The Present Treatment of Uterine 
I 
Displacements. 
by 
Paul F. Munde, M. D., 
Professor of Gynaecology at the New York Polyclinic 
and at Dartmouth College; Gynaecologist to 
Mt. Sinai Hospital. 
REPRINTED FROM THE 
American Gynaecological and Obstetrical Journal 
for June, 1895. [Reprinted from the American Gynaecological and Obstetrical Journal 
for June, 1895.] 
THE PRESENT TREATMENT OF UTERINE DISPLACE- 
MENTS.* 
Professor of Gynaecology at the New York Polyclinic and at Dartmouth College ; Gynae- 
cologist to Mt. Sinai Hospital. 
Paul F. Munde, M. D., 
Unquestionably the greatest progress in gynaecological therapeu- 
tics during the last ten or fifteen years has been made in the domain 
of diseases of the uterine appendages and tumors of the uterus. The 
most brilliant achievements of modern surgery have been gained in 
either removing diseased appendages, ovarian tumors, or the uterus 
together with its fibrous neoplasms ; and to emulate these successes 
of the leaders in this province of surgery is the great aim of the ma- 
jority of our young gynaecologists. The proceedings of our medical 
societies and our medical journals teem with reports of successful or 
new operations of this kind, and naturally the interest of the whole pro- 
fession is attracted more to this class of cases than to the comparatively 
commonplace ailments which I propose to discuss in this paper. And 
still I think I am justified in calling the attention of this Society, and 
through it of the profession generally, to the changes which have 
taken place during the last decade in the views held and the prac- 
tices followed by gynsecologists as to the significance and treatment 
of displacements of the uterus. 
Although not of vital importance, like the majority of the diseases 
of the uterus and appendages referred to, displacements of the uterus 
are still so frequent and so often productive of evil influences upon 
the women afflicted with them that they form not only a very common 
variety of cases for which the physician is consulted, but also call for 
* Read before the American Gynaeological Society, Twentieth Annual Meeting, 
May 28, 1895. 
Copyright, 1895, by J. D. Emmet and A. H. Buckmaster. 2 
Paul F. Munde, M. D. 
positive and effective treatment. In former years a very much 
greater importance was attached to these displacements of the uterus 
than is now the case. In the older books, even down to editions 
issued within the last four or five years, we find many pages devoted 
to the setiology, pathology, symptoms, and treatment of uterine dis- 
placements, the majority of these symptoms being attributed entirely 
to the malposition of the organ, and the treatment being usually di- 
rected chiefly to its restoration and maintenance in the normal posi- 
tion. This statement applies not only to displacements backward 
and downward, but with equal force to those forward-that is, ante- 
flexion and anteversion-for the treatment and cure of which innumer- 
able complicated contrivances have been devised. Thus in Dr. 
Thomas' well-known and at that time deservedly popular Text-book 
on Diseases of Women, fifth edition, 1880, we find given the following 
symptoms of anteflexion : '' Pain over epigastrium and in groins and 
back, irritable bladder, leucorrhcea, dysmenorrhoea, sterility, nervous 
disturbance and despondency, pain on locomotion, menorrhagia, tend- 
ency to abortion, pain on sexual intercourse, pelvic neuralgia, sense of 
depression at the epigastrium " ; besides other more or less obscure 
reflex signs. Under anteversion we find a much smaller array of 
symptoms, the chief of which are dysmenorrhoea and sterility pro- 
duced by the pressure of the os against the posterior vaginal wall, 
irritable bladder, rectal irritation and tenesmus, further, inability to 
walk. At that time we all, relying upon this great authority, blindly 
accepted his statements without using our own judgment as to 
whether or not all these symptoms were actually due to the displace- 
ment and distortion of the uterus. As a result of this supposed train 
of agonizing sufferings we find in the edition mentioned as well as in 
those preceding it descriptions and cuts of a large number of exceed- 
ingly complicated vaginal pessaries devised solely for the purpose of 
lifting up and straightening out the anteverted or anteflexed uterus. 
