[Reprinted from the New York Journal of Gynecology and Obstetrics 
for July, 1894.] 
THE TREATMENT OF A RETRO-DISPLACED ADHERENT 
UTERUS COMPLICATED BY PREGNANCY* 
IJerman L. Collyer, M. D. 
I have obtained such satisfactory results in the treatment of 
many patients suffering with the above complication, that I feel they 
would be received by the profession with interest ; more especially 
at a time when the literature is so filled with operative procedures. 
Many patients will readily submit to treatment, though long, rather 
than undergo any severe operation, such as would necessarily be in- 
dicated in a case of adhesions surgically dealt with. 
Many years ago it occurred to me, that abortion could be pre- 
vented in the retro-displaced adherent uterus, if treatment was insti- 
tuted early enough, in properly selected cases. It is, therefore, my 
purpose in this communication to report my experience and to cite a 
few illustrative cases which have come under my observation, in sup- 
port of my views on the subject of the treatment and curability of 
this complicated condition. In prefacing my remarks I hope to be 
correctly understood, as there seems to be some diversity of opinion 
regarding the ultimate results of retro-position with adhesions of the 
uterus. 
This complication is by no means a rarity; on the contrary, it has 
been my experience to meet with it quite frequently. The fact that 
this complication exists proves beyond a doubt that adhesive pelvic 
peritonitis, with its sequelae, may occur without complete destruction 
of function of the tubes and ovaries, aside from the existence of the 
pathological, abnormal position of the uterus. 
Case I.—Mrs. B., native of Germany, twenty-six years old, con- 
sulted me in January, 1887, on account of recurrent miscarriages. She 
* Read before the New York Obstetrical Society May i, 1894. 2 
Herman L. Colly er, M. D. 
had been married four years and a half, during which time she had 
had one child and three miscarriages ; the latter being in succession, 
near the third month, and occurring during the past two years. Her 
health had always been excellent until the birth of her child, one year 
after marriage. The delivery was attended by a midwife, who removed 
the placenta in pieces ; which the patient thought caused all her trou- 
ble, as she had fever and pain during a long convalescence and never 
felt the same nor well afterward. Menstruation has been fairly regular 
with profuse flow for ten days, attended by pains in the back and sides 
—more especially the right side of the abdomen—during the intervals 
between the miscarriages. The last period was April i, r887, and in 
May the patient began to think she was pregnant, which I corrobo- 
rated by a digital examination which showed, in addition, a retro- 
verted uterus—with firm posterior adhesions fixing the fundus be- 
low the promontory and within the hollow of the sacrum. To the 
right, and within the broad ligament, a marked thickening was readily 
felt. There was some descent and the cervix was lacerated. The 
fundus was perceptibly enlarged, presenting all the characteristic 
signs of early pregnancy. In spite of my endeavors to alleviate the 
pain and elevate the fundus uteri by local treatment, the pains con- 
tinued to increase and finally terminated in abortion in July, the pa- 
tient being unattended by any one. Some weeks later she returned to 
me with a marked endometritis and a boggy exudation in both broad 
ligaments. I again placed her on local treatment of glycerin tam- 
pons, occasionally painting the vaginal vault with tincture of iodine. 
In the following October I curetted thoroughly with the sharp curette, 
packing the uterine cavity with iodoform gauze, endeavoring at the 
same time to restore the uterus to its normal position, but without 
avail. Menstruation, however became normal, lasting only four 
days, and the exudation cleared up considerably. In January, 1888, 
the existence of early pregnancy was again discovered and the pos- 
terior adhesions were noticeably relaxing. Iodoform gauze saturated 
in glycerin was substituted for the cotton tampon and packed about 
the uterus, putting the adhesions on the stretch, and were allowed to 
remain in position three to six days with marked benefit. After two 
weeks’ treatment, a Thomas-Cutter pessary was employed, with most 
excellent results. The adhesions separated sufficiently to allow the 
fundus uteri to become disengaged and be lifted out from under the 
promontory of the sacrum, and a Munde bulb pessary was substituted 
to hold it in position. 
At the time of separation of the adhesions, there were manifesta- Treatment of a Retro-Displaced Adherent Uterus. 
3 
tions of expulsive pains and a slight sanguineous discharge, which was 
controlled easily by the fluid extract of viburnum prunifolium in 3 ss. 
doses, repeated hourly. 
The pessary was removed at the end of the fourth month of gesta- 
tion, as its employment was no longer required, and pregnancy pro- 
gressed normally and uninterrupted to its end. 
On September 14, 1888, the patient was delivered of a healthy 
child of about nine pounds and a half in weight, and convalescence 
was normal. 
Twelve days after delivery the uterus was found retroverted and 
was replaced, being held in position by the bulb pessary formerly 
used. After the expiration of six months treatment was found wholly 
unnecessary, as the uterine supports proved themselves amply suffi- 
cient, to retain the uterus in its normal position. 
