THE 
DIAGNOSIS AND TREATMENT 
-OF- 
UTERINE FLEXIONS. 
Read before the Yorkville Medical Association, April 1887. 
JOHN BLAKE WHITE, M.D., 
NEW YORK, 
Physician to Charity Hospital, Consulting Surgeon, House of Refuge, 
Randall's Island, etc. 
[Reprinted from Gaillard's Medical Journal for July, 1887.] 
NEW YORK: 
1887. 
The Judson Printing Co., 16 Beekman St. THE DIAGNOSIS AND TREATMENT OF 
UTERINE FLEXIONS.' 
By JOHN BLAKE WHITE, M.D., New York. 
Physician to Charity Hospital, Consulting Surgeon House of Refuge, Randall's Island, etc. 
The normal position of the uterus is somewhat slightly turned for- 
wards, with an evident point of curvature commencing a very little above 
the os internum. This fact should be well borne in mind, or the natural 
tendency of the fundus forwards might be mistaken for a moderate 
displacement anteriorly. When this curve is sufficiently great to pro- 
duce a decided angle either backwards or forwards, the displacement 
is termed retroflexion or anteflexion, respectively, and assumes patho- 
logical importance in proportion to the degree of special functional 
derangement, as well as general disturbance created in the system at 
large. 
Schroeder describes a flexion as a displacement " in which the 
direction of the axes of the two portions of the uterus are not quite nor- 
mal." This cannot be technically correct, because the organ rests in 
the pelvic cavity, and is supported in such a manner that freedom of 
motion is permitted, so that its normal position will necessarily vary 
with every change of position of the body, and the direction of the axes 
would thus be continually altered. The above definition of flexion, 
therefore, is not a good one, and will have to be qualified, at least, in 
order to clearly indicate what is the physiological and what the patho- 
logical degree of change of the uterine axis. I would define a true 
flexion of the uterus to be a change of relation of the cervix and 
fundus maintained continuously and unaffected in any respect by the 
position of the body. A flexion either forwards or backwards under 
these circumstances would be clearly pathological, and result, if not 
immediately, at least in a short time, in the manifestation of symptoms 
characteristic in quality and sufficiently important to require a resort 
to measures of a more or less surgical nature for their amelioration and 
permanent relief. 
' Read before the Yorkville Medical Association, April 28th, 1887. 2 
An allusion to the more common symptoms of flexion is all that is 
necessary, for the close relation that exists between the uterus and 
certain other pelvic organs will suggest results of uterine displacements 
which may be anticipated. 
Many constitutional evils have been attributed to womb disloca- 
tions which, in reality, were not at all due to such conditions ; while, on 
the other hand, important constitutional defects have been entirely over- 
looked, when undoubtedly superinduced by displacements, and there- 
fore have escaped the attention which they justly merited. 
Scanzoni went so far as to assert that " flexions of the womb do not 
acquire any importance, nor are followed by any serious dangers, save 
when they are complicated with an alteration in the texture of the 
organbut Gaillard Thomas does not evidently accord with such ex- 
treme views, for he cleverly quotes in refutation of this statement a 
paragraph from Scanzoni's own work, " that in well-marked flexion 
the canal of the neck is always more or less impermeable, which 
opposes an insurmountable obstacle to conception," which is clearly an 
admission, after all, of the importance of flexion, though uncomplicated 
with texture alteration. 
As the uterus rests in the pelvis in juxtaposition to the bladder 
anteriorly and the rectum posteriorly, pressure upon either one of these 
two organs is occasioned when displacement occurs; hence disturbances 
of the organ impinged upon must be expected. 
When the womb is anteflexed incontinence of urine and other 
symptoms of irritability of the bladder become manifest in due time. 
When retroflexion exists, various disturbances referable to the digestive 
organs are observed, resulting in obstinate constipation, though the 
oppositecondition doessometimesobtain. Flexion necessarily constitutes 
a barrier to the egress of the menstrual discharge, as well as to the en- 
trance of spermatozoa after coition; in each case producing disorders 
which bear relation to these respective functions. 
