Compliments of the Author. 
THE TREATMENT OF UTERINE FLEXIONS. 
BV VIRGIL O. HARDON, M. D., LECTURER ON OPERATIVE GYNAECOL- 
OGY, SOUTHERN MEDICAL COLLEGE, ATLANTA, GA. 
In a paper read before the Atlanta Society of Medicine, Octo- 
ber 20, 1885,* I gave a description of a mechanical device which 
was offered as a substitute for pessaries in the treatment of ute- 
rine displacements. It is proposed in this paper to elaborate in 
greater detail the principles upon which that method is based, 
and the manner of its application to the treatment of flexions, to 
which class of displacements it is especially applicable. 
It is a matter of common observation that cases are now and 
then seen in which a marked flexion of the womb persists for a 
long time without producing any symptoms. It is extremely 
probable that such instances are much more common than is 
usually supposed, since it is only by accident that they come under 
the notice of the physician. In such cases the organ is found 
high up in the pelvis, almost beyond the reach of the examining 
finger and the flexion is usually forward. I have never seen this 
condition in any other than nulliparous women in whom the 
uterine ligaments and the vaginal walls have retained their virgin 
firmness and tone. In such cases there is no tenderness or en- 
largement of the organ, no interference with the functions of the 
bladder, and no pain, except perhaps a tendency to dysmenorrhoea. 
If flexion of the womb may persist for years without producing 
any symptoms, this fact would seem to demonstrate that it does 
not constitute a disease fer se, and that of itself it is incapable of 
producing the symptoms usually attributed to it. 
But, on the other hand, the majority of cases of uterine flexion 
which are brought to the notice of the physician present a strik- 
* Atlanta Medical and Surgical Journal, December, 1885. 
Reprint from The Atlanta Medical and Surgical Journal August, 1886. 2 
ing contrast to the foregoing picture and are accompanied by a 
group of painful symptoms which demand active treatment for 
their relief. Pain in the back, difficulty of locomotion, sense of 
fullness in the pelvis, dragging sensations in the loins, vesical tenes- 
mus, frequent or painful micturition, leucorrhoea, dysmenorrhoea, 
menorrhagia and metrorrhagia are the principal features of such 
cases. Vaginal examination shows the womb to be low down in 
the pelvis, tender to the touch, its walls thickened so that the 
whole organ is enlarged, though usually of normal depth, and 
its endo-cervical mucous membrane in a state of chronic inflam- 
mation. This condition is most commonly seen in women who 
have borne children, and in such cases there will, as a rule, be 
found associated with it some accident of parturition, such as 
laceration of the cervix, rupture of the perineum, or injury to the 
vesico-vaginal or recto-vaginal septum. In those less frequent 
cases in which this condition presents itself in a nulliparous 
woman, there usually exists a stenosis of the cervical canal, a 
uterine polypus or a fibroid tumor. 
There are found, then, two groups of cases of uterine flexion 
differing essentially with each other as regards clinical history. 
The one presents a variety of morbid symptoms of such severity 
that the patient is a decided invalid and seeks medical aid. The 
other presents an entire absence of symptoms, and the condition 
is brought to the notice of the physician only by accident. What 
factor determines this marked difference ? The study of this 
question cannot fail to throw light upon the proper treatment of 
’uterine flexions. 
The symptoms which are characteristic of the first group of 
cases, and which form a tout ensemble which every practitioner 
will at once recognize from his own clinical experience, are attrib- 
utable to three causes: 
1. Traction upon the uterine supports 
2. Obstruction of the uterine circulation. 
3. Traction upon the bladder. 
In the first class are found pain in the back, dragging sensa- 
tions in the loins, difficulty of locomotion; in the second, leucor- 
rhcea, dysmenorrhoea, menorrhagia, metrorrhagia, sense of fullness 3 
in the pelvis; and in the third, vesical tenesmus and frequent and 
painful micturition. I shall endeavor to show that these three 
causative conditions have their origin in a sinking down of the 
womb below its normal position in the pelvis, and are unconnected 
with flexion of that organ, and that the lack of morbid symptoms 
in the second group of cases is explained by the fact that the ute- 
rus remains at its normal elevation. 
