Division of the Cervix back- 
ward in some forms of Ante- 
flexion of the Uterus, with 
Dysmenorrhcea and 
Sterility. 
BV 
h. p. c. wilson; m; d., 
Ex-President of the Medical and Chirurgical Faculty of 
Maryland, and of the Baltimore Academy of Medicine ; 
Surgeon to the Hospital for the Women of Mary- 
land ; Consulting Gynecologist to St. Agnes's 
Hospital, and to the Union Protestant 
Infirmary ; Member of the British 
Medical Association; Fellow of 
the British Gynecological 
Society. 
SBPRINT FROM VOLUME XI 
(GnnecoloQical ffiransactions. 
1886. DIVISION OF THE CERVIX BACKWARD IN 
SOME FORMS OF ANTEFLEXION OF THE 
UTERUS, WITH DYSMENORRHEA 
AND STERILITY. 
BY H. P. O. WILSON, M. D., 
Baltimore, Md. 
Mr. President and Fellows : The subject of my paper 
to-day is an old one-as old as the history of gynecology. 
Originated by such names as Sims and Simpson, and taught 
and practiced by them with such brilliant results to the end 
of their days, it is no wonder that division of the cervix uteri 
was carried to such extremes as to be done by nearly every 
physician of gynecological pretensions, and for every con- 
ceivable disease. 
From want of a judicious selection of cases, from being 
done by unskilled hands in proper cases, from being done 
where it should never have been done, and from improper 
management after done, this operation has been so misused 
as to have been barren of good results and prolific of bad in 
the hands of many practitioners. It has shared the fate of 
many valuable remedies and many new operations in proving 
that the abuse of a thing is no argument against its proper 
use. 
In advocating division of the cervix backward, in properly 
selected cases, I realize that sharp criticism will follow; but 
it is truth for which we are in search, and, if from anything 
I may say the truth on this important subject can be estab- 
lished contrary to my views, I shall be amply repaid, and 
gladly recant my present convictions. 2 
II. P. C. WILSON. 
Since so many of my professional brethren have turned 
down this operation, they have been floundering from post 
to pillar in search of the best means to retain open a con- 
tracted cervical canal and stenosed os, and straighten a bent 
uterus. 
Tents, glass plugs, hard-rubber stems, bougies, and steel 
dilators have their advocates; but, after full trial of them 
all, I have found not one so safe and so efficient as the knife 
in the class of cases to which I shall call your attention. 
The cases in which I especially recommend this opera- 
tion are: 
1. Those of anteflexion of the uterus, with an elongated, 
indurated cervix, where the body is bent upon the neck, or the 
neck upon the body, or where they are bent upon each other, 
thus forming a more or less acute angle at the internal os. 
2. Those cases of not such acute flexion, but where the 
cervix is hyperplastic and indurated, as blue as a mulberry 
and as dense as cartilage. 
3. Those cases where there is a hard and unyielding band, 
encircling and constricting the internal os, through which 
the probe passes with difficulty, and gives to the hand the 
sensation as if passing over rough and dense cartilage, while 
the finger of the other hand in the sulcus, between the body 
and neck in front, gains the impression of a strong cord tied 
around the uterus at the point of union between body and 
neck. 
The conditions described in the third class are frequently 
found in the first, and are occasionally present in the second; 
and, in typical cases of anteflexion of the uterus, where the 
knife should be used in preference to other remedies, all of 
the lesions above described are co-existing. 
Nearly all such cases are sterile. The very rare excep- 
tion proves the rule. 
In all these cases we find the Nabothian and utricular 
glands hypertrophied and indurated, so that the probe, in 
passing from the external os along the cervical canal and 
through the internal os into the cavity of the uterus, feels as DIVISION OF THE CERVIX BACKWARD. 
3 
if it were passing over the surface of an Osage orange, instead 
of a soft and pliant mucous membrane. 
No dense, unyielding cervix should be forced open, and, 
if so, it will be done with far greater hazard than could ac- 
crue from a clean incision with a sharp knife and scissors. 
