[Reprinted from the New York Journal of Gynaecology and Obstetrics 
for March, 1894. 
A STUDY OF TWENTY-TWO CASES OF DUDLEY'S 
OPERATION FOR PATHOLOGICAL ANTEFLEXION* 
By Leroy Broun, M. D., 
Assistant Surgeon, Woman's Hospital. 
In the American Journal of Obstetrics for February, 1891, Dr. E. 
C. Dudley describes an operation for " straightening the anteflexed 
uterus." 
In January of that year, by invitation, Dr. Dudley did this opera- 
tion before a collection of guests at the Woman's Hospital. 
The patients were examined by some of those present before the 
operation and after, the common consensus being that the uterus 
was straightened to a great extent, and the canal changed to one of a 
natural curve. 
This operation consists essentially in first thoroughly divulsing and 
■curetting the uterus, dividing the posterior lip of the cervix down to 
and below its vaginal junction, bringing the apices of the divided lip 
into the angle of the division, thus bending each portion on itself, and 
fixing them in this position with sutures. 
The exit of the uterine canal is thus moved backward into the an- 
gle of the division, and at the same time the fundus seems to rise in 
the pelvis. 
Originally, in addition, a portion was removed from the anterior 
lip and the raw surface afterward brought together from side to side 
by sutures. This has since been omitted as being of no material ad- 
vantage. 
As far as I can learn, this operation has not been adopted by gynae- 
cologists in general, and only in part by those of the Woman's Hos- 
pital. I have been able to collect thirty-three cases, and these have 
chiefly been taken from the histories of the above hospital. 
The majority of these patients were known to me, and many of 
them I have seen from time to time; hence it is that I feel especially 
* Read before the New York Obstetrical Society, January 2, 1894. 2 
Leroy Broun, M. D. 
prepared to report on their progress and the final outcome of the 
work. 
As usual with hospital patients, I have not been able to keep up 
with all. Of the twenty-two brought together in this paper, I have, 
with few exceptions, either seen or heard of them during the last few 
months. Concerning those who have not been reached in this way, I 
have been well informed as to their condition before losing sight of 
them. 
For the convenience of study I have divided the patients whose 
operations I report into three classes: Those who have been entirely 
relieved of symptoms, those who have been partly so, and those who 
have received no benefit. 
Under the head of entire relief from all symptoms there are fifteen 
patients. Three received only partial benefit and foilr no relief in 
any way. 
With many the relief afforded by the operation has been so marked 
that I wish to give in detail some of these cases. 
One, a Mrs. R. M., presented herself at the hospital during Decem- 
ber, 1890, complaining of severe dysmenorrhoea and menorrhagia, 
together with menstrual and intermenstrual pelvic pains of such 
severity as to incapacitate her for any hard work or walking any dis- 
tance. The local condition was an acute pathological anteflexion. 
After the operation she had, unfortunately, a considerable rise of 
temperature, with peri-uterine infiltration. In the course of time this 
cleared up, and in April of 1891 I was told by her that she was never 
as well in her life, menstruating without pain, free from all pelvic 
pains, and being able to walk any distance. I heard from her later 
on, with the same report. 
Another, Mrs. M. A., of the hospital, November, 1890, under Dr. 
B. Emmet, gives the same history of distress. The local condition 
was one of a pathological anteflexion, with a remarkably profuse muco- 
purulent cervical discharge. Since leaving the hospital she has been 
seen by me at different times, the uniform report being no menstrual 
or pelvic pains and an ability to do all work. The improved drain- 
age had had no effect on the cervical discharge. 
Again, Mrs. L. B., May, 1891, presented herself in Dr. Cleveland's 
service, having at menstruation severe headaches with vomiting, to- 
gether with excessive pain over both sides. This patient had been for 
the same trouble divulsed and curetted in January previous by one of 
our prominent gynaecologists, without permanent relief. When last 
heard from, about a year afterward, she was relieved of all symptoms Dudley's Operation for Pathological Anteflexion. 
3 
and in perfect health. She has since been married and moved from 
the city. 
Miss M. A., May, 1891, and Miss B. C., February, 1893, both of 
Dr. Cleveland's service, gave similar histories of nausea, cephalalgia, 
dysmenorrhoea, and intermenstrual pains. Both were and are at the 
present date entirely relieved, having gained weight and being in per- 
fect health. 