i. Traction upon the uterine supports. The manner in which 
the womb is supported in the pelvis has been clearly demonstra- 
ted by Savage in his admirable investigations of the anatomy of 
the female pelvic organs.* He found by drawing down the womb 
with a vulsellum in the axis in which prolapse occurs, that tension 
was first exerted upon the utero-sacral ligaments. When, by 
the forcible stretching of these ligaments, the womb had descended 
about an inch in the pelvis, “ some retaining agent, other than the 
broad ligaments, still prevented its arrival at this last stage (com- 
plete prolapse). The obstruction was found to be due to the 
sub-peritoneal pelvic cellular tissue, particularly where it sur- 
rounds and accompanies the uterine blood-vessels.” It is only 
when this tissue is divided and the womb is drawn half through 
the vulva that the broad and round ligaments are put on the 
stretch. As long, therefore, as the womb remains at its normal 
elevation, it is supported principally by the utero-sacral ligaments 
and that portion of the pelvic cellular tissue which surrounds and 
accompanies the uterine blood-vessels. 
The utero-sacral ligaments form a portion of the diaphragm of 
cellular tissue which, radiating horizontally in all directions from 
its uterine attachment, in a plane extending from the middle of the 
posterior surface of the pubic bone to the junction of the third 
and fourth sacral bones, forms the roof of the pelvis. The at- 
tachment of this diaphragm to the womb on all sides takes place 
at a point corresponding to the line of union of the cervical with 
the corporeal portion of the organ, or about opposite the internal 
os. Through this diaphragm the cervix projects downward into 
the vagina and the body upward into the abdominal cavity, each 
portion being virtually free from other attachment, since the broad 
* The Surgery, Surgical Pathology and Surgical Anatomy of the Female Pelvic Organs. New 
York, 1S80. Plates xviii. and xix. 4 
and round ligaments are so lax that they are not put upon the 
stretch as long as the womb remains entirely within the pelvis. 
The womb is slung, as it were, upon a universal pivot, and there- 
fore as long as the position of the point of support is unaltered, 
its axis may vary greatly in direction without producing any 
traction. But it is obvious that if, from any cause, the normal 
equilibrium between the uterine supports and the weight to be 
supported be destroyed, so that the womb sinks below its normal 
position, traction upon the utero-sacral ligaments and the pelvic 
cellular tissue will exist in- exact proportion to the distance that 
the womb descends in the pelvis. 
2. Obstruction of the uterine circulation. The womb receives 
its supply of blood through two arteries, the uterine and the 
ovarian. The uterine artery, a branch of the internal iliac, 
passes downward into the pelvis between the two layers of the 
broad ligament close to its iliac attachment. Upon reaching a 
point a little below the level of the os uteri, it curves inward and 
upward and comes into contact with the uterus just above the 
uterine insertion of the vagina. It then passes upward along the 
lateral border of the uterus, between the two layers of the broad 
ligament, giving off numerous horizontal branches which enter 
the womb at right angles. Upon reaching the superior angle of 
the uterus it anastamoses freely with the ovarian artery. The 
ovarian artery, the analogue of the spermatic artery in the male, 
is given off by the aorta just below the origin of the renal arte- 
ries. Passing downward to the pelvis it supplies the ovary. But 
numerous large branches ramify in the upper portion of the broad 
ligament and anastamose freely with the uterine artery at the 
upper angle of the uterus. Thus the womb is supplied with 
blood from above and below, the two sources of supply being 
supplementary to each other, as is proven by the fact that when 
either artery is abnormally small, as is not infrequently the case, 
the other is correspondingly enlarged. The venous arrangement 
is similar to the arterial. The blood passes from the uterus 
toward the heart by the uterine vein at about the level of the 
middle of the cervix and by the ovarian vein at the upper 
angle of the womb. These two veins are connected by a venous 5 
sinus, continuous with both, which passes upward along the lateral 
border of the uterus between the folds of the broad ligament, re- 
ceiving at short intervals horizontal branches from the womb, 
and which is entirely devoid of valves. This sinus communicates 
with that of the opposite side by an intricate venous plexus within 
the uterine walls, extending without interruption from one side 
to the other, and from the os to the fundus.* 
Since the uterine artery and the uterine vein follow the lateral 
border of the womb throughout its length and are closely bound 
to it by connective tissue, it is easy to see that any con- 
siderable flexion of the organ at any point will produce a sharp 
flexure in these vessels at that point and a diminution of their 
calibre. But it is difficult to understand how such a constriction 
can interfere in any degree with the circulation of blood in the 
womb, since both artery and vein give off lateral branches 
throughout their course, which render every horizontal segment 
of the womb independent of every other portion as respects its 
circulation. The circulation of the portion above such a constric- 
tion will still be carried on through the ovarian artery and vein, 
and that of the portion below the constriction through the uterine 
artery and vein, and each will be as perfect as though no flexion 
existed. At a late meeting of the London Obstetrical Society, 
Dr. John Williams described the following experiment to test the 
influence of flexions in causing congestions. He stitched the 
fundus of the uterus closely to the cervix, thus securing the 
acutest flexion possible, and then injected a colored fluid into 
one of the veins of the broad ligament. Immediately the veins 
of the other side of the uterus became distended with the injec- 
tion. On making a section, the whole of the veins in the uterus 
were found injected. J This proves what the arrangement of the 
vessels has already shown, that the acutest flexion does not inter- 
fere with the circulation of blood in the uterus. 