Lassitude, languor, headache, backache, hot flashes, nausea, pain 
down the anterior aspect of the thighs, frequent and painful urination, 
and a sense of dragging pain in the pelvis are among the general symp- 
toms of uterine flexion. Supra-pubic pain in anteflexion and sacro- 
lumbar pain in retroflexion, amenorrhcea, dysmenorrhoea, menorrhagia, 
leucorrhcea, and sterility are among the more special symptoms ob- 
served, which, with a history of the patient's condition, may serve to aid 
very materially in arriving at a correct diagnosis, if they do not at once 
warrant the institution of an examination for the purpose of definitely 
determining the position which the uterus occupies. In order to make 3 
a satisfactory examination of the cervix either the dorsal or Sims' posi- 
tion may be selected. To facilitate exploration of the several parts of 
the womb, I have had my vaginal specula modified to meet the want 
of certain important features in which even the most practical form ot 
speculum now in use seemed to be deficient* I refer to the necessity 
of greater conformity to the vaginal canal, especially the posterior 
curve. The success attained through this device in facility of intro- 
duction, in readiness of adaptability, and perfect command of the parts 
to be examined or treated, has been satisfactorily demonstrated on 
repeated occasions. 
The lower blade, A, of the speculum just represented, is construct- 
ed to conform, when the instrument is introduced, to the posterior va- 
ginal wall, which, owing to the sacral concavity, is not a straight canal. 
If the womb is anteflexed the cervix will necessarily be forced back- 
wards, and the posterior vaginal wall elongated. The curved blade ot 
the speculum will aid in bringing the cervix into view far better than 
an instrument not possessing this feature in its construction. 
Fig. I. 
Fig. 2. 
The two upper blades, B and C, are concavo-convex, permitting 
fullest dilatation of the vagina superiorly at points where least re- 
sistance is offered by the anatomy of the region. 
*Medjcal Record, April 24th, 1886. 4 
The same modification applied to the Sims' speculum renders it 
(Fig. 2) a more useful instrument when the blade conforms to the re- 
quirements of this vaginal curve. Less effort is needed on the part of 
the attendant to hold it in place, since the amount of leverage required 
is lessened by the perfect adjustability of the instrument. The curved 
blade, when the speculum is in situ, facilitates the introduction of the 
uterine sound or sponge tents, and renders more practicable local treat- 
ment of the endometrium or the use of the metratrep in remedying 
flexions. 
No better classification of the causes of uterine flexion can be found 
than that of Dr. Gaillard Thomas in his work on the diseases of women, 
as follows: 
I. Any influence which increases the weight of the uterus, as inflam- 
mation or congestion ; tumors in the walls or cavity, pregnancy, hy- 
pertrophy, subinvolution, fluid retained in the cavity, masses of cancer 
or tubercle. 
II. Any influence weakening uterine supports, as rupture ot the 
perineum, weakening of vaginal walls, stretching of uterine ligaments, 
want of tone in uterine tissue, degeneration of uterine tissue. 
III. Any influence which pushes the uterus out of place, as tight 
clothing, heavy clothing supported on the abdomen, muscular efforts, 
ascites, abdominal tumors, abscesses or masses of lymph, repletion of 
the bladder. 
IV. Any influence which displaces the uterus by traction, as lymph 
deposited on peritoneum of pelvic viscera, cicatrices in vaginal walls, 
shortening of the uterine ligaments. 
Diagnosis.-Ordinarily flexions may be readily recognized, upon 
digital examination, by noting the relation of the os to the vaginal wall, 
and also by observing the direction of the vaginal wall; both of which 
have a tendency forwards in retroflexions and backwards in anteflexions. 
The position of the fundus can be determined by bimanual manipula- 
tion quite easily in anteflexion, but it is a much more difficult matter to 
discover it when retroflexion exists, as tumors in the posterior vaginal 
cul de sac are not infrequently met with, and as they resemble the body 
of the uterus very closely they might be readily mistaken for it. 
A symptom of great diagnostic importance in retroflexion is pain 
in the lower part of the spine, which is sometimes mistaken for a symp- 
tom of spinal lesion. 
Indications of paralysis frequently supervene in retroflexion, and 
affect the lower extremities more especially. This symptom is occas- 
ionally of an hysterical nature, but in some cases it is genuine, and 5 
doubtless due to pressure of the displaced organ upon the pelvic nerves, 
seriously impairing their motor distribution to the lower extremities, 
and interfering, also, with trophic function. 
A local neuritis may lead to myelitis producing paralysis, or the 
latter condition may be only the result of reflex influences, without the 
existence of any actual lesion of the nerve centres. 