All accidents from cutting are the result of improper after- 
treatment. Accidents from forcible stretching are the im- 
mediate result of the force employed. Accidents from tents, 
plugs, and stems follow from septic poison, or long-contin- 
ued irritation in an organ, naturally rebellious of foreign 
bodies within its cavity. 
For straightening the uterus, and overcoming a contracted 
internal os, with its accompanying dysmenorrhea and ste- 
rility, the tent is the most dangerous of the above remedies; 
but, when the patient luckily escapes the critical secondary 
results, it is the most efficient except the knife; and I do 
not hesitate to say that we had better cut again and again 
than use the harsh means advocated by some to dense and 
unyielding tissue. 
A clean cut into the cervix uteri and through the internal 
os, under proper antiseptic precautions, with proper treat- 
ment afterward, and exemption from meddlesome manipula- 
tion for a reasonable time, is not more dangerous than a simi- 
lar cut elsewhere, and nothing to compare to that from the 
tent, steel dilator, or stem. It is much the most efficient, 
much the least shocking, and much the most rational of all 
remedies for rectifying an anteflexed uterus, such as I have 
described. 
Moreover, simple dilatation is not sufficient to rectify an 
anteflexed uterus with a contracted internal os or with a 
hyperplastic cervix. To expand and contract is a part of 
the natural life of the uterus. We see it expanded from two 
and a half to thirteen inches in pregnancy, and the os suffi- 
ciently dilated to transmit the head of a twelve-pound child ; 
and yet we see that same uterus contracted again to three 
inches, and flexed and stenosed at the internal os, so that the 
smallest uterine probe enters with difficulty, while the patient 4 
H. P. a WILSON 
suffers from dysmenorrhea and future sterility. I have per- 
fectly cured several such cases, after they had borne children, 
by cutting the cervix backward and the internal os back- 
ward and forward. 
This is the surest means of rectifying an anteflexed uterus 
in any of the conditions described in the early part of this 
paper. Simple dilatation will not do. The uterus is sure 
to contract and retract to its original bend. It is true that 
strong steel dilators may tear the tissue, but, to say nothing 
of the violence done to such rigid parts, and the dangers 
arising therefrom, they are as liable to tear wrong as right, 
bilaterally as posteriorly, and thus we may complicate the 
case with a bilateral laceration of the cervix. 
An anteflexed uterus, with stenosis at the internal os, and 
ail the accompanying troubles of the intra-uterine mucous 
membrane, is not put in any better condition by dividing the 
cervix bilaterally, but is usually left in the same, if not in a 
worse state, than before the operation. The uterus still re- 
mains anteflexed, and the neck bending upon the body, or 
the body and neck bending upon each other, as effectually 
closes the os to the exit of the uterine secretions as if the 
cervix was not patulous from the division. In addition to 
this, the bilateral incision, if at all extensive, usually leaves 
the cervix in the condition of a bilateral laceration. 
Not so where the cervix is divided backward. All who 
have done the posterior section know of its tendency to close, 
and the success of such an operation depends greatly on the 
skill of the operator in causing it to heal without too great 
closure. 
Again, by the posterior section and division of the strict- 
ure at the internal os, backward and forward, the circular 
muscular fibers of these portions of the uterus are rendered 
powerless, and, the longitudinal fibers being in full force, the 
body is pulled up, and the cervix is pulled back; and, even 
where this operation fails to fully straighten the organ, it 
leaves it with a straight and open cervical canal into its cav- 
ity, instead of a tortuous and obstructed one, and thus there DIVISION OF THE CERVIX RACKWARD. 
5 
is a free outlet to the menstrual flow, as well as to the secre- 
tions of the uterine mucous membrane between the monthly 
periods. 