Dr. Thomas himself has told me that he has spent many a sleepless 
night working out the problems of these mechanical contrivances, 
and where now are all these wonderful appliances ? Cast aside, hid- 
den away in drawers which are scarcely ever opened, or else con- 
signed to the ash barrel. I use this strong language only to empha- 
size the change which has taken place in our views during the last 
fifteen years-yes, even during the last five years-on this subject of 
the significance and pathological importance of anterior displace- 
ments of the uterus. It is chiefly in regard to these anterior displace- 
ments that so great a change has taken place in our recent opinions The Present Treatment of Uterine Displacements. 
3 
and practice. Increasing experience has taught us that the symp- 
toms of anteflexion, even of the major degrees, are practically nil; 
that an anteflexion of the third degree, for instance, manifests its 
presence in the virgin and nulliparous woman, if indeed it does so at 
all, by dysmenorrhcea, in the married woman by sterility, and even in 
the major degrees of anteflexion these results are very frequently 
absent. The minor degrees produce practically no symptoms what- 
ever. In anteversion such symptoms as present themselves are 
scarcely ever due to the anteversion itself, which is by far a less fre- 
quent displacement than was formerly supposed. It is true that 
occasionally we meet with an anteversion of such a degree, pure and 
uncomplicated, that the fundus rests directly upon the symphysis 
pubis and the cervix is tilted high up into the excavation of the sacrum. 
Then of course distressing pressure on the bladder and perhaps more 
or less irritation of the upper portion of the rectum are produced by 
the displacement; but I really do not believe that I have seen more 
than two or three such extreme cases of anteversion in the last fifteen 
years. 
Whenever there are any decided local symptoms caused by an 
anteversion we may be sure that a downward displacement of the 
organ-that is, a prolapsus of the first degree-is associated with it, 
and this prolapsus is the element in the case to which the symptoms 
must be attributed. If we find a woman with anteversion and prolap- 
sus in the first degree unable to walk or remain long on her feet it 
must be our object to elevate the whole uterus, together with as much 
of the vaginal walls as may also be prolapsed, rather than to merely 
attempt to lift the fundus away from the bladder. Pessaries for ante- 
flexion and anteversion are therefore now but rarely used. I have 
hundreds of them, mostly of the types devised by Dr. Thomas, lying 
stowed away in drawers in my office which are never opened except 
when I wish to demonstrate to my students the instruments which 
formerly were used and which are now practically obsolete. 
For anteflexion I may say that I never use nowadays an intravaginal 
supporter. None that I know of will elevate the anteflexed fundus 
properly, none will straighten out a sharply flexed uterine canal, and, 
as I have already mentioned, their only possible indication would be 
for either dysmenorrhcea or sterility, in neither of which instances 
they would be effectual. We relieve the dysmenorrhcea, and perhaps 
also the sterility, by dilating and straightening the uterine canal, keep- 
ing it straight by intra-uterine stems (if we approve of them, which I 
do not say that I do, except on rare occasions), and we keep the canal 4 
Paul F. Mundd, M. D. 
wide by repeated packing with sterilized or iodoformized gauze. In 
this way we cure dysmenorrhoea usually, sterility frequently, and that 
is all that the anteflexion calls for. 
In anteversion with prolapsus we confine ourselves chiefly to re- 
lieving the prolapsus, and this I have found to be best done, so 
far as any vaginal support is concerned, by the pessary devised by 
Dr. Eugene C. Gehrung, of St. Louis, with which 1 have many years' 
experience and without which I would really not know what to do in 
cases of anteversion and prolapsus and cystocele. It is in my estima- 
tion the only vaginal instrument which will keep up a prolapsed an- 
terior vaginal wall and bladder comfortably and without injury to the 
patient. 
Now, of course, the question will be asked, How is it that so 
astute an observer as Dr. Thomas and with him so many others in 
recent times were so misled as to attribute all the symptoms men- 
tioned to the anterior displacement ? It may not be easy to answer 
this question in a manner exactly satisfactory to everybody. To me 
the reason seems perfectly plain, since many of the symptoms com- 
plained of were due not to the version or flexion, but to the concomitant 
catarrhal conditions of the uterus and tubes, to chronic enlargement 
of the uterus, so-called hyperplasia, induced by the catarrh, or by 
subinvolution, and to a certain amount of relaxation of the uterine 
supports and pelvic floor. To the relief and cure of these concomi- 
tant conditions should have been directed and probably were also 
unconsciously directed in those days the theiapeutic efforts which 
benefited the patients. The pessaries played very little if any part in 
the improvement. 
