The Treatment of Backward Displacements 
of the Uterus, 
BY 
HOWARD A. KELLY, M.D., 
PROFESSOR OF GYNECOLOGY AND OBSTETRICS IN THE JOHNS HOPKINS UNIVERSITY 
BALTIMORE, MARYLAND. 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
FROM 
December, 1896. Extracted from The American Journal of the Medical Sciences, December, 1896, 
THE TREATMENT OF BACKWARD DISPLACEMENTS 
OF THE UTERUS. 
HOWARD A. KELLY, M.D., 
PROFESSOR OF GYNECOLOGY AND OBSTETRICS IN THE JOHNS HOPKINS UNIVERSITY, 
BALTIMORE. MARYLAND. 
It has been the task of the present generation of gynecologists, and 
the special work in particular of Prof. B. S. Schultze, of Vienna, to 
demonstrate the fact that the normal uterus is not fixed, but occupies a 
variety of positions in the pelvis at different times, according as it is 
influenced by the movements of contiguous structures, and most of all 
by the bladder, empty, partially distended, or full. The position of the 
uterus we now know to be one of mobile equilibrium, in which, how- 
ever, the fundal end remains directed anteriorly and the cervical end 
posteriorly; ante-positions, whether anteflexions or anteversions, are 
rarely pathological. 
On the other hand, any persistent posterior position of the uterus in 
which the fundus is displaced back into the hollow of the sacrum, or is 
found lying in a plane posterior to the cervix, is abnormal. Backward 
displacements constitute one of the most important gynecological ques- 
tions of the day for two reasons ; in the first place, because of their 
extreme frequency; and, in the second place, because we are still in an 
evolutionary stage regarding their treatment. 
As there can be no rational treatment without a consideration of the 
particular causes acting to produce the displacement in each case, I shall 
briefly enumerate those most frequently found: 
1. Congenital causes, due to a short vagina or to an imperfect devel- 
opment of the uterus, in which the retroposition has existed from child- 
hood. 
2. Retropositions developed acutely by sudden or severe strain. 
3. Retropositions caused by tumors in the uterus or adnexae. 
4. Retropositions, the sequelae of pregnancies, due to subinvolution of 
the uterus, or to injury of the pelvic floor, or to both combined. 
Just as it is important to bear in mind the cause of the retrodisplace- 
ment, so is it important to stujdynearefoHy- matology in each 2 
KELLY: BACKWARD DISPLACEMENTS OF UTERUS. 
case, for, as the symptoms are mild or severe, more or less energetic 
plans of treatment will be required. 
In many instances, including also the congenital forms, the discovery 
of the malposition is purely accidental and the patient, who suffers no 
inconvenience whatever, will require no treatment of any kind. In 
others both the local and the general symptoms are marked, the local 
symptoms being due to the flexion or version effecting a stasis in the 
circulation, a sense of dragging due to the associated descensus of the 
uterus, with pain in the back and legs. The interference with the blood- 
supply of the uterus naturally produces its most distressing symptoms 
at the time the congestion of the organ is greatest—at the menstrual 
period. Backache and dragging pain in the sides are due to the tug- 
ging on the broad ligaments arising from the tendency of the displace- 
ment to increase as it advances through the various stages of descensus 
and prolapsus. Locomotion may be difficult and painful, and the 
mechanical interference with the rectum or with the distention of the 
bladder by the misplaced fundus not infrequently seriously interferes 
with the special functions of these organs. 
The general symptoms produced by retrodisplacements, while they 
are often called I’eflex, are in reality more frequently due to the dis- 
ordered state of health produced by the local discomforts, keeping the 
patient house-ridden and interfering with her taking fresh air and ex- 
ercise. We find, therefore, as we might expect, such products of mal- 
nutrition as anaemia, nausea and indigestion, constipation, headache, 
and hysteria. 
Treatment. By taking up any one of the numerous text-books on 
gynecology written fifteen or more years ago, it will be seen that the 
treatment of retropositions, both flexions and versions, was then con- 
ducted by using curved uterine sounds or so-called “ uterine repositors,” 
introduced into the cavity of the uterus and twisted or bent to force 
the fundus into an anterior position. These “repositions” were then 
followed by a vaginal pack or the use of a pessary. It is not without 
■significance to note, too, that this was also the period of active treat- 
ment of anteversions and anteflexions in exactly the same way. 