When this operation was first suggested it was hoped that it might 
prove a means of treating sterility, the local condition being an acute 
anteflexion. This has not yielded uniform results, nor can we expect 
any operation to do so-for there are too many conditions involved 
in the bringing about of this state. Two such patients I have found, 
Mrs. S. H. R., May, 1891, and Mrs. S. M., also May, 1891, the former 
of Dr. Cleveland's service, the latter kindly furnished me by Dr. 
Baldwin. Both were sterile ; one became pregnant three months 
after the operation, and the other, who also complained of cephalalgia 
and pelvic pains, was at once relieved and a year and a half after- 
ward was reported as three and a half months pregnant. 
With this satisfactory result before us, I ask your attention in 
considering those with whom the operation has not yielded such a 
happy return. 
Three received only partial benefit; one was relieved of the dys- 
menorrhoea, yet the pain persisted on the left side. An examination 
in December last gave the uterus in normal curve and a tender ovary 
to the left. 
With another the operation was done in the hopes of relieving 
both the anteflexion and an engorged ovary and tube to the left. 
This proved to be more than catarrhal, and eventually she may be 
forced to a coeliotomy. 
With another the internal os had, after the operation, tightly con- 
tracted, the patient being miserably nervous and having pelvic 
pains. 
Of the four who received no benefit, one I have heard from only 
by letter; another, I am told, has an aggravated varicose condition 
about the vulva and inner part of the thighs. 
With another the operation was done for hysteria in the hope of 
affording some relief, there being a contracted internal os. 
Another received no early relief from the cephalalgia and nervous- 
ness. She was afterward again divulsed and curetted by a different 
operator, who kept the uterus packed with gauze for two weeks. 
She has since been relieved of symptoms, though failing to become 4 
Leroy Broun, M. D. 
pregnant. This case, I am told by the physician doing the second 
operation, was in no way primarily satisfactory. 
I feel inclined to attribute this failure to some cause with which I 
am not at present acquainted-possibly a subsequent contraction of 
a tight internal os, for ten months after the first operation, in looking 
her up, I found she had lately moved but was told by her friends that 
she had been entirely relieved. 
Let us put aside the case of hysteria and of varicose veins and we 
are left with twenty cases, of which fifteen (seventy-five per cent.) have 
reported a complete cessation of all symptoms for relief from which 
the operation was done. 
Extending, as almost all do, over a period of from one to three 
years, these results should be a fair test of the value of the operation 
as a remedial measure. 
Some have stated that such a procedure is too extensive for such 
a minor condition of affairs and insist on ascribing to it a danger 
which is more imaginary than otherwise. 
Of the thirty-three cases collected, only two have been interrupted 
in their recovery by a rise of temperature. Of these, one should not 
have been operated on and the rise of temperature in the other was 
undoubtedly due to some sepsis introduced at the time of the opera- 
tion. The recovery of the others has been as even as that from an 
ordinary trachelorrhaphy or curetting. 
When we review the usual methods of treating a pathologically 
anteflxed uterus, I know of none that promises as much as this. A 
simple divulsion and curetting does not suffice, for it is only a ques- 
tion of time when the uterus will lapse into the same condition as 
before the operation. The addition of uterine gauze packing goes 
further and is more radical, yet the anteflexion will still exist and in 
time reproduce the same symptoms. 
The use of the stem, so commonly in vogue, does act well, yet it 
is a thing that demands constant watching. It is this constant super- 
vision that can not help engendering in the patient a mental condi- 
tion equal to, if not worse than, the local trouble. 
With a personal experience of five of these operations and the 
knowledge of the progress of others, I feel cohvinced that we can ob- 
tain from it excellent results. By it the normal drainage function of 
the uterus is restored. In the majority of cases the relief attending 
this restoration of drainage is gradual, excepting the dysmenorrhoea. 
It is customary for the patient to note her improvement from 
month to month. Again, it is not at all uncommon to have a history Dudley s Operation for Pathological Anteflexion. 
5 
of a profuse menstruation occurring for a few months after the opera- 
tion, which will decrease to one of normal without interference. 