What I have said of anterior displacements does not, however, 
apply by any means in an equal degree to the posterior and down- 
ward displacements of the uterus. While a uterus may be retro- 
verted or retroflexed to the first, second, and even third degree with- 
out producing any local or general symptoms whatever, this I hold to 
be rather the exception than the rule. A retroversion of the first de- 
gree,.in which the body of the uterus occupies the same horizontal 
plane as the vagina, or at least not more than an angle of 135°, pro- 
duces actually no symptoms whatever, except that possibly it may be a 
cause of sterility, especially if the external os is unusually small. A 
retroversion of the second degree also probably gives no special dis- 
comfort ; but a retroversion of the third degree in which the axis of 
the vagina and that of the uterus are at a right angle certainly does 
in the majority of instances exert pressure enough upon the lower The Present Treatment of Uterine Displacements. 
5 
portion of the rectum to interfere with free defecation and give rise 
to congestion of the rectum and haemorrhoids. If in each of these 
degrees of displacement a flexion exists instead of a version the 
amount of discomfort to the patient will be proportionately increased. 
If the displacement occurs in a virgin or in a nulliparous married 
woman the uterus is small and at least for a time no local or general 
effect follows the displacement. In course of time the ovaries, how- 
ever, very frequently follow the body of the uterus into the pelvic 
cavity and lie at the bottom of Douglas' pouch, where they may 
eventually become adherent and give rise to decided inconvenience. 
If the woman has borne children and the backward displacement is 
the result of parturition in consequence of relaxation of the pelvic 
supports and subinvolution of the uterus, I think it is the exception 
for such a displacement of a major degree to exist for a year or 
longer without giving rise to the usual symptoms of this condition, 
namely, bearing down, sensation of dropping and weight in the pelvis, 
sacralgia, inability to stand or walk any distance. Finally, I do not 
think that I am exaggerating when I say that it is the exception for 
any well-marked backward displacement of the uterus to exist with- 
out, after a lapse of time varying in different cases from several 
months to several years, a chronic enlargement of the organ coming 
on, together with chronic endometritis which materially increases the 
discomforts of the patient. In addition to the chronic congestion of 
the organ and the possible prolapse and adhesion of tne appendages, 
the fundus uteri very frequently in old cases becomes adherent to the 
opposing surface of Douglas' pouch, and reposition of the organ 
then becomes impossible except by a more or less complicated and 
dangerous operation. 
I should not have dilated so much upon these well-known symp- 
toms of backward displacement of the uterus had I not wished to 
compare the significance of this displacement with that anteriorly 
first referred to, and I found it necessary to do this in order to ex- 
plain why I consider retroversion and retroflexion to be pathological 
conditions usually requiring rectification. 
As little as I use vaginal supports for anterior displacements, so 
indispensable have I found such mechanical means-of a different 
variety, of course-for backward displacements. I know pessaries to 
be a necessary evil, and nevertheless I find myself obliged to employ 
them daily. It is simply the question in my mind of choosing be- 
tween two evils-either to allow the patient to go unrelieved, or else 
to elevate her uterus and keep it in position by a pessary. This, of 6 
Paul F. Mundt, M. D. 
course, does not cure her, but at least she is benefited so long as she 
wears the support. One might as well compel a patient with a lame 
leg to stay in bed or be confined to a chair for the want of a crutch 
or cane as to deprive a woman of the ability to walk and be comfort- 
able simply because one does not approve of pessaries. Of course 
they must be properly fitted and adapted to each individual case, and 
I am perfectly aware that this is not always easy and requires some 
practice and perseverance. As I have already stated, pessaries do 
not cure displacements ; at least, if they do, they do so only in a 
minority of cases. I see that Dr. Davenport, at the last meeting of 
this Society, agreed substantially with the views which I enunciated 
in a paper read before the International Medical Congress in London 
in 1881, on The Curability of Uterine Displacements, where I stated 
that I had cured by pessaries only 5.5 per cent (that is, seven out of 
one hundred and twenty-seven cases) of backward displacement. 