A logical conclusion from these anatomical facts is that no ob- 
struction can take place in the circulation of any part of the 
uterus from flexion of the organ, unless there be at the same time 
♦Savage, opus cit., plates viii. and ix. 
t American Journal of Obstetrics, September, 1885, p. 978. 6 
a constriction of the uterine or the ovarian blood-vessels at some 
point outside of the womb, that is, within the cellular tissue of 
the broad ligament. But if these two conditions co-exist, there 
will be a circulatory interference in the portion of the womb 
between the point of flexion and the point of constriction in the 
cellular tissue. No argument is needed to prove that traction 
upon an elastic tissue containing a blood-vessel will produce con- 
striction of that vessel. We have seen that no such traction upon 
the cellular tissue exists as long as the womb remains at its nor- 
mal elevation. But when it has descended to the distance of an 
inch, and not before, traction is exerted upon the pelvic cellular 
tissue, “ particularly where it surrounds and accompanies the 
uterine blood-vessels.” Hence in a case of flexion, accompanied 
by prolapse, we have the two factors necessary for interference 
with uterine circulation, while in flexion, unaccompanied by pro- 
lapse, one of the essential factors is absent. 
3. Traction upon the bladder. It is commonly stated in the 
text-books that in flexions of the womb, pressure of the fundus 
upon the bladder produces irritation of that viscus. Of course 
this statement can apply only to anteflexion, since in retroflexion 
such pressure would be an anatomical impossibility. If pressure 
upon the bladder could produce vesical irritation, no woman would 
be free from this symptom. The normal condition of the womb 
is a state of anteflexion, so that the organ rests on the bladder. 
In addition to this, the bladder is always subjected to a varying 
amount of pressure from the weight of the superimposed intes- 
tines which rest upon it and follow it down as it contracts during 
micturition. Hence no bladder is ever free from pressure, and 
the extra weight of an anteflexed womb, which normally weighs 
only one and a half ounces, cannot produce any appreciable effect. 
The sensation which leads to a desire for micturition originates, 
according to Michael Foster,* in the circular muscular fibres with- 
in the bladder, especially the portion situated just posterior to the 
vesical termination of the urethra, sometimes spoken of as the 
vesical sphincter. As the bladder becomes distended by the ac- 
cumulation of urine, such distention, when it has reached a certain 
* Text-book of Physiology, London, 1878, p. 337. 7 
point, is resisted by these circular muscular fibres. This muscu- 
lar resistance, together with the escape perhaps of a few drops of 
urine into the urethra, gives rise to a desire to micturate, through 
a nervous mechanism which it is not necessary to describe here. 
Forcible mechanical expansion from any other cause will give rise 
to the same sensations and to spasmodic contractions of the blad- 
der. If the bladder be empty, such spasmodic contractions will 
constitute vesical tenesmus, and if frequently repeated will soon 
become painful. 