Now, we have absolutely given up the use of the sound or repositor 
or of instruments of any sort within the uterus, and find only a limited 
field of utility for the pessary. Instead, the most efficient plans of 
treatment at present, where treatment is required, are purely surgical, 
attacking the displacement either through the vagina or abdomen, or 
through both avenues at once. 
The correct method of dealing with any given case of retrodisplace- 
ment will fall under one of the following heads : 
1. Cases in which no treatment is required. 
2. The use of a pessary. kelly: backward displacements of uterus. 
3 
3. Manual reposition and massage. 
4. Operation upon the vaginal outlet. 
5. Operation on the uterus at the vaginal vault. 
6. Shortening the round ligaments. 
7. A suspensory abdominal operation, or ventrofixation. 
8. An operation upon the vaginal outlet and a suspensory operation 
combined. 
No treatment. As I have already said, where the discovery of the 
flexion is the accident of an examination, or where the patient’s distress 
is purely mental, imagining that she cannot have good health with the 
uterus “ out of place,” the physician should quiet her mind by assuring 
her that she runs no risk, and should advise against any treatment what- 
ever. 
Pig. 1. 
Fig. 2. 
Smith-Hodge pessary with somewhat rounded an- 
terior bar. This is the size most commonly used. 
Munde pessary, particularly useful 
in retroflexions, on account of the re- 
inforced posterior bar. 
Pessaries. A pessary is often useful in relieving the local symp- 
toms of the displacement, and it does this, as a rule, not by correcting 
the displacement, but by checking the tendency to still greater displace- 
ment. In other words, many of these retrodisplacemeuts are only the 
initial stages in the formation of a marked descensus or even a prolapsus 
of the uterus ; and if the patient were to be examined some months 
later the descensus would be observed, and later the cervix would be 
found at the vaginal outlet, and at a still later date protruding from 
the vaginal orifice. The pessary obviates this tendency to extreme 
downward displacement, and, taking the tension off the broad ligaments, 
relieves the sensation of ‘' dragging ” and “ falling out ” so often com- 
plained of. I would insist that retroversions and retroflexions are but 
rarely cured by the use of the pessary, and this in spite of the numer- 4 
KELLY: BACKWARD DISPLACEMENTS OF UTERUS. 
ous statements to the contrary which might easily be adduced from 
earlier writers. The only pessaries I ever find use for are the Hodge 
pessary, with a flat nose; very rarely the Smith-Hodge pessary, with a 
pointed nose; quite frequently the Munde pessary, like the Hodge, but 
with a thick posterior bar; and still more frequently a hard-rubber ring- 
pessary. In choosing a pessary for a particular case, one must be selected 
which fits the vagina nicely without making pressure upon any of its 
walls or stretching it in any direction. The large pessaries, “ horse- 
pessaries,” which draw the vaginal walls out tense in all directions in 
order to prevent the descensus, are to be absolutely rejected. They 
always in the end either increase the relaxed condition of the vagina or 
ulcerate through its walls. The smaller pessaries fit loosely, gently splint 
the vaginal walls, and so limit the excursive movements of the uterus. 
Fir:. 3. 
Showing the mechanism of support by the simple hard-rubber ring-pessary 
There should be room on all sides to insert the finger easily between the 
pessary and the walls embracing it. The soft-rubber ring-pessaries, 
although convenient to introduce, ought never to be used, as they 
soon become foul and produce irritating discharges. The patient with 
a simple retroflexion will often experience relief from the insertion of 
one of the hard-rubber rings or a Hodge pessary, when she may go home 
and need no further treatment. I can hardly give any definite rules 
for the use of any one of these particular forms of pessary, as the selec- 
tion seems to be rather a matter of instinctive judgment. I find that 
the Hodge or the Hodge-Munde does best in nulliparous women ; in 
parous women, when the vaginal outlet is somewhat relaxed, the best KELLY: BACKWARD DISPLACEMENTS OF UTERUS. 
5 
instrument, without doubt, and often the only one which will stay in, is 
the cradle-pessary. 
The simple hard-rubber ring, although more painful to introduce, 
when once in is less apt than the others to press on tender points and is 
in consequence more easily worn. 