The crucial test for flexions is, as tersely stated by Gaillard Thomas, 
to place the patient in position for examination, introduce a Sims' spec- 
ulum, and gently probe the uterus to the fundus. A curve should be 
given to the sound which, by vaginal examination, the uterus has been 
found to have. The curve must be altered, and an attempt to pass it 
should be made each time that the instrument does not appear to enter 
the uterine canal with facility. This operation is more easily described 
and understood than practiced with the ordinary uterine sounds, but 
with the metratrep* the curve can be readily formed while the instru- 
ment is being introduced, and the character of the flexion, with its de- 
gree, can be most accurately determined. 
The bimanual method of examination is sometimes attended with 
so much difficulty that recourse must be had to the sound, or some in- 
strument much more flexible than the ordinary uterine sounds. To 
meet what appeared to me to be a requirement for a suitable instrument 
for diagnosis and replacement, I devised and had made, by Tiemann & 
Co., 107 Park Row, the following instrument which I have denominated 
the metratrep, from the two Greek words, the womb, and 
vpeneev to guide. 
Fig. 3- 
The instrument is composed of two parts : One is a straight tube 
of fine calibre, narrower at one extremity than at the other, and made 
of highly polished metal. At the larger end two rings are attached, to 
enable the operator to steady and guide the stem when using the in- 
strument. At the tapering end of this tube there is a highly flexible 
and elastic spiral attachment, pervious, like the tube it forms d part of, 
which terminates in a blunt probe point. The spiral extremity is 
graduated to the depth of a normal womb, not exceeding two inches 
* -M. Y. Medical Journal, April io, 1886. 6 
and a half in length, and, being extremely pliant, can be made to follow, 
without the slightest effort, a most devious flexion withoutproducingpain. 
The second part, which may be combined with, or disunited from, 
the first part at will, by means of a catch, consists of a split metalic 
spring, made to fit the calibre- of the tube already described, precisely 
as a sword would slide into its scabbard, and is furnished with a sepa- 
rate handle, upon which is attached a graduated dial plate and a move- 
able index. The point of the spring, which is within the spiral inclosure 
when the two parts are combined, can be made to turn upwards or 
downwards by means of a governing screw at the handle; the index 
meantime records faithfully every change of direction impressed by the 
will of the operator. 
Treatment.-The indications tor treatment are clearly as follows: 
i. Replacement. 2. Retaining the uterus in place. 3. Removing all 
causes of flexion as far as it is practicable to do so. 4. Prevention of a 
recurrence of flexion. The accomplishment of the first indication is 
simple enough in many instances, but there a're cases where flexions are 
maintained by influences of such long standing that it is a difficult 
matter to correct them so effectually as to prevent their recurrence. 
I have no doubt that it is for this reason, especially, authorities 
speak so despairingly of realizing permanent good results after restoring 
the uterus to its normal position when it has been displaced any length 
of time. I have little doubt also that the somewhat imperfect and irra- 
tional method of replacement has had much to do with the unsatisfac- 
tory results realized. 
Recent anteflexions can usually be corrected by the introduction of 
the finger into the vagina, thereby fixing the cervix; meanwhile, by 
pressing with the other hand between the pubis and fundus, the uterus 
may be elevated and pushed backwards into place. In retroflexion the 
reduction is effected by fixing the cervix with one or two fingers of one 
hand in the vagina, and endeavoring, with the other hand, to raise the 
fundus uteri from behind through the abdominal wall. 
This operation can sometimes be readily performed through the 
rectum, by placing the patient in the knee-chest position. When it is 
found impossible to effect reduction of the uterus in the different ways 
described, recourse must be had to a suitable instrument for the pur- 
pose of elevating and replacing the fundus. 
I have not seen any serious consequences result from careful and 
skillful efforts to overcome moderate adhesions with the metratrep, 
and therefore believe that Schroeder's* cautions, that free mobility of the 
*Schroeder, Ziemssen Cyclopaedia, 7 
organ should exist before any attempt be made at instrumental re- 
placement, may be modified in respect to the use of the metratrep in 
skillful hands. The ordinary uterine sound is certainly not without 
danger when used in such cases for replacing the fundus. This instru- 
ment, when introduced in conformity with a flexion to be corrected, is 
turned over so that it shall occupy with the uterus its natural position. 