I have attended the patient in four confinements since that time, 
and there is not a trace of the old trouble remaining nor the slightest 
tendency to retro-displacement. 
Case II.—Mrs. F. consulted me in the summer of 1888. She was 
thirty-one years old ; had been married twelve years, giving birth to 
three children which were born, during the first five years of her 
married life. The last delivery, for some unknown reason, was a still- 
birth, resulting in ill-health and uterine disease, associated with 
sterility, for seven consecutive years. Menstruation had been regu- 
lar every thirty-two days, varying in amount, but later only a scanty 
flow for one or two days. She complained of constant pains in the 
back and in both sides of the abdomen with impairment of locomo- 
tion. Constipation sometimes for a week, attended by severe bear- 
ing-down pain ; severe frontal headaches, with occasional epileptiform 
convulsions when overtaxed mentally or physically. 
An examination revealed a sharp retroflexed uterus with firm pos- 
terior adhesions ; the ovaries were laterally displaced and enlarged, 
imbedded in an exudation, the right one being perceptibly the larger. 
The fundus uteri presented below the level of the cervical portion, 
forcing down the posterior ad-de-sac and resting on the rectum in 
the hollow of the sacrum. The uterus was hyperplastic and firmly 
adherent. 
The employment of treatment twice a week, with glycerin tam- 
pons exerting pressure on the adhesions and exudates, soon produced 
evidence of improvement. The Thomas-Cutter pessary was substi- 
tuted as soon as the point of toleration was reached but had to be dis- 
carded soon after, on account of the distressing symptoms produced ; 4 
Herman L. Collyer, M. D. 
not, however, before it had rendered good service. A bulb pessary was 
substituted for it and held the uterus at the same level, which was 
just beneath the promontory of the sacrum. While wearing the ring 
in this condition the patient conceived. On February 16, 1889, the 
diagnosis of pregnancy at the seventh week was made; her last men- 
struation appearing December 14th. The physical signs in this case 
differed materially, in that the elastic enlargement was perceptibly 
noticeable in the left tubal cornu of the uterus, causing me to appre- 
hend a possible rupture of the Fallopian tube or of the structure of 
the uterus. At the tenth week of gestation, the uterus had assumed 
the natural symmetrical enlargement at the fundus so characteristic 
of pregnancy. 
As gestation advanced, the uterus developed more than usual in 
the antero-posterior diameter, accompanied by increasing pain which 
was controlled only partially by the fluid extract of viburnum. On 
several occasions, morphine was necessary to give relief until the fifth 
month had been reached ; whence the pains abated except at the ap- 
proach of what would have been a menstrual period. The pessary 
was removed soon after the fourth month and the vagina packed with 
iodoform gauze, which remained five days in place. 
As the uterus developed, the enlarged sensitive ovaries were very 
conspicuous on its sides, often giving rise to pains when accidentally 
pressed. 
Labor occurred September 21st, marred by an epileptic convul- 
sion ; otherwise normal. The convalescence was similar to that ot 
Case I. The pessary was found to be necessary for eight months 
after delivery ; a perfect cure resulting. 
Case III sought my advice for the first time in August, 1888. 
Mrs. K., thirty-two years old, married thirteen years, had had four 
children and five miscarriages ; the latter occurring in succession 
after the delivery of the last child nine years ago. Since that time, 
she had suffered pains continuously. The labor was complicated by 
sepsis, with a slow convalescence. Each miscarriage seemed to add 
more to her misery. The last occurred three years prior to her visit 
to me at the third month of gestation, as the previous ones had. The 
uterus was found retroverted and adherent posteriorly, with a large 
bilateral rent with everted lips ; there was also hyperplastic endome- 
tritis. The right ovary was slightly enlarged and there was lacera- 
tion of the perinaeum. 
After a few months’ treatment, preparatory to the repair of the 
gervix, the uterus was restored to the normal position and the patient, Treatment of a Retro-Displaced Adherent Uterus. 
5 
without my knowledge, entered one of our large hospitals for opera- 
tion. In March, 1891, two years and a half after the first call, she 
again consulted me with the following conditions : Laceration of the 
perinseum, retroflexion of the gravid uterus at the seventh week with 
posterior adhesions, enlargement of the right ovary with retro-lateral 
fixation of the tube and ovary and with evidences of the repaired 
cervix. 
Under the same restorative treatment she progressed in the same 
manner as did the previous cases, giving birth to a child, November 
25, 1891. Convalescence similar, except that an Albert Smith pessary 
seemed best suited to the case and it was discarded, after it had been 
worn six months, with no return of the displacement. 