Manual reposition and massage. When there is no lateral disease 
in the pelvis, and where the uterus is movable and the vaginal outlet is 
not broken down, the following plan of manual reposition may be used 
a few times, in the hope of effecting a cure by simple means : 
Pig. 4. 
Cradle-pessary in place, showing the absence of a posterior bar. 
First, the cervix is caught by a pair of tenaculum-forceps and drawn 
down to the vaginal outlet; by pulling the uterus down in this way, 
although the displacement is increased, the angle of flexion is straight- 
ened out. 
Second, with the index-finger in the rectum, the fundus of the dis- 
placed uterus is pushed forward. 
Third, the cervix, held by the tenaculum-forceps, is pushed high up 
into the sacral hollow, into the place previously occupied by the retro- 
flexed fundus. 
Fourth, if an assistant will hold the cervix in this position, the oper- 
ator can easily bring the fundus into extreme anteflexion by grasping 
it bimanually through the vagina or rectum and the abdominal walls. 
While such a procedure is often easily carried out on an examining- 
table, with sensitive patients, or where the abdominal walls are thick, 
it will sometimes be necessary to use an anaesthetic. Such a mode of 
treatment should be preceded by a careful evacuation of bladder and 
rectum. 
Where the fundus of the uterus is dislodged with difficulty from the 6 
KELLY: BACKWARD DISPLACEMENTS OF UTERUS. 
Reduction of retroflexion. The anterior cervical lip of the retroflexed uterus is caught with tenaculum-forceps, and traction is made in the direction 
indicated by the arrow; this straightens the uterus, as shown in the next figure. 
Fig. 5. kelly; backward displacements of uterus. 
7 
utero-sacral hollow, it will often he of great assistance to put the patient 
in the knee-breast position, so as to inflate the rectum with air while 
pushing the fundus forward, and carrying the cervix back into the sacral 
hollow. Then placing her back into the dorsal posture the fundus will 
easily be brought into extreme anteflexion. 
After replacing the uterus it must be held in its new position, until 
the next treatment is given, by pledgets of cotton saturated with boro- 
glyceride skilfully placed in the upper part of the vagina, and a wool- 
tampon below. The object of this pack is to give an elastic support 
to the cervix, holding it as far back as possible in the sacral hollow. 
To this end the packs should be applied in front of the cervix and no 
cotton should be placed in the posterior fornix. 
Fig. 6. 
Retroflexed uterus shown straightened by traction of the cervix down to the vaginal outlet. 
The vaginal operation for retroflexion. The treatment of retroflex- 
ions by an operation through the vagina, although simpler than any 
abdominal operation for the same purpose, and a course less liable to 
meet with opposition on the part of the patient, was, strange to say, 
one of the last methods to be proposed. In Germany, where the sug- 
gestion originated, the names of Mackenrodt and Diihrssen have been 
most prominently connected with vaginal fixation. The operation con- 
sisted in an incision, either longitudinal or transverse, through the 
vagina in front of the cervix, for the purpose of detaching the bladder 
from the uterus, and then of bringing forward the fundus and fasten- 8 
KELLY: BACKWARD DISPLACEMENTS OF UTERUS. 
While the cervix of the straightened uterus is held down at the vaginal outlet the index-finger is introduced into the rectum and the 
fundus pushed forward in the direction of the arrow to the position shown in the drawing. 
Fig. 7. KELLY: BACKWARD DISPLACEMENTS OF UTERUS. 
9 
ing it in such a way as to secure a permanent anteflexion. The me- 
chanical results of the operation were satisfactory, for the uterus 
remained permanently anteposed. 
In America this way of treating anteflexion has never been more 
than sporadically practised, while in Germany it has now been almost 
completely given up on account of the serious difficulties encountered in 
case of pregnancy. The firm adhesions between the uterus and the 
Fig. 8. 