To accomplish this it will be noted that the uterine portion of the 
sound is obliged to describe a very long curve, which not only subjects 
the organ to the liability of serious injury, but actually contorts the 
longitudinal muscular fibres with the other tissues and vessels of the 
womb so that congestion is promoted, and the symptoms, for which the 
operation was deemed necessary, instead of being relieved, are aggra- 
vated, and the displacement almost immediately recurs. 
This method of reduction has always seemed unscientific and unnatu- 
ral to me, and so it must have appeared to the immortal Sims, who de- 
vised a more suitable uterine repositor, a full description of which 
may be found in Thomas' work on diseases of women, page 314. 
This is an admirable instrument, and is serviceable in some cases of 
flexion, but, although the modus operandi is simple and in accord with 
reason, its use will not meet with the requirements of all cases. The ute- 
rine staff is too straight to admit of its easy introduction in cases of 
marked flexion, and the elevation of the fundus is somewhat too hastily 
and abruptly effected. The objection as to the straightness of the staff 
has been partially met by making it jointed, thereby increasing the 
value of the instrument, but not wholly meeting all useful indications. 
It should be borne in mind that when the uterus becomes flexed it 
does not assume its abnormal position by describing a circle with the 
fundus and twisting itself out of position, but the organ simply is 
dragged or falls out of place, curving backwards or forwards, in the 
direction of the influences at work. It is true that it may be pushed 
out of its axis by morbid attachments, in which case it falls in the di- 
rection opposite to that of the morbid agent; but its flexion is, never- 
theless, in the direction of its weakest support, producing the same 
physical defect as if directly dragged from its normal position in the 
pelvis. If retroflexion or anteflexion is permitted to remain for any 
length of time, the uterus becomes congested and heavy, and drags 
upon its various attachments, which are stretched and rendered irritable. 
The fundus, pressing continuously upon some adjacent organ or inter- 
vening tissue, excites a local inflammation which results in lymph exu- 
dation, and, becoming organized, binds the body of the womb to this 
unnatural position. 8 
The only way to correct such a flexion must, therefore, be a resort 
to some instrument which can return the body of the organ to its 
natural position without injury, and by the same track it followed in 
becoming displaced. This is to be effected by carefully introducing 
into the uterine canal a flexible staff which can be made firm at will, 
and operated so as to cautiously elevate the fundus, and at the same 
time gradually permit the surrounding soft parts to reassume their 
respective relations in the pelvic cavity. This operation can be best and 
most safely performed by the metratrep* If this instrument is intro- 
duced into an anteflexed or retroflexed uterus, its spiral extremity, 
yielding to the maldirection, would follow the precise degree of flexion 
existing, and faithfully record it on the dial. The restoration of the 
uterus to its normal position is effected by operating the governing 
screw at the handle, while the combined instrument is held steadily and 
firmly in place. As the screw is slowly turned in the opposite direc- 
tion to the existing flexion, the body of the womb is gradually and 
painlessly lifted into its proper place, and the fact announced by the 
index when it is accomplished. The instrument may be then with- 
drawn carefully, and the uterus left in its redressed position. 
To prevent the recurrence of flexion I have been in the habit of 
placing a tampon of carbolized glycerine around the cervix, packing 
it anteriorly or posteriorly, with especial reference to the pre-existing 
flexion, and this may be permitted to remain for two or three days. 
The recumbent posture should be particularly enjoined for two or more 
weeks, during which time the carbolized tampon should be renewed 
every two or three days, and moderately warm vaginal douches regu- 
larly administered. 
General tonic treatment should not be overlooked as a valuable, if 
not necessary, means of restoring tone to the flaccid uterine tissue. 
Some strengthening influence may be expected from the internal ad- 
ministration of iron, ergot and ext. cannabis purificat. When the patient 
is permitted to leave the couch chalybeate tonics should, of course, 
be continued, and cold hip baths, medicated with sea salt, regularly 
taken. An artificial Kreuznach bath may be devised with advantage ac- 
cording to the following formula: One half a pound of Kreuznach salt, 
two pounds common salt, to three gallons of water. Let the patient 
remain in this bath from ten to twenty minutes once or twice daily. 
Some of the same solution, warmed, may be used with good effect as 
a vaginal douche once or twice daily. 