Where there is any extensive change in the annexa, it is too much 
to ask of this operation to expect symptomatic relief from such. 
Yet where there are the side pains, which often accompany a uterus 
with a tender endometrium and anteflexed, this restoration to the 
uterus of its drainage power will give relief. 
In seeing, from time to time, some of my own patients and those 
of others, I have been impressed with the importance of accentuating 
a few of the operative steps. 
1. In general, the posterior lip should be divided down to and 
slightly below its vaginal junction ; anything short of this is not usu- 
ally sufficient. Entering the peritoneal cavity is an accident and of 
course to be avoided ; yet if it should happen, no complication ought 
to arise with necessary care. 
2. If the internal os is tightly constricted, in addition to being di- 
vulsed, I think it should be incised posteriorly, the incision being a 
continuation of that of the posterior lip. Dr. Dudley in a way sug- 
gests this when he says " the incision is somewhat deepened by means 
of a scalpel, especially on the side of the cervical canal." 
When this is neglected, the internal os may, if originally con- 
stricted, again partly or entirely contract within a few months and a 
return of some of the symptoms result. 
This I have seen happen in a few of the cases coming under my 
notice. When there is a tightly constricted internal os, with a large 
uterine body, I believe it will be of advantage to pack the uterus with 
gauze, in addition to the regular Dudley operation. 
Before closing this paper with the appended tables I wish to em- 
phasize that all of the operations have been done only when there 
were well-developed uteri, with a pathological anteflexion. 6 
Leroy Broun, M. D. 
- 
Name. 
Date of 
operation. 
Operator. 
Symptoms calling for 
operation. 
Relief from 
dysmeiiorrhoea. 
Relief from reflex nervous- 
ness and pelvic pains. 
Notes. 
Mrs. R. M. 
Miss C. J. 
December 
28, 1890. 
November, 
1890. 
Dr. B. Emmet. 
Dr. Cleveland. 
Severe dysmenorrhoea, 
with menorrhagia ; 
general pelvic pains 
preventing walking. 
Dysmenorrhoea, with 
menorrhagia and re- 
Complete. 
Complete. 
Complete; can now walk 
any distance without 
inconvenience. 
Relieved of nervous- 
ness. 
Seen last in the latter 
part of 1891. 
Seen last early in 1893. 
flex nervousness. 
Mrs. M. Q. 
November, 
1890.' 
Dr. B. Emmet. 
Dysmenorrhoea, with 
severe pain over both 
sides, incapacitating 
her for daily work. 
Complete. 
Relieved of pains 
throughout pelvis. 
When seen last in the 
early part of 1892 the 
muco - purulent dis- 
charge still profuse, 
otherwise good. 
Mrs. S. H. R. 
Miss L. B. 
May, 1891. 
May, 1891. 
Dr. Cleveland. 
Dr. Cleveland. 
Sterility. 
Headaches and vomit- 
Complete. 
Entire cessation ofceph- 
Became pregnant soon 
after leaving hospital. 
Last heard from in the 
ing at periods ; severe 
pains over both sides. 
alalgia and vomiting, 
also of pains over 
sides. 
latter part of 1892. 
This patient had been 
previously divulsed 
and curetted during 
the latter part of 1890 
without permanent 
relief. 
Miss M. A. 
Miss B. C. 
January, 
1891. 
February, 
i893- 
Dr. Cleveland. 
Dr. Cleveland. 
Dysmenorrhoea, cepha- 
lalgia, and nausea at 
periods. 
Dysmenorrhoea, with 
pain over sides and 
back. 
Complete. 
Complete. 
Cessation of nausea and 
vomiting at periods. 
Cessation entirely of 
1 pelvic pains. 
Last heard from in De- 
cember, 1891. 
Last seen in December, 
1893- 
Patients entirely Relieved. Dudley's Operation for Pathological Anteflexion. 
7 
Name. 
Date of 
operation. 
Operator. 
Symptoms calling for 
operation. 
Relief from 
dysmenorrhcea. 
Relief from reflex nervous- 
ness and pelvic pains. 
Notes. 
Miss G. L. M. 
June, 1893. 
Dr. Cleveland. 
Dysmenorrhcea, with 
pain over left side 
during period. 