The position of the uterus in the last diagram is here shown in dotted outline. The next 
step is to thrust the cervix back in the direction of the arrow, into the sacral hollow, giving 
the uterus the position shown in the drawing. 
anterior vaginal wall hindered the development of the pregnant uterus 
and produced such abnormalities in the position of the child as some- 
times to necessitate severe operative procedures to effect delivery. A 
careful consideration of this subject has been undertaken by M. Graefe, 
of Halle, who presented his results to the Leipzig Obstetrical Society, 
October 21, 1895, reported in Monatsschrift f. Gehurtshulje und Gynd- 
kologie. After reciting the difficulties he has encountered, Graefe an- 
nounces that in future he will employ vaginal fixation only in women 
who have passed the climacteric. 
An operation purely American is the method of Dr. W. R. Pryor, of 10 
KELLY: BACKWARD DISPLACEMENTS OF UTERUS. 
New York, described in the Medical Record, July 20, 1895, under the 
title “A New Method of Treating Adherent Retroposed Uteri.” Dr. 
Pryor attacks the posterior cnl-de-sac, incising it broadly and opening 
the peritoneum through the vagina, The fingers are introduced through 
this opening and any adhesions broken up. An iodoform-gauze pad is 
now inserted into the pelvis behind the cervix, with the patient in the 
Trendelenburg position. By this posture the small intestine is made 
to escape into the abdominal cavity and a second pad is inserted into 
Fig. 9. 
The fundus is now in a position to be caught easily bimanually The forceps are removed, 
and while the index-finger of one hand continues to push the cervix back, the other hand 
takes hold of the fundus and scoops it over into anteflexion, in the direction of the arrow. 
the pelvic cavity, when the table is lowered to a horizontal position, 
The pads are now withdrawn from the pelvis and a wad of gauze in- 
serted in the opening just within the cut edges. The uterus is now 
brought into anteflexion bimanually, taking care not to displace the 
gauze. It is important that the cervix should be held high up through- 
out the convalescence, so that the intra-abdominal pressure will fall on 
the posterior surface of the uterus. The wad of gauze in the cul-de-sac 
is not disturbed for from seven to ten days, when it is carefully re- kelly: backward displacements of uterus. 
11 
moved and replaced, under chloroform, with the patient in the Sims’s 
position. A week after the first dressing another is made, and in five 
days this, too, is changed ; the vagina is kept packed for a month to 
support the uterus. The result in Dr. Pryor’s method is to produce a 
dense mass of lymph about the utero-sacral ligaments, and the operation 
pulls the posterior pole of the uterus back, while it does not affect the 
mobility of the fundus, as all other operations do. This is in direct 
Fig. 10. 
The vaginal finger then pushes the cervix up toward the promontory, while the outside hand 
forces the fundus down into an exaggerated anteflexion. 
line with some of the practical suggestions made by Stinger, of Leipzig, 
in the early history of the operative treatment of retroflexions. The 
subsequent histories of two of Dr. Pryor’s cases, communicated by letter, 
show that such patients may go through a normal pregnancy after- 
ward. 
Dr. H. T. Byford, of Chicago (Medical News, October 81, 1896), ad- 
vocates a plan of operating, used in ten cases, by which the adhesions of 12 
kelly; backward displacements of uterus. 
the uterus to the bladder are less extensive than in the usual vagino- 
fixation cases ; he shortens the round ligament also through the vaginal 
incision. The reaction, however, of the profession against vaginal oper- 
ations for retroflexion is now so strong that it is doubtful whether even 
such skilful operators as Dr. Pryor and Dr. Byford will be able to 
stem the tide turning in favor of direct methods of treatment from 
above through the abdomen. 
The operation advocated by Wertheim (Centralblatt f. GyndkoL, No. 
10, 1896) also attacks the round ligaments through a vaginal incision. 
The vagina is incised, the bladder detached from the uterus, and the 
round ligaments caught and drawn into the vagina, where they are at- 
tached to the borders of the incision. 
Shortening of the round ligaments (Alexander’s operation). The 
extraperitoneal shortening of the round ligament was one of the first 
and seemingly the most rational forms of operation proposed to relieve 
retrodeviations of the uterus. The rationale of the operation depends 
upon the assumption that the round ligaments are important anatomical 
structures in the retention of the uterus in anteposition. It must there- 
fore be assumed that, in cases of retrodeviations or retroflexions, relax- 
ation and lengthening of the round ligament have taken place. The 
operation is performed by an incision into both inguinal canals, without 
opening the peritoneum, and so catching up and drawing out the round 
ligaments until the body of the uterus is brought strongly forward. 