Mechanical means for retaining the uterus in place may prove neces- 
* New York Medical Journal, April io, 1886. 9 
sary when a selection may be made of a suitable pessary. I will not 
test your patience unnecessarily by reviewing in detail the various pes- 
saries which are more or less beneficial, as you are already familiar with 
the most approved patterns. A mere allusion to two or three which 
I have found useful will suffice. The intra-uterine pessary, various 
modifications of which are described in works on diseases of females, 
is sometimes required; but great care should be exercised in resorting 
to them, as serious inflammation has resulted from their use. 
The employment of eccentric rings has in some cases proved suc- 
cessful in retaining the uterus in place, by keeping the cervix in a 
position which tends to prevent the body from falling out of its normal 
axis. 
The variously modified Hodge's lever pessary, constructed of hard 
rubber or copper zinc covered with soft rubber, which is quite flexible, 
will do well in supporting the uterus in many instances. Thomas' 
horse shoe modification of Hedge's pessary may be used with advan- 
tage, and Schultze's retroflexion pessary will be found to answer its pur- 
pose admirably in the class of cases for which it is best adapted. 
The following case, which I saw in consultation with my friend Dr. 
De Laney Carter, will prove interesting, as it illustrates the value of the 
metratrepxw restoring along standing flexion, with permanent good results. 
Miss G about eight or nine years prior to becoming a patient 
of Dr. Carter took care of an invalid father whom she often was obliged 
to lift unassisted, this requiring great muscular effort in each instance. 
For seven years she was more or less of an invalid, when she had a fall 
seriously injuring her arm. After this accident she was confined to bed 
for a time, and more particularly had her attention called to symptoms 
referable to the pelvic organs, as dysmenorrhcea, obstinate constipation 
and vesical irritability, resultingin frequent and painful urination. On 
recovering from the acute effects of the accident, though able to be 
about, she was neve? free from headache, backache, hot flashes, las- 
situde, languor, irregular and painful menstruation, ovarian neuralgia, 
more or less leucorrhcea, occasional nausea and vomiting, and con- 
tinued vesical irritability. 
So persistent and distressing were these symptoms that she visited 
two or three distinguished gynaecologists, who recognized the presence 
of an acute anteflexion of the uterus, and corrected the condition in the 
usual way ; but the displacement immediately recurred. One of the 
gentlemen she consulted advised Tait's operation as a means of 
relief. When she was examined by Dr. Carter and myself, a complete 
anteflexion of the uterus was discovered. Replacement was thought 10 
advisable, and hope entertained of ameliorating some of the most dis- 
tressing symptoms. 
The angle of flexion was so acute that the ordinary sounds could 
not be introduced without great difficulty, and efforts to do so were 
accordingly abandoned. 
On inserting the metratrep it was necessary to cause the spiral ex- 
tremity to conform to the uterine curve by the agency of the govern- 
ing screw, while the instrument was in process of introduction. When 
the instrument was inserted to the funduS, the uterine curve was found 
to have reached its fullest extent, as indicated by the index. Very 
gradually and carefully the staff was raised and carried backwards and 
downwards, so as to place the uterus in a retroverted position, when 
the instrument was withdrawn and a tampon of carbolized glycerine 
packed about the cervix, anteriorly, as already described. 
The operation caused no immediate reaction, but for several days 
subsequently some pain was experienced. The patient was advised to 
remain in the recumbent position, and a moderate dose of codeia ad- 
ministered at intervals. 
Three weeks after the operation the patient was examined, and the 
uterus was found in its normal position. 
A Simpson sound, with the natural curve, was readily admitted to 
the fundus without causing pain. Again six weeks afterwards she was 
examined by Dr. Carter, who found the organ in place. 
It is needless to add that much relief has been realized from the 
operation. The successful reduction of long standing flexion, without 
immediate recurrence, is thus fully proven, and the undertaking estab- 
lished as a safe procedure. It is, moreover, demonstrated that it is a 
practical thing to prevent the recurrence of flexion when reduction has 
been effected in the manner advocated, and the case subsequently 
treated as advised. 
Similar good results have occurred in my experience, but I will not 
consume more of your time with the details. 
I cannot close these remarks without expressing my grateful ap- 
preciation of your patience and interest in a subject which has afforded 
me some interesting study. 
94i Madison Avenue.