THE TREATMENT OF POSTERIOR DISPLACEMENTS 
OF THE UTERUS. 
By H. J. BOLDT, M.D., 
Professor of Gynecology in the New York Post-Graduate Medical School and Hospital; 
Gynecologist to St. Mark’s Hospital and to the German Poliklinik ; 
Consulting Gynecologist to Betli-Israel Hospital. 
New York. The Treatment of Posterior Displacements 
of the Uterus. 
The treatment of posterior displacements of the uterus has received so 
much attention from the hands of writers, that it is almost necessary to offer 
an apology if one intends to say something more on this subject, especially 
when there is nothing new to be offered. My excuse, however, is one which I 
hope will make the transgression on the space of a medical journal pardon- 
able—namely, to attempt to prevent the family physician to become imbued 
with the idea that a posterior displacement so frequently requires an operation 
as one would be led to believe from the writings of some authors, and also to 
prevent the'belief to become general that vaginal fixation is the operation for 
this condition, and that operation should consist of the vaginal fixation of 
the uterus. 
I am led to write a few remarks on the subject by a well written article 
by Dr. Wakefield, in the New York Medical Record for June 19th. I regret very 
much that the doctor did not give the references for the following statement: 
“We are told by nearly all writers that before taking into consideration any 
operative procedure for the cure of this affection, we should, if possible, place 
the organ in its normal position by bimanual manipulation and retain it there 
for several months by means of pessaries or tampons, until the round lig- 
aments and other supports have had a chance to regain their natural tonicity. 
We are then told that should this fail we are justified in considering some 
operative treatment for the patient’s relief, providing the symptoms are 
sufficiently troublesome to warrant us in subjecting her to an operation.” 
He says that he cannot agree with such advice. Neither can I, nor any one 
else who understands anything about gynecology. Neither am I acquainted 
with any exponent of this department who would make this statement with 
the advancement which gynecology has attained during the past few years. 
A patient who has an uncomplicated posterior displacement, if the uterus can 
be retained in anteposition by means of a properly adjusted pessary will give 
no symptoms due to the former posterior displacement, and consequently an 
operation is never indicated, except when the patient’s mind is in such con- 
dition that the mere fact of her knowing that she wears a uterine supporter 
has a deleterious influence on her. The pessary itself, if it be one properly 
selected, causes no inconvenience whatever; the patient, in fact, should not be 
aware of her wearing one, except by the knowledge that she feels better. The 
simple posterior displacements of congenital origin, if at all productive of 
symptoms, will hardly ever be benefitted by the use of a pessary, because the 
body of the uterus will usually flex over the upper bar; this is also the case 
in many posterior displacements of multipara. I do not wish to discuss the 
anatomical reasons for this, but simply limit myself to clinical facts. In such 
cases there is no operation in gynecology which is crowned with more satis- 
factory, nay, with such good results, as shortening the round ligaments, if 
performed correctly, and this I say not from belief, from hearsay, or from 
having seen some of my colleagues do the operation, but from practical exper- 
ience in a large number of cases upon whom I performed the operation and in 
which I could follow the results for a long period, in none less than one year. 
From the above it is obvious, that not the operation or the respective form of treatment plays the important role in the first instance, but the indication for 
any one variety of treatment stands foremost. I have not heretofore written 
a word in favor of shortening the round ligaments, although I began doing the 
operation ten years ago, but I feel myself called upon to defend it now, since 
my experience is sufficiently large and dates back long enough. It appears to 
me that those who have so many objections to it seemingly have had insuffi- 
cient personal experience with it. I have yet to find an operator, who having 
performed it fifty or more times, utter a word of adverse criticism against it. 
I admit that some of the objections enumerated by the opposing writers are 
correct; the ligaments at times are difficult to find, yet in no instance have I 
failed to find them. They are not infrequently thin at the terminal ends, but 
the increase in size as we approach the uterine cornu is sufficient in all cases 
to keep the uterus permanently anteposed if the shortening is made to that 
extent. Sometimes a ligament when thin and adherent in the inguinal canal 
will tear when making traction upon it, but this so seldom occurs that we 
should not take such occasional accident into account; in my experience it 
has happened either four or five times, and in all cases except one instance I 
have been able to again find the ligament and shorten it as desired, and in 
this one case the result with shortening only the one ligament was all that 
could be desired, as far as the position of the uterus and the complete relief 
of all symptoms were concerned. When suppuration occurs it is invariably 
the fault of some error in the technique or the material used. Wounding of 
the femoral artery, as mentioned by Dr. Wakefield, can not occur; “unskilled-’ 
hands have no business to do this or any other operation, and the assistant 
mentioned by the doctor, as having been cited by Dr. Munde, who was about 
to tie off the artery mistaking it for the ligament, should not have been 
entrusted with work which requires a full knowledge of the anatomy of parts 
upon which an operation is contemplated. The only objection to which I 
concede as being valid, is that occasionally a hernia may result in those cases 
who have had the misfortune, owing to some oversight or error, to have more 
or less suppuration in the wound. It is said by some of the adversaries to 
this operation that it is successful in only part of the cases. This assertion I 
most emphatically oppose. I have stated above, that the secret of treatment 
of any kind is to know the proper indication for applying the respective ther- 
apeutic agent. If the operator expects to get a good result from this operation 
in a case of adherent retro-displacement, although the adhesions be slight, 
unless they be first thoroughly and completely separated, he will be dis- 
appointed ; the same holds good if small fibromata are present in the uterus, 
if they are not enucleated, or if procidentia, even if only of the first degree, 
is present. In short it is applicable only in cases of uncomplicated posterior 
displacement, and in such the anatomical result is excellent in every instance, 
however, with the proviso that the operator knows his business. 