This form of operation has the advantage of little risk, and some opera- 
tors have handled a long series without a death; for example, McGannon 
(American Gynecological and Obstetrical Journal, August, 1896, p. 202) 
reports ninety-one cases without a death ; four pregnancies, with three 
normal deliveries. 
The disadvantages of the operation are that the ligaments are some- 
times found with great difficulty or not at all, and that relapses are not 
infrequent. The results, also, vary widely in the hands of different 
operators. 
The most satisfactory plan for shortening the round ligaments is that 
elaborated by Dr. G. M. Edebohls, of New York (.Annals of Gynecology 
and Pcediatrics, October, 1896, p. 26), who proceeds in the following 
manner : 
The whole length of the inguinal canal is opened up, and the liga- 
ment drawn out at the internal ring and shortened by stripping it out 
of its peritoneal investment as it is pulled outward. The wound is then 
closed after the manner of the Bassini operation for inguinal hernia. 
Dr. Edebohls has operated on one hundred and sixteen cases in this 
way, with only four failures. Twelve of the cases became pregnant, 
with two abortions, six normal labors, and four not yet delivered. 
Treatment of ventrofixation or suspension of the uterus. I conceived KELLY: BACKWARD DISPLACEMENTS OF UTEEUS. 
13 
the idea of attaching the retroflexed uterus directly to the anterior 
abdominal wall above the symphysis, operating through an abdominal 
incision, early in the year 1885, and carried it out in the case of Miss 
W., April 25, 1885. This was about the time when abdominal surgery 
began to make such strides in all directions, and I found while visiting 
Europe in the summer of 1886 that Prof. Sanger, of Leipzig, Prof. 
Werth, of Kiel, and Lawson Tait had already performed similar ope- 
rations to correct a retroflexion found incidental to an abdominal 
operation for diseased appendages. 
The first article on the subject of ventral operations in prolapse and 
retroversion, by Prof. R. Olshausen, appeared in the Centralblatt f. 
Gyndkologie, October 23, 1886, twelve days before my own paper was 
read before the Philadelphia Obstetrical Society (American Journal of 
Obstetrics, January, 1887, pp. 33 and 67). Prof. Olshausen also quoted 
Prof. Koeberle, of Strasbiirg, who performed coeliotomy for retro- 
flexion, in the year 1877, in a case of persistent constipation endanger- 
ing life, produced by the pressure of the retroflexed fundus upon toq 
rectum. 
The technique of all these early operations belongs to the crude ex- 
perimental stage in the surgical treatment of retroflexions, which has 
now been carefully elaborated so as to leave little to be desired ; for 
example, the first effort to hold the misplaced uterus forward was made 
by utilizing the stumps after the removal of one or both ovaries or 
tubes, attaching them either laterally to the incision, or fastening 
them in the incision itself. Olshausen made use of the round ligaments 
close to the uterus, bringing the anterior face of the uterus up against 
the abdominal wall. 
In 1889 and 1890 I made an effort to simplify the technique of 
the operation and to avoid a peritoneal incision in the following man- 
ner : After emptying the bladder and bowels the retroflexed uterus 
was brought into anteflexion bimanually, and then by means of two or 
three fingers in the vagina was pushed up against the anterior abdomi- 
nal wall just over the symphysis with enough force to make a decided 
elevation there. A large, curved needle threaded with silkworm-gut 
was then passed boldly through the skin, muscle, and peritoneum ; then 
through the uterus, to be brought out again through peritoneum, mus- 
cle, and skin. The silkworm-gut suture, introduced in this way, caught 
the uterus on its posterior surface near the fundus, and held it well in 
anteflexion. The patient was then kept quiet in bed, and the suture 
held in place by means of shot clamped on each side close to the 
abdominal wall. The shot was kept from cutting through the skin by 
resting on a silver plate with slits in it to accommodate the silkworm- 
gut. After a week or ten days the suture was cut on one side and drawn 
out. I recall five cases in which this plan was tried, and in every one 14 
KELLY: BACKWARD DISPLACEMENTS OF UTERUS. 
of them the success was only temporary, and I was obliged later to 
open the abdomen and make a direct attachment of the uterus to the 
abdominal wall. ( Vide J. W. Williams, American Journal of Obstetrics, 
1890, p. 729.) 