Complete. 
No pains over sides. 
Heard from in Decem- 
ber, 1893. 
Mrs. S. M. 
May, 1891. 
Dr. Baldwin. 
Sterility ; cephalalgia, 
with pelvic pains. 
Relieved at once of the 
cephalalgia and pelvic 
pains. 
A year and a half after- 
ward was reported 
three and a half 
months pregnant. 
Miss Z. D. 
Dr. Cleveland. 
Dysmenorrhcea; pains 
over side and back. 
Complete. 
Relieved. 
Miss M. 
June, 1891. 
Dr. Cleveland. 
Dysmenorrhcea ; pain 
over both sides and 
severe backache. 
Not relieved for 
some months; af- 
ter this a marked 
monthly improve- 
ment ; now com- 
plete. 
Now an entire cessation 
of all symptoms ex- 
cepting a right ova- 
rian pain at time of 
menstruation. 
Heard from in Decem- 
ber, 1893. 
Miss L. 
July, 1893. 
Dr. Broun. 
Dysmenorrhcea ; reflex 
nervousness. 
Complete. 
Complete. 
Last seen in October, 
i893- 
Miss L. N. 
May, 1891. 
Dr. Cleveland. 
Severe dysmenorrhcea, 
with pain over both 
sides. 
Not completely at 
first ; at present 
entirely so, as 
stated by a friend. 
Complete; gained flesh. 
Has occasional pains 
over a prolapsed left 
ovary. 
Miss E. E. 
June, 1893. 
Dr. Cleveland. 
Dysmenorrhcea, with 
pain over sides. 
At present writing 
almost complete. 
Complete. 
Miss B. 
September, 
i893- 
Dr. Broun. 
Irregular and scanty 
menstruation. Dys- 
menorrhcea ; constant 
pain over left side, 
Menstruation now 
regular and pain- 
less. 
Pain over left side not 
present since the op- 
eration. 
In addition to the usual 
operation, the uterus 
was packed for four 
days with gauze. 
Patients entirely Relieved.-(Continued?) 8 
Leroy Broun, M. D. 
Mrs. L. 
Mrs. F. W. P. 
Dec., 1891. 
March, 
1893. 
Dr. Winchester. 
Dr. Cleveland. 
Severe dysmenorrhcea. 
Dysmenorrhoea, with 
pelvic pains of bear- 
ing-down character. 
No relief. 
No relief. 
No relief. 
Am told by the operator 
that patient has an 
extensive varicose con- 
dition over labia and 
Miss L. 
April, 1892. 
Dr. Haskins. 
Hysteria ; contracted 
internal os. 
groins. 
Mrs. McG. 
September, 
1890. 
Dr. Dudley. 
Cephalalgia ; sterility 
and nervousness; dys- 
menorrhcea. 
No relief. 
Some time after was 
again divulsed and 
curetted with constant 
uterine gauze packing 
for two weeks, when 
patient was relieved 
of all symptoms. The 
operator tells me the 
canal was of a normal 
curve. 
Name. 
Date of 
operation. 
Operator. 
Symptoms calling for 
operation. 
Relief from 
dysmenorrhoea. 
Relief from reflex nervous- 
ness and pelvic pains. 
Notes. 
Mrs. S. H. 
May, 1892. 
Dr. Anderson. 
Dystnenorrhcea ; pains 
Complete. 
Pain over left side con- 
Seen last December, 
over left side. 
tinues. 
1893 ; local condition 
excellent ; prolapsed 
left ovary. 
Mrs. G. 
August, 
Dr. Broun. 
Dysmenorrhoea ; severe 
Pain greatly dimin- 
Negative. 
When last seen, in De- 
cember, had gained 
1893. 
pain over both sides. 
ished, and at times 
almost none. 
weight and improved 
Mrs. E. G. 
May, 1891. 
Dr. Cleveland. 
Dysmenorrhoea, cepha- 
Complete. 
Complete relief from 
Seen last December, 
lalgia, pains over both 
sides, and intensely 
cephalalgia ; nervous- 
1893; internal os 
ness greater than be- 
contracted. 
nervous. 
fore operation. 
Patients not Relieved. 
Patients partially Relieved.