These secretions are, to a greater or less extent, retained 
in the cavity of an anteflexed uterus during the intervals of 
menstruation, and become acrid, and irritating to the mucous 
surface. They are a prime cause of the hypertrophy and in- 
duration of the utricular glands, with inflammatory thicken- 
ing of the intra-uterine mucous membrane. 
With this factor added to the semi-labor pains of dys- 
menorrhea every month, and the obstruction to proper cir- 
culation and innervation by the constriction at the seat of 
flexion, I am not surprised to find in nearly every case of de- 
cided anteflexion that the Nabothian and utricular glands 
are as hard and prominent as the rough surface of an Osage 
orange. 
To overcome this diseased condition of the endometrium, 
it is not only necessary to relieve the stricture at the internal 
os, but also to straighten the organ, or at least, to give a free 
and straight outlet from the uterine cavity. 
I maintain that rapid, forcible dilatation with any of the 
numerous uterine dilators, or the slower dilatation with tents, 
or bougies, or glass or hard-rubber plugs, will not accomplish 
the desired results alone, in a large number of cases, and will 
not accomplish them as efficiently in any as a judicious use 
of the knife, with proper after-treatment. 
I maintain further, that keeping up the above remedies 
for any length of time is apt to produce hyperplasia and in- 
duration of the cervix, thickening and induration of the Na- 
bothian glands and cervical mucous membrane, and chronic 
endometritis, and, in the end, does not accomplish what the 
knife will for dysmenorrhea, sterility, and the multitude of 
reflected nervous disorders. 
Division of the cervix backward up to the vaginal junc- 
tion, and the internal os backward and forward, is the only 
operation from which we are likely to get satisfactory re- 
sults. I would discard the bilateral section, the taking out of 6 
H. P. C. WILSON. 
a V-shaped portion from the posterior lip, Fritsch's method 
of making four cuts into the external os, and connecting 
these with a circular incision, by which uterine tissue is re- 
moved, as the core from an apple, and also the modification 
of this operation, by which four cuts are also made through 
the internal os, and a glass plug inserted, to be worn for 
weeks or months. The glass plug effectually corks up the 
cavity of the uterus, and, on its removal after sueh a length 
of time, the operator is fortunate if he has not all the results 
that follow a foreign body in any organ. 
None of these methods will straighten an anteflexed uterus, 
nor give a free and direct exit from the uterine cavity. It 
will remain bent as before, and the cervical canal and inter- 
nal os will be crooked and obstructed, as can be seen by 
bending a roll of paper upon itself. Moreover, by any of 
these methods, an amount of cicatricial tissue will be left 
which greatly exceeds that from the posterior section, and 
this is one of the chief difficulties against which we have to 
guard in division of the cervix. 
Let me say here, that I have never seen good from any 
pessary for an anteflexed uterus in the conditions described 
in the beginning of this paper. Any mechanical contrivance 
which pushes upward and backward the body of the uterus 
will necessarily carry upward and forward the indurated and 
constricted cervix to just the same extent; so that the rela- 
tion of body and neck to one another is unaltered. It has 
the same bend, the same stricture, the same stenosis. It has 
grown so, and the conditions arising therefrom are best recti- 
fied by the knife, in the blood-letting, the suppuration, the 
innervation, the paralyzing of the circular muscular fibers of 
the uterus, and in relaxing the stricture at the internal os. 
These results follow the division of the cervix backward 
from the internal os to the vaginal junction. 
As I have said before, every anteflexed uterus of long 
standing, with an indurated cervix and stenosed and strict- 
ured internal os, has hypertrophied and indurated Nabothian 
and utricular glands and a diseased mucous membrane from DIVISION OF THE CERVIX BACKWARD. 
7 
os tincse to fundus uteri. Whatever means we use to straight- 
en the organ, overcome the stenosis, and give a free outlet 
from the uterine cavity, and however successful we may be 
in our efforts to this end, we will fail in curing a large pro- 
portion of such cases if we do not follow up our surgery with 
local medication to the diseased endometrium and judicious 
constitutional treatment. The patient should be allowed to 
thoroughly recover from the operation, which usually re- 
quires one month. She should then be allowed to return to 
her home, or absent herself from all treatment for one month, 
except such means as may be used to improve her general 
health, amuse her mind, and brace up her nervous system. 