The method which I now employ and have tested in a long series of 
cases with the most satisfactory results is the following : In the first 
place, the case is carefully selected, avoiding patients who are simply 
hysterical and whose complaints are of a general nature in no way de- 
pendent upon the local lesion. I also refuse to operate upon cases in which 
the symptoms are not pronounced and in which the patient applies for 
treatment simply because she imagines that she cannot have good health 
as long as the retroflexion exists. Taking, then, the class of cases in 
which marked and persistent symptoms are produced by the local affec- 
tion, and in which the simpler measures described fail to give relief, 
the operation is performed as follows : 
The instruments needed are a needle-holder, curved needles, scalpel, 
silk suture, two pairs of artery-forceps, silver wire and catgut, and an 
elevator. 
After due preparation of the patient and careful evacuation of the 
bowels and bladder, she is placed upon the operating-table with hips 
elevated. It is best to leave her in this position one or two minutes 
before opening the abdomen, in order to allow the intestines to gravitate 
toward the diaphragm. An incision 3to 4 cm. long is then made just 
above the symphysis pubis, in cases in which the abdominal walls are thin 
or of medium thickness; a longer incision may be necessary in stout 
women. The length of the incision is less than that in any other ab- 
dominal operation except for the evacuation of ascitic fluid, and owing 
to its low position the scar is in time completely hidden, in the course 
of a year or two being scarcely visible. 
The peritoneum is opened the full length of the skin-incision, and 
caught at once on both sides with forceps and drawn outward. One or 
two fingers are now introduced through the incision and the fundus of 
the uterus caught and raised into anteflexion. 
I invariably use as a suture-material for suspending the uterus a 
medium-sized silk about a half millimetre in diameter ; catgut absorbs 
too quickly to insure a permanent adhesion between the uterus and the 
anterior abdominal wall, and I have had no experience with silkworm-gut 
or silver wire because the silk is so much easier to handle and has given 
such perfect satisfaction. 
The suture is passed in the following manner : one side of the incision 
is lifted up by two fingers so as to expose a portion of the anterior 
abdominal wall on its peritoneal surface. The movable peritoneum 
and subperitoneal tissues are then transfixed with a curved needle at a 
point 1 or 2 cm. away from the lower angle of the incision. The kelly: backward displacements of uterus. 
15 
amount of tissue taken in is about 1 cm. in width and 2 or 3 mm. in 
depth ; the same suture is then passed through the posterior face of the 
uterus 1 or 2 cm. back of the fundus, and finally brought out through 
the peritoneum and subperitoneal tissue on the opposite side of the ab- 
dominal wall at a point corresponding to that of entrance. When this 
suture is tied it at once brings the uterus up snugly against the anterior 
abdominal wall in anteflexion. 
One more suspensory suture is all that is needed to hold the uterus 
permanently in anteposition. This is passed like the first, but about a 
centimetre higher up on the abdominal wall and a half-centimetre below 
it on the posterior surface of the uterus. This is tied, and the abdomi- 
nal wound closed by sewing up the peritoneum with a continuous catgut 
suture, then drawing together the fascia above the muscle with one or two 
silver wire mattress-sutures, and finally closing the superficial fat and 
skin with continuous catgut sutures. Before completely closing the 
peritoneum the patient should be dropped to a horizontal position to 
let the air out from the peritoneal cavity. 
Sometimes when the uterus is brought forward out of retroflexion 
the fundus lies so deep in the pelvis and is so completely covered by 
coils of intestine that it is exceedingly difficult to get at it to pass the 
first suture ; in the average case the symphysis pubis forms a satisfactory 
point of counter-pressure to support the fundus pressed against it by 
two fingers, while the first suture is being passed ; but in the class of 
cases referred to, when this simple manoeuvre does not avail, the fundus 
may still be brought within easy reach by using an elevator, in the 
manner shown in Fig. 11, to form an artificial point of counter-pres- 
sure during the introduction of the suture. 
Upon closing the incision a simple dressing of dry. sterilized gauze is 
applied, and the patient is kept in bed for three weeks. After getting 
up she ought to take only gentle exercise for some weeks longer, and for 
at least six months avoid lifting and heavy work. The bowels should 
be kept emptied at regular intervals, and, above all, the bladder should 
be emptied not less than once in three or four hours, according to the 
amount of excretion ; it is possible for an overdistended bladder to tear 
a suspended uterus away from its moorings. 