The relation of the uterus to the bladder is one of contact only, 
there being no cellular connection between the two viscera. Hence 
as long as the point of uterine support is undisturbed, flexion of 
the organ can produce no traction upon the bladder. But the 
vagina is closely connected to the bladder from its uterine inser- 
tion to the commencement of the mrethra by a layer of cellular 
tissue, constituting with the walls of the two cavities the vesico- 
vaginal septum. Any descent of the womb is accompanied by a 
corresponding descent of this septum. Savage declares it to be 
a rule without exception that the bladder, notwithstanding the 
yielding character of its connection with the vagina, invariably 
follows the uterine cervix, whatever be the amount of downward 
displacement.* At the beginning of a uterine prolapse, it is obvi- 
ous that the portion of the bladder dragged downward will be 
the point of its highest attachment to the vaginal wall, which is 
at the uterine insertion of the vagina. But as the prolapse in- 
creases, more and more of the bladder will become involved, until 
at length the traction will come to be exerted upon the portion 
constituting the internal sphincter. Since the anterior wall of the 
bladder is closely attached to the os pubis, traction upon the pos- 
terior wall will produce a forcible dilatation of the circular mus- 
cular fibres with its resulting sensation of a desire for micturition. 
As the degree of prolapse increases beyond this point, the amount 
of traction upon the bladder and of vesical disturbance will neces- 
sarily increase pari passu. 
I have endeavored to demonstrate from an anatomical point of 
view that the symptoms accompanying those cases of uterine flex- 
*Opu» cit., p. 83. 8 
ion which come under the notice of the physician are due to the 
sinking down of the womb in the pelvis, and not to the flexion. 
But such anatomical deductions are valueless unless confirmed by 
clinical observation. To complete the argument, it is necessary 
to show that when the womb is at its normal elevation in the pel- 
vis such symptoms do not appear, and that when they are present 
the womb is found low down in the pelvis, and the symptoms are 
relieved by raising the organ to its normal elevation. A close 
and careful study of this subject, extending over several years of 
active practice, has convinced me of the truth of both these propo- 
sitions. Since my attention has been directed to the subject, I 
have constantly been on the lookout for a case of flexion which 
presented the characteristic group of symptoms, but in which the 
womb had remained at its normal elevation. Thus far I have 
failed to find one such case. I have incidentally met with cases 
in which there was flexion with the womb high up in the pelvis. 
But in all such cases there were no subjettive symptoms which 
would indicate its existence. Whenever I have found the group 
of symptoms which depend upon traction upon the uterine sup- 
ports, obstruction of uterine circulation and interference with the 
functions of the bladder, I have always found the womb low down 
in the pelvis, and have also found that raising the organ to its 
normal elevation caused an abatement of such symptoms. 
In all works upon gynaecology there is to be found a more or 
less incomplete recognition of these facts. But nowhere, except 
in a very recent article by E. C. Dudley,* do their full significance 
and their relation to the treatment of uterine flexions seem to be 
appreciated. It is interesting to note that the methods of treat- 
ment of flexions which have yielded the best results have been 
such as accord perfectly with this theory. Pessaries which raise 
the womb as a whole, such as those of Hodge, Hewitt and Gehrung, 
have been found more satisfactory than any others. It is also a sig- 
nificant fact that the methods prescribed for the treatment of ante- 
flexion, retroflexion and prolapse are frequently quite identical. 
Mechanical conditions so diverse in themselves assuredly cannot 
be successfully treated by similar methods unless they possess 
♦Pepper’s System of Medicine. Phila., 1886, Vol. IV., page 147, et seg. 9 
some element in common. Clinical experience has thus led to 
the adoption of methods of treatment whose rationale has escaped 
recognition. Yet, although in a measure satisfactory in some 
cases, those methods have been so influenced by the erroneous 
theories upon which they are based that they have fallen far short 
of the degree of success that they might otherwise have attained. 
Consequently, they have never met with more than a half-hearted 
acceptance with the majority of the profession. Forty years ago, 
Meigs declared that “pessaries are necessary evils.”* Twenty- 
five years later, Sims, with unconscious plagiarism, reiterated 
precisely the same words.-f- The practitioner of to-day endorses 
their dictum. The explanation of this seeming paradox is simple. 
The benefit derived from a pessary is exactly in proportion to its 
ability to raise the womb as a whole. The harm wrought 
by it is in proportion to the power expended in the endeavor to 
correct a flexion. 
