
history of the case makes it clear that it is the primary fac- 
tor in the case, the first step should be the attempt to cure 
the pelvic trouble by treatment. The only exception to 
this rule is in those cases where the general health is so 
much reduced that the strain necessary to undergo local 
treatment would be too great. Here attempts must first 
be made to so improve the nervous condition, by rest, food, 
and tonics, that treatment may be begun. The Weir 
Mitchell treatment, either thoroughly carried out or modified 
to suit the individual case, will serve as a model. In cases 
of this sort, if local treatment is entirely neglected there 
may be improvement up to a certain point, but beyond that TIIEIR INFLUENCE ON THE NERVOUS SYSTEM. 
15 
it will not advance if the special treatment of the genital 
complication is neglected. 
Where the malposition is secondary, if taken in time 
local treatment may sometimes be avoided. With the im- 
provement in the condition of the general system the uterus 
may recover itself. If it has persisted for some time, how- 
ever, it in turn becomes one of the causes which keep up the 
depreciated state of the general health and must be rectified 
before perfect health is restored. In these cases of pro- 
found nervous debility, every organ and function must be 
interrogated, and the ability to correctly estimate the path- 
ological significance of the various departures from the nor- 
mal condition which are found, and the choice of the order 
and methods of treatment, is a matter requiring extreme 
delicacy and skill, and upon it depends the success of the 
physician. 
As to the methods of treatment to be pursued, it is not 
the purpose of this paper to go into details. A few general 
considerations may be urged. Malpositions uncomplicated 
by adhesions or by inflammatory conditions in the pelvis, 
especially in unmarried women, may frequently be restored 
to their normal position and a pessary adjusted with a mini- 
mum of nervous strain to the patient at one sitting under 
ether. Where there are adhesions, or even in cases where 
there are not, but the vagina is narrow, the abdominal walls 
rigid and the bimanual method of reposition difficult or im- 
possible, the slower method by packing the vagina is to be 
recommended. 
Where the uterus on examination in the dorsal position 
seems normal, but yet the patient complains of symptoms 
which suggest some displacement, the examination in the 
erect posture for the slighter degrees of prolapse should not 
be neglected. 
Of especial importance to my mind in this connection are 
slight tears of the perineum, impairing the integrity of the 16 
UTERINE DISPLACEMENTS. 
pelvic floor. These are often overlooked because they not 
infrequently occur either at the sides where they loosen the 
attachments of the pelvic fascia or beneath the mucous mem- 
brane in the muscular structure of the perineal body, and 
the almost intact external perineum gives no evidence of 
the damage done. These changes, the result of parturition, 
are a fruitful source of prolapse of both uterus and vaginal 
walls, and their repair by a plastic operation will do much 
towards restoring the general health. 
In the obstinate cases of retroflexion where a pessary will 
not hold the uterus forward, the Alexander operation of 
shortening the round ligaments or one of the other more 
serious operations may be considered.