Between October, 1889, and October, 1896,1 have operated upon two 
hundred cases of retrodisplacements in the Johns Hopkins Hospital, 
and upon nineteen in my private hospital. In addition to these there 
were some cases operated upon outside of these two institutions. In no 
case has there been a death in any way connected with the operation 
either during the convalescence or at a remoter period, and I know of 
no case in which there has been a hernia or any serious interference 
with any function of the bladder. In tracing the subsequent histories 
I have learned of pregnancy in fourteen cases, in but one of which was 16 
KELLY: BACKWARD DISPLACEMENTS OF UTERUS. 
there any difficulty attributed to the operation; that was one of the 
earliest cases, operated upon in 1889, in which a protracted suppuration 
in the wound brought about such dense adhesions between the fundus 
and the abdominal wall that the patient, at the termination of her labor 
some years later, was only delivered by the forceps. 
I am not able to state with certainty the exact number of relapses 
Fig. 11. 
Elevator used as a point d’appui during the passage of the first suture through the uterus, 
into retroflexion, as I find it impossible to secure the subsequent his- 
tories of all my cases ; I have seen, however, but four failures. 
The operation just described relieves the retroflexion by holding the 
uterus in a position of great mechanical advantage to meet the forces 
which tend to displace it. The intra-abdominal pressure now falls upon 
its posterior surface, and instead of tending to produce a retroflexion KELLY: BACKWARD DISPLACEMENTS OF UTERUS. 
actually increases the anteflexion. While the immediate effect of the 
operation is to fix the uterus to the anterior abdominal wall (ventro- 
fixation, hysteropexy), this is not the final result obtained, which is a 
suspension of the uterus by its posterior surface, allowing it the full 
freedom of all its normal movements ; if, for example, the patient is 
examined two or three months after the operation, the body of the 
uterus will then be found lying in easy anteflexion in contact with the 
Fig. 12. 
Fibrous suspension-cords attaching the posterior surface of the uterus to the anterior ab- 
dominal wall. The left sutures remain at the wall and the right at the uterus. Drawing 
from a specimen removed more than a year after the suspensory operation. 
anterior abdominal wall; the examiner will also find that he is able to 
raise it without resistance and to push it backward or sidewise ; one 
position, however, it will not take : he cannot throw it again into retro- 
flexion. The explanation of this freedom of motion and this restriction 
is found upon opening the abdomen, as I have done in a number of 
instances at intervals of from one to several years, when the uterus is 
seen to be connected with the anterior abdominal wall by one or two 
bands of adhesions. 18 
KELLY: BACKWARD DISPLACEMENTS OF UTERUS 
The accompanying illustration of suspended uterus, with adhesions, 
shows one of these cases, with two long bands of connective tissue run- 
ning up from the posterior surface of the uterus to the abdominal wall 
on either side. These hands are broader at the ends and drawn out 
thin in the middle. One of the silk suspension-sutures appears on one 
side just under the abdominal wall, while the other is in contact with 
the uterus ; both were encapsulated when the uterus was removed. 
fig. is. 
Relaxed vaginal outlet. The arrows represent the directions of the forces of intra-abdominal 
pressure constantly increasing the descensus. The triangular outline shows the effect of 
diminishing the size of the outlet by an operation. The picture must be viewed with the pro- 
montory vertically above the symphysis. 
Treatment of backward displacements by an operation upon the vaginal 
outlet and a suspensory operation combined. In my operative cases of 
retrodisplacement the proportion between married and single women 
was about two to one, and most of the former were women who had 
borne children and in whom the displacement of the uterus was associ- 
ated with a weakening of the pelvic floor and a gaping, relaxed vaginal 
orifice In such cases it is best, if possible, to correct both affections at 
one sitting by suspending the uterus in the manner described, followed 
by a reparative operation upon the outlet, restoring its normal calibre 
and lifting it up under the pubic arch, and giving the vagina again its 
normal direction at right-angles to the line of pressure of the intra- 
abdominal forces. 19 
KELLY: BACKWARD DISPLACEMENTS OF UTERUS. 