If the morbid symptoms usually attributed to flexion are due 
to prolapse of the womb, an important question relates to the 
causation of that prolapse. An uncomplicated case of flexion is 
rarely seen in practice. Not because such cases do not exist, but 
because they require no treatment. The uncomplicated cases 
are seen only by accident; the complicated ones apply for relief. 
In every case of flexion, accompanied by marked symptoms, some 
complication will be found to exist. It may be a morbid growth 
in the womb, a stenosis of the cervical canal, a laceration of the 
cervix, a rupture of the perineum or a vaginal fistula. Any path- 
ological condition which adds to the weight of the womb by in- 
creasing the amount of its solid tissues, or by inducing congestion, 
will cause it to settle down to a greater or less degree below its 
normal level. To consider all the causes which may produce 
this result would be to write a treatise on gynaecology, since 
nearly all morbid conditions of the pelvic viscera will give rise 
to some degree of increase of the weight of the womb. In 
nulliparous women the most frequent complication is stenosis of 
the cervical canal, which, by giving rise to obstructive dysmenor- 
4‘Females and their Diseases. Phila., 1848, p. 144. 
t Clinical Notes on Uterine Surgery. New York, 1873, p. 364. 10 
rhoea, induces a chronic congestion. In fertile women the most 
frequent complication is laceration of the cervix uteri, which in- 
creases the weight of the womb by interfering with the proper 
involution of the organ after labor. 
It follows that in the treatment of uterine flexions there are 
two indications to be met: first, to raise the womb to its normal 
elevation; second, to remove the cause of increased weight. The 
elevation of the womb is to be regarded as the first step in the 
treatment, because there is present, as a rule, a greater or less de- 
gree of the so-called chronic pelvic cellulitis, whose removal is 
a necessary prerequisite to any safe and efficient operative pro- 
cedure. Whatever view may be taken of the pathology of this 
condition, clinical experience has shown that it is not safe to divide 
or dilate an obstructed cervical canal, repair a lacerated cervix or 
even to introduce a sound to the fundus as long as it exists. The 
quickest and most efficient method for its removal, in common 
with the other symptoms of prolapse, is to raise the womb to its 
normal level in the pelvis and keep it there by appropriate me- 
chanical support. 
The normal position of the womb has been the subject of much 
discussion, and has never been satisfactorily determined, since 
scarcely any two authorities exactly agree upon this point. The 
womb is, within certain limits, a movable organ, since its position 
varies in different subjects and at different times in the same sub- 
ject. It floats in the pelvis like a ship moored to a pier. As a 
ship so moored rises and falls with the tide and sways to and 
fro with the .motion of the waves, so the womb rises and falls 
with the respiratory movements of the diaphragm and oscillates 
laterally and antero-posteriorly with the changes in the position 
of the body and the degree of distention of the bladder and rec- 
tum. Hence it is impossible to exactly define its normal position. 
But in every patient suffering with symptoms of prolapse, if the 
womb be not bound, down by adhesions, it will be found that there 
is a certain point of elevation in the pelvis, to which if the womb 
be raised the symptoms are relieved. When this point has been 
found, the normal position of the womb has been determined 11 
for that individual case. To maintain this position is the proper 
function of mechanical support. 
The question of how to support the womb by mechanical 
means is as old as the history of medicine. From the pomegran- 
ate, which Hippocrates inserted into the vagina for this purpose, 
down to the latest invention of the modern gynaecologist, the 
medical mind seems to have run riot in the multiplication of pes- 
saries. Their almost infinite variety is the best evidence of their 
failure to accomplish the purpose for which they are intended. 
Thomas, after having invented thirteen different pessaries for the 
cure of anteflexion and anteversion, says: “Were I asked at the 
present moment whether I believed that in the aggregate they 
have accomplished more good or evil, I should be forced to give 
a doubtful reply.”* The objections to pessaries in the treatment 
of flexions are manifold, and are universally recognized even by 
their most ardent advocates. It would therefore be superfluous 
to recount them here. The method which I recommended in 
my previous paper, and to which I have given the name of the 
“supporting tampon,” is free from these objections. Its use is 
not debarred by the presence of so-called chronic pelvic cellulitis, 
nor by any amount of pain or tenderness in the roof of the pelvis. 