Under this plan the intra-uterine mucous membrane will 
improve, and will be ready to receive the local treatment, 
which shall carry on the patient to full restoration of health. 
In cases of years' standing, this will not be accomplished 
in months. No patient should undergo intra-uterine medica- 
tion for a longer time than one or two months, and she may 
require to return to the gynecologist two or three times after 
intervals of two or three months' rest before the desired end 
is attained. 
The best remedy for these diseased conditions of the cer- 
vical and corporeal mucous membrane is Churchill's tincture 
of iodine, freely painted over the whole surface two or three 
times a week, and followed by pads of cotton soaked in gly- 
cerine. 
Iodine internally should be given at the same time, and 
everything done to improve the general health. 
This plan of treatment can not be successfully instituted 
till, by the preceding operation, the cervical canal has been 
permanently straightened and opened, to allow the free in- 
troduction of iodine and the free exit of all uterine secre- 
tions. 
I know that some distinguished gynecologists are opposed 
to any intra-uterine medication, and deny its power for good; 
but I am just as sure of the therapeutical value of this plan 
of treatment to this mucous membrane as I am of the benefit 8 
II. P. C. WILSON. 
to be derived from local treatment to any diseased mucous 
membrane in the body. 
My first operation for anteflexion of the uterus was done 
on May 28, 1868. The lady had been married five years, 
was sterile, and suffered with great dysmenorrhea. The 
cervix was indurated and conical. The internal os was hard 
and contracted, so that a fine probe was introduced with diffi- 
culty. The body and neck were bent upon each other, and, 
at the seat of flexion, the sensation in front to the finger was 
as if the nterus was encircled by a firm, constricting band. 
Under chloroform, with scissors, the cervix was divided 
backward up to the vaginal junction. Sims's uterotome, with 
a very narrow, blunt-pointed blade, was forced through the 
internal os, and the stricture here was divided backward, 
bringing the incision outward and backward into that made 
by the scissors. The knife was then reversed, and the in- 
ternal os was split forward at the point of flexion. After 
the cessation of hemorrhage, the incision was packed with 
small pledgets of cotton soaked in Monsel's solution and 
water, and the vagina was tightly tamponed. In two 
months the patient conceived, and, at the end of nine months, 
gave birth to a fine child after an easy and natural labor. 
Since then I have performed this operation about four 
hundred times. 
I am doing it more frequently now than ever before, be- 
cause, after an experience of eighteen years, I have found 
nothing in the class of cases described which ultimately 
gives me such good results and is so free from danger. 
I have never lost a patient whose death could be attributed 
to this operation. 
In my early experience, from injudicious and too med- 
dlesome after-treatment, I frequently met with cases of pelvic 
cellulitis and peritonitis, which brought some of my patients 
near to the grave; and they only recovered after weeks or 
months of severe illness. For many years I have had no 
such accidents to follow this operation. I have learned to 
cut my patients, and let them almost absolutely alone for ten DIVISION OF THE CERVIX BACKWARD. 
9 
days or two weeks, and then to manipulate them with great 
gentleness and caution. 
I have had a case of severe pelvic cellulitis from simply 
passing a probe for diagnosis. I have lost one patient from 
the use of tents, after the greatest antiseptic precautions and 
rest, and I have had a number ill from peritonitis and cellu- 
litis following tents. These accidents show that, after the 
uterus has undergone such an operation as section, it should 
be placed absolutely at rest till it thoroughly recovers from 
the shock and the inflammation and suppuration which fol- 
low, otherwise dangerous symptoms may result. 
Dr. William T. Howard informs me that Dr. Roberts 
has reported one death in a series of eleven cases of forcible 
dilatation of the uterus, and that he has had one death in a 
much larger number of cases. 