The diagnosis of retro-displacement complicated by pregnancy is 
a simple matter to those familiar with uterine disease, but unfortu- 
nately that does not apply to all in the profession. But to every in- 
telligent doctor, with an ordinary “ tactus eruditus,” the conditions 
present, with few exceptions, may be clearly recognized. Any devia- 
tion backward of the uterus from its normal axis constitutes a retro- 
displacement. With these displacements, as a result of some prior 
inflammatory reaction, we have agglutinations of varying densities, 
which constitute adhesions. The principal cause, and probably the 
only one, is sepsis in some form ; the natural tendencies being to 
abortion but, as in other instances, exceptions occur here also. 
The diagnosis of adhesions is readily and positively proved by plac- 
ing the patient on the left side or in the genupectoral posture with an 
attempt to replace the uterus by one or two fingers per vaginatn. It 
will be found that, if adherent, the adjacent tissues posteriorly will 
move with it. 
In favorable cases, the ovarian regions are free from complication. 
It must be remembered that impaction of the uterus must not be 
confounded with this condition. The differential point in impaction 
is the posterior or sacro-uterine ligaments constricting the fundus of 
the uterus between them and, when the attempt is made to elevate 
the organ, the ligaments stand out prominently on either side. Bi- 
manually the uterus is felt between the palpating hand and the ex- 
amining finger, eliciting the characteristic diagnostic sign of preg- 
nancy, which is the elastic enlargement at the rundus uteri or its 
occurrence in either cornu, strengthened by collateral signs such as 
amenorrhoea, bluish discoloration about the cervix and the anterior 
vaginal wall, with acceleration of the pulse and the sympathetic morn- 
ing nausea and vomiting. It must not be overlooked that in cases of 6 
Herman L. Collyer, M. D. 
retro-displacement with adhesions, the development of the uterus 
is usually antero-posterior and lateral ; not until the uterus is lifted 
above the promontory, does elongation occur. In the early weeks of 
pregnancy, the cavity of the uterus lengthens, about a fourth of an 
inch in the first two months. Hegar’s sign, i. e., a softening of the 
lower uterine segment,* is absent in many cases, due to the hyper- 
plasia existing in many cases of displacement which softens very slowly. 
Ovarian complications are readily distinguished by palpation and 
by exclusion, and the same may be said of tube complications. I do 
not wish to infer that every case of retro-displacement of the adherent 
uterus complicated by pregnancy can be cured, but, I do say, every 
case unattended by treatment will terminate in one of two ways : the 
first and most frequent is by abortion, the second, though rare, by the 
uterus becoming incarcerated. I have examined one such case, which 
refused advice or treatment and was lost sight of. The pregnancy 
had reached the fourth month. 
The treatment of these cases depends largely upon the individual 
patient. Some tolerate more manipulations than others. This pe- 
culiarity, must be learned, in every case, by observation and trial. 
It is very necessary to treat the patient at least twice a week, placing 
her on the left side with the index finger, (one finger is sufficient) used 
per vaginatn and thus endeavoring to replace the uterus with as much 
force as the patient will tolerate comfortably; holding it in the newly 
obtained position with iodoform gauze, cotton or wool tampons, satu- 
rated in pure or borated glycerin, for one or more days. In course 
of time the patient becomes tolerant of sufficient interference to em- 
ploy the Thomas-Cutter pessary which acts mechanically in the same 
manner as do the tampons, except more effectually and forcibly, to- 
ward separating the adhesions and restoring the uterus to a normal 
position. 
The length of time necessary to continue its use varies in each 
case; usually from one, to six weeks is sufficient. As soon as the 
object is obtained for which the lever pessary is designed ; it may be 
replaced with one of the internal pessaries, as the needs of the case 
seem to demand, which must be worn until such time that the uterus 
will be found too large to return to its retro-displacement. The end 
of the fourth month will be found, sufficient to insure safety against 
such a return in all cases. 
In conjunction with the local and mechanical treatment, internal 
* American System of Gynaecology, Mann, of Buffalo, Treatment of a Retro-Displaced Adherent Uterus. 
7 
medication is of great importance to relieve the distressing symptoms 
arising from the physiological increase of the uterus, and the necessary 
devices for separating the adhesions. 
The agglutinations in this complication seem to absorb or to sepa- 
rate more readily ; possibly due to the fact that the pregnant condi- 
tion may act a part, toward inducing absorption, aside, from its me- 
chanical influence by the physiological increasing growth. 
The nerve sedatives and carminatives display their influence and 
should be employed from the beginning, as soon as symptoms de- 
velop. The most valuable seem to be the viburnum preparations. 
Codeine and morphine should only be resorted to when other things 
fail to relieve pain. 
In some cases, the iodides are followed by marked improvement. 
All cases are much benefited by the judicious employment of the 
chalybeates with strychnine in conjunction with laxatives. Gentle ex- 
ercise in the open air is of the greatest importance ; in fact, anything 
which tends to improve the general tone of the patient’s physical and 
mental condition. 
log East Fifty-fourth Street.