In recapitulating the various ways of treating retrodisplacement I 
mentioned under 4 an operation upon the vaginal outlet alone, and I 
did this to call attention to the fact that if it were necessary to elect, in 
any given case, between the vaginal and a suspensory operation, I should 
always prefer the lower vaginal operation, as by lifting up the vaginal 
outlet under the pubic arch the uterus is supported very much as it is 
held up by a pessary, and so the tendency to further displacement is 
checked, and although the displacement persists the patient is often 
entirely relieved of her distress. The performance of a suspensory 
operation alone, on the other hand, in a case in which the outlet is re- 
laxed, will not prove beneficial, as the tendency of the cervix, and with 
Fig. 14. 
The restored outlet, sutures seen inside. The intra-ahdominal pressure no longer tends to 
produce further displacement. 
it the body of the uterus, is always to drag down toward a relaxed 
outlet, and this descensus persisted in will in time rupture the suspensory 
adhesions of the most successful operation and so reproduce the retro- 
flexion. 
Recapitulation. The various operative methods cited for treating 
retroflexions resolve themselves into two classes : the direct methods, 
which attack the body of the uterus ; and the indirect methods, which 
deal with the uterus mediately by the round ligaments, the broad liga- 
ments, or the utero-sacral ligaments. Of the indirect methods, the two 
which promise the best results are that of Pryor, acting through the 
vagina on the cervical end of the uterus in order to produce enough 
scar-tissue about the utero-sacral ligaments to hold the cervix well back 20 
KELLY: BACKWARD DISPLACEMENTS OF UTERUS. 
in the pelvis; and that of Pagenstecher, which endeavors to accomplish 
the same thing by suturing and shortening the round ligaments. The 
other indirect method is that of Alexander, acting upon the opposite 
pole of the uterus by means of the round ligaments. I think the best 
elaborated technique of this procedure is that of Dr. Edebohls, of New 
York. 
The direct methods are two : the vaginal fixation, and the abdominal 
fixation or suspension. The vaginal operation has been practically 
abandoned, and the only abdominal operation which has thus far stood 
the test of prolonged trial in a number of cases is my own, which I have 
for this reason carefully described. The student interested in this sub- 
ject should not fail to consult a carefully prepared digest by Dr. C. P. 
Noble, of Philadelphia, who has admirably presented the effects of sus 
pension and ventrofixation upon pregnancy and labor. (See American 
Journal of Obstetrics, 1896, vol. xxxiv., No. 2.) 
Almost all writers upon the subject of the operative treatment of 
retroflexions have been in the habit of discriminating between various 
classes of cases ; for example, a distinction is made between those past 
the childbearing period and those still within it; and operations such 
as vaginofixation, which experience has shown ought not to be per- 
formed during the childbearing period on account of the danger to 
patient and child in case of pregnancy, may very properly be performed 
in a woman who is not likely to become pregnant. 
A distinction generally recognized is between the adherent and mobile 
retroflexions. Some operators, while unwilling to open the peritoneum in 
the case of a non-adherent movable uterus, feel that sufficient justifica- 
tion for coeliotomy exists when there are posterior adhesions or disease 
of one or both adnexa. Although this distinction was emphasized at 
the recent Gynecological Congress at Geneva, I have not dwelt upon it 
here, as I have shown by my own statistics that the danger to life from 
a properly performed suspensory operation is no greater than in any 
other so-called simpler operations. In addition to this the peritoneal 
incision always affords an opportunity of inspecting the appendages 
and discovering diseases often unsuspected, such as hydrosalpinx and 
adhesions of less grade ; in one instance I found a commencing papil- 
loma of the right ovary, not larger than a split-pea in size. 
My conclusion in the whole matter would be that operative measures 
are only to be resorted to for the relief of retroflexion in those cases in 
which there is good reason to believe that the displacement seriously 
interferes with the patient’s health and comfort. Then, if the case is 
one calling for operation in a woman who has borne children, first 
always look well to the vaginal outlet, and restore it, if it is broken 
down. The Alexander operation, as performed by Edebohls, will yield 
excellent results ; my personal preference is to deal directly with the 
retroflexed body of the uterus by a suspensory operation. Anjericai} Johrifal 
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