When this operation is to be performed, any pre-existing 
cellulitis should be wholly removed by previous treatment. 
The bowels should be thoroughly emptied. Then, under an 
anesthetic (with the patient on a table in front of a good 
light, and with a Sims' speculum in the vagina), a tenaculum 
should be firmly fixed in the anterior lip of the os uteri, and 
never be removed till tamponing of the vagina begins. 
The uterus should be gently pulled forward, so as to make 
its tissues a little tense and to fix its position. With one 
blade of a pair of straight scissors up the cervical canal, and 
the other blade behind the cervix up to the junction of the 
vagina with the uterus, a quick cut should be made through 
the posterior lip of the cervix, and immediately a second cut, 
to divide that portion which had slipped from the blades of 
the scissors in bringing them together the first time. Sims' 
uterotome, with a very narrow, blunt-pointed blade, should 
then be passed through the internal os; and, as it is brought 
out, with the cutting edge backward, the internal os should 
be freely divided, and the cut prolonged backward into 
that made by the scissors. The cutting edge of the knife 
should then be reversed, and the internal os divided forward. 
Having determined beforehand to what extent we desire to 10 
h p. a Wilson-. 
open the internal os, a sound of this size is introduced. If 
it goes in freely, the cutting is completed; if not, one or 
both the incisions should be deepened till the sound passes 
readily. We should not now be in too great a hurry to apply 
dressings, but should let the parts bleed freely, only interfer- 
ing with the hemorrhage in case of accidental division of 
the circular artery, which must be secured by ligature or 
torsion. When bleeding has completely or nearly stopped, 
a roll of cotton (two and a half inches long, and thick enough 
to fill the opening at the internal os), on a sliding appli- 
cator (and previously dipped in a mixture of Monsel's solu- 
tion of iron, glycerine, and carbolic acid), should be passed 
through the internal os. The applicator should then be with- 
drawn, so as to leave half the cotton in the uterine cavity 
and the other half in the cervical canal. Upon this are packed 
small pledgets of cotton, squeezed out of Monsel's solution 
and water (one of the former to two of the latter), until the 
cervical canal and cut surfaces have been accurately tam- 
poned. Over this is placed a wad of cotton soaked in glycer- 
ine, and then the whole vagina is carefully tamponed with 
wads of cotton squeezed flat out of cold water. 
The patient is then lifted into bed, kept perfectly quiet, 
and not allowed to sit up for eight or ten days. At the end 
of two weeks she is allowed to step about her room a little, 
in three weeks she is permitted to walk about the hospital, 
and in four weeks to walk out on the street. The bowels are 
not disturbed, nor the dressings removed till the third day, 
when she is lifted on a table, and in the semi-prone position, 
with a Sims' speculum and pair of dressing forceps, all dress- 
ings are removed. A pledget of cotton soaked in glycerine, 
with a string attached, is then placed against the os uteri, 
and is pulled away by the patient the following day. This 
simple dressing is continued every other day for a month. 
A gentle purgative is given on the third day, and, if neces- 
sary, every day afterward. From absolute rest such patients 
are usually constipated. 
All manipulation of the uterus is punctiliously avoided DIVISION OF THE CERVIX BACKWARD. 
11 
for two weeks and more if there is any uterine irritability. 
I then commence by passing the sound very carefully every 
other day for a week, and follow this every second day by 
gently stretching, with my steel dilators, the internal os, so 
as to prevent undue contraction from cicatrization. 
If you perform this operation, and interfere with it too 
soon, or if you let it go on to healing and cicatrization with- 
out interfering at all, or if the operation when well is not 
followed up by judicious intra-cervical and intra-uterine 
treatment, it had better never be done. 
By this operation I have cured more cases of sterility 
than by all other means put together; and, in the class of 
cases described in the early part of this paper, no treatment 
is so efficient in relieving the dysmenorrhea and the reflected 
nervous symptoms arising from the pathological lesions above 
described. 