It is therefore applicable where pessaries would be entirely out of 
the question, and, even though applied by unskillful hands, is in- 
capable of doing harm. It is indicated in any case in which the 
symptoms show the existence of traction upon the uterine sup- 
ports, obstruction of uterine circulation or interference with the 
functions of the bladder. The relief which it gives to such symp- 
toms is immediate, and places the patient in a very short time in 
a suitable condition for any operative procedure which may be 
necessary for the removal of the cause of the prolapse. 
In order to properly apply the supporting tampon, it is neces- 
sary to first ascertain the position in the pelvis at which the womb 
is most free from pain. This may be done by raising the womb 
upon the index finger in the vagina while the patient stands. If 
the womb be bound down by adhesions this cannot be accom- 
plished. But fortunately adhesions are rarely found. When the 
♦Diseases of Women, New York, x88o, p. 67. 12 
womb has been gently raised about as far as the finger can 
reach and held at that point for a short time, the patient will find 
that her pain and discomfort are greatly diminished. She must 
then be placed upon a table in Sims’ position and Sims’ speculum 
introduced. A pledget of cotton saturated with glycerine must 
be placed in the posterior cul de sac, another in the anterior fornix 
and a third and fourth on either side, so as to completely encircle 
the cervix. The size of these pledgets must be such as to fill the 
space between the cervix and the vaginal wall on all sides with a 
moderate degree of distention. The cervix will thus be held 
with a tolerable degree of firmness in its normal axis. A larger 
pledget of cotton, also wet with glycerine, must then be placed 
immediately below the cervix, so that it will lie between it and 
the vaginal promontory. The size of this pledget must be such 
that when in position it will raise the womb to the point where it 
has been found to be most free from pain and, resting upon the 
vaginal promontory, will form a platform of support for the or- 
gan. The patient may then resume the standing position, and if 
the tampon be properly applied she will be sensible of immediate 
relief from its application. A certain amount of experience is 
necessary in order to insert the tampon in such a manner that 
it will remain where it is placed and hold the womb in the desired 
position. If it be packed too firmly around the cervix, the natural 
mobility of the womb will be abolished and the jar of every mo- 
tion will be felt in the pelvis by the patient. On the other hand, 
if too loosely applied, it will be found in a few hours to have 
fallen down into the lower part of the vagina and all its useful- 
ness will be gone. Experience alone will enable the operator to 
avoid these two extremes. 
In my former article upon this subject, I stated that “ a tampon 
of cotton should never be allowed to remain in the vagina for 
more than twenty-four hours” on account of its interference with 
the daily use of the vaginal douche of hot water which I consid- 
ered an indispensable adjunct to the treatment. Further ex- 
perience has convinced me that I overrated the value of the daily 
douche, and that patients improve with equal rapidity under a less 
frequent use of it. I was led to experiment in this direction on 13 
account of the objection made by patients to the trouble and ex- 
pense incident to daily treatment. I have found that if properly 
applied the tampon will, as a rule, retain its position for forty- 
eight hours, and the disinfectant properties of the glycerine will 
prevent its becoming foul in that time. It should then be removed, 
a hot vaginal injection used and a new tampon inserted. Under 
this treatment all tenderness and engorgement in the cellular tis- 
sue will rapidly subside, the womb will return to its normal 
weight and size, endo-cervicitis and leucorrhoea will cease, men- 
struation will become normal, pain in the back, loins and pelvis 
will disappear. The rapidity with which these changes will take 
place will be of the nature of a revelation to one who uses the 
supporting tampon for the first time. 
The second indication in the treatment, the removal of the cause 
of increased weight of the womb, it would be superfluous to no- 
tice at length, since it involves processes whose description is 
found in every text-book of gynaecology. Suffice it to say that 
whatever may be the complicating pathological condition whose 
presence is the cause of increased weight of the uterus, it must 
be remedied by appropriate therapeutic or operative measures. 
The beneficial results obtained by the use of the supporting tam- 
pon will thus be rendered permanent. If the use of the tampon 
be discontinued without fulfilling this second indication, it will be 
only a question of time when the original condition will return, and 
the patient will be as badly off as at the beginning of the treat- 
ment. In other words, the supporting tampon is a palliative and 
preparatory measure merely. To expect more of it would show 
a lack of appreciation of the principles involved in its use.