Ventral fixation or hysterorrhaphy have been brought in comparison with 
the Adam-Alexander operation by various writers. There is no comparison 
between the two; anyone who will perform hysterorraphy on the indication 
which I have given for shortening the round ligaments, is in my opinion guilty 
of exercising very poor judgment, to say the least. I have been guilty of such 
error in former years before having had experience with a better operation, 
and I openly confess my mistake. At the present time no one has the right 
to open the abdomen for the sole purpose of ventro—fixating a freely mobile 
uterus. It is only indicated when the uterus is fixed by such dense adhesions 
that these cannot be severed by forcible rapid massage according to B. S. 
Schultze, or the ordinary pelvic massage according to Thure Brandt, as described by me in the American Journal of Obstetrics in 1889. Even in a 
number of instances with such dense adhesions, I have lately opened the 
posterior cul-de-sac and severed the adhesion from below with my fingers and 
scissors, and then finding that the adnexa were not diseased too much, so that 
self-repair could take place, I shortened the ligaments with most gratifying 
ultimate results. The incision behind the uterus must be made sufficiently 
large to allow the operator to work freely with his fingers, and after all 
adhesions have been completely torn or cut, after which it can again be 
closed, only leaving sufficient opening for a drain, which is left in the peritoneal 
cavity for twenty-four hours, to give exit for the sanguinous oozing from the 
torn and cut adhesions. I also consider ventral fixation indicated in a limited 
number of patients having procidentia with or without backward displace- 
ment. It is self understood that if the cervix or the perineum requires repair, 
that this should also be done at the same time. It may be permissible for me 
to say here that I am astonished to sometimes see the citation of a very large 
number of operations, in a comparatively short space of time, for the relief of 
simple posterior displacement, by a single operator. It is obvious to me that 
such operator is either not possessed with good judgment, or that he is not 
conscientious, or perhaps afflicted with “ operating fever,” because as I have 
already stated, only a moderate percentum require operation at all, and con- 
sidering that I personally see not less than 300 to 350 such cases annually in a 
clientele of more than 3,500 new patients in my clinics and private practice, 
and comparing this number with those upon whom I find an actual necessity 
for operation, I believe that I am justified in making the above assertion. 
A word now as to vaginal fixation, that operation for which a number of 
writers have spoken so favorably, including myself at a former time. Seven 
years ago I began to do the operation from which the latter modifications 
arose, namely the utero-vaginal ligaturing according to Schuecking. In 1891 
I read a short paper on the subject before the New York State Medical 
Society. In 1892 I did a modified operation, and was the first also to do the 
vaginal fixation as practiced by Duehrssen. This was some time before the 
operator mentioned published his procedure. My knowledge was due to the 
kindness of one of the internes at the Charite hospital in Berlin, who wrote 
me a very graphic description of the work. All vaginal methods have, how- 
ever, been given up by me, because the facts were made too convincing that 
the ultimate outcome is bad. Vaginal fixation is a dangerous operation for 
women who are liable to become pregnant again; I will not cite details, the 
literature is teeming with the citation of examples. The only vaginal operation 
which I can concede to for the cure of uncomplicated retroflexion or version, 
is the shortening of the round ligaments by this route; but why should we 
constantly seek something new when the old and well tried method has given 
such satisfactory results to all who have mastered it ? 
If, however, one has pelvic work to do per vaginam in which it is 
necessary to open the peritoneal cavity, as the removal of an ovarian cyst, or 
an exploratory vaginal section, and he finds it necessary to correct a displaced 
uterus, let the attachment be made to the bladder peritoneum and not to the 
vagina, which is much safer in its result for the patient should she subse- 
quently become pregnant. 
DENVER MEDICAL TIMES PRINT, DENVER, COLO.