There are cases of sterility and dysmenorrhea, originat- 
ing in other conditions of the uterus and its appendages, 
which this operation does not benefit, and for the relief of 
which it should never be undertaken. Let me repeat one 
case in illustration: 
Mrs. P., aged thirty-four, was sent to me by Professor John 
Stage Davis in April, 1880. From early girlhood she had been 
in the habit of bathing her feet in cold water every morning, 
never stopping for the menstrual period when it came. This 
occurred at the age of fourteen, with great pain. Menstrua- 
tion recurred regularly afterward, but with such intense pain, 
and so profusely, as to compel her to keep her bed during each 
period, up to the time of coming to me. 
At nineteen she had an attack of bilious intermittent fever, 
and then was seized with severe headache for the first time. 
After this she was never free from headache for one day during 
fifteen years, or until she came under my care. The head- 
aches were sometimes on one side, sometimes on the other, and 
sometimes in the top or front of the head. These were greatly 
intensified at each menstrual period, and worse as the flow came 
on. She was reduced to a skeleton. Her nervous prostration 12 
II. P. C. WILSON. 
great. Professor Davis had exhausted the best medical skill 
for her relief without any success. She had been married 
thirteen years and never been pregnant. 
I found her with an anteflexed uterus, the neck bent upon 
the body, and the body upon the neck. 
There was much hyperplastic enlargement of the cervix. It 
was dense and hard like gristle. The probe showed the uterus 
to be two inches and three quarters deep. It passed with diffi- 
culty through the internal os, as if passing through a gristly 
stricture. The Nabothian and utricular glands were hyper- 
trophied and indurated, and felt with the probe as if it were 
moving over the surface of an Osage orange. 
She was very anxious for children, but had long since given 
up all hope of them. Her great desire was for the relief of her 
constant, and at times intolerable, headaches and excruciating 
dysmenorrhea. 
With such a uterus, and of so long a standing, what could 
be done to relieve this wretched woman ? for this organ was 
clearly the cause of all her troubles-her dysmenorrhea, her re- 
flected neuralgic headaches, her wasted frame, and her melan- 
cholia. Her nerve-supply was so much expended on the uterus 
that there was little to give to other organs, and they all suf- 
fered more or less functionally. 
The indications were : 
1. To relieve the stricture at the seat of flexion, and give a 
free outlet to the uterine secretions and menstrual flow. 
2. To remove the cervical hyperplasia. 
3. To restore the intra-uterine mucous membrane to a 
healthy condition. 
For such a case I had nothing to offer but division of the 
cervix backward up to the vaginal junction, and the internal 
os backward and forward ; and, when well from this operation, 
to follow it up with intra-uterine medication and judicious con- 
stitutional treatment. I frankly told the lady that the hope 
of conception was remote. I could promise nothing certainly, 
but advised her either to submit to this operation, oi' have 
nothing done. 
In April, 1880, she was given chloroform by Dr. Robert T. 
Wilson, and I performed the operation as described in the fore- DIVISION OF THE CERVIX RACKWARD. 
13 
going pages. Her recovery was uninterrupted, and she returned 
home in a month, with directions as to hygiene, and a tonic 
and alterative constitutional treatment. 
From the time that I operated her headaches and dysmen- 
orrhea became less and less, and wholly disappeared in a short 
time. 
She returned to me four times after this, at intervals of 
about four months, when I mopped out the uterine cavity with 
Churchill's tincture of iodine every other day, for two or three 
weeks, and painted the cervix with the same. She took a pill 
containing iodine, quinine, and strychnia three times daily for 
months. 
One year after the operation she had a miscarriage, and two 
years and eight months after the operation, and nearly sixteen 
years after marriage, she was delivered of her first child, now 
a healthy, beautiful little girl. 
I might go on to report very many similar cases in which 
dysmenorrhea, sterility, and numerous nervous disorders have 
been cured by this operation, but I have already taxed your 
patience too greatly, and will claim your indulgence no longer.