Davenport compiles the statistics of five observers (Munde, Lbhlein, 
Frankel, Sanger, Davenport), in all five hundred and eighty-four 
cases, with fifty-two cures by pessaries, or a little over eleven per 
cent. I do not think that in the fourteen years which have elapsed 
since I wrote this article my results with pessaries as regards the per- 
manent cure of backward displacements have been any better than I 
then stated, and still I continue to use pessaries for want of anything 
better. 
Before leaving this subject of pessaries I wish to state that I have 
used for the last ten years or thereabout only one variety of pessary 
for anteversion and prolapsus-namely, the Gehrung-and for retro- 
displacements of the uterus the various modifications of the lever 
pessary of Hodge as devised by Albert Smith, Thomas, Noeggerath, 
and myself; these modifications consisting mainly in lengthening or 
broadening the instrument and increasing or diminishing its curves, 
and for cases of retroflexion adding a bulb to its post-cervical end. 
Further, I will state that I use only instruments made of hard rubber 
or some other hard unalterable substance. In place, therefore, of the 
numerous complicated pessaries which were formerly described the 
number now thought necessary by me for the satisfactory treatment 
of uterine displacements is narrowed down to two chief varieties, and 
three or four modifications. 
It still remains for me to discuss one form of displacement- 
namely, prolapsus. So far as any palliative treatment of this condi- 
tion is concerned, I am not aware that anything new has been devised 
in recent years. Thure Brandt, it is true, has claimed to have cured The Present Treatment of Uterine Displacements. 
7 
some of the most inveterate cases of complete prolapsus of the uterus 
and vagina by his peculiar method of massage, and Schultze, Pro- 
fanter, and a few others have reported similar successful results ; but 
this method of pelveo-genital massage has not become popular in this 
country either with physicians or patients-a fact which, on reflection 
and on considering the highly sensitive character of the majority of 
our ladies, does not seem particularly surprising. So far as my expe- 
rience goes, the number of mechanical supporters which formerly were 
recommended in the text-books and sold by instrument makers, retail 
and wholesale, has been very materially reduced, very much to the 
benefit of the patient's health and pocket. The majority of such cup- 
and-stem instruments-that being their usual character-but rarely 
kept the prolapsed uterus and vagina in place satisfactorily, and sooner 
or later caused ulceration. They never effected a cure ; in fact, 1 do 
not know of any instrument which has ever cured a vaginal and uter- 
ine prolapsus except by producing so deep an ulceration and result- 
ing cicatrix as to retain the prolapsed organs in the pelvis. 
Astringent tampons, rest in bed, local faradization, and massage 
are all too troublesome, tedious, and uncertain methods to induce us 
to employ them very generally. 
So far all that I have said only shows the progress in recent years 
in the more correct appreciation of the significance of uterine dis- 
placements and a curtailment of the palliative methods of treatment. 
If this were all the progress that has been made in this particular line 
it would still be worth accepting and recording. But a great deal 
more has been done. 
Not satisfied with the imperfect results obtained by pessaries in 
retrodisplacements, and with the view of permanently curing such 
cases, various surgical methods have been introduced and very exten- 
sively practiced during the last ten or fifteen years. 
i. The most prominent of these operations is that re-discovered 
by Dr. William Alexander, of Liverpool, and now known by his name. 
It consists in opening the inguinal canal on either side of the sym- 
physis pubis, picking up the round ligaments of the uterus, drawing 
them out as far as they will go in each individual case, cutting off the 
surplus, and stitching the remainder of the ligament into the canal. 
The fundus uteri is then approximated more or less to the anterior 
abdominal wall and lifted out of the pelvis, an anteversion being sub- 
stituted for the retroversion or retroflexion for which the operation 
was performed. Absolute mobility of the uterus and appendages, 
with an entirely healthy condition of the latter, are the essential 8 
Paul F. Mundd, M. D. 
requisites for this operation. I have performed Alexander's operation 
now seventy-seven times-that is, on seventy-seven patients-and 
have, with but three or four exceptions, succeeded in finding the liga- 
ments without any great trouble, drawing them out, and stitching 
them into the wound. I was, I believe, the first to perform this oper- 
ation in this country, on the 12th of December, 1884. I have had 
the opportunity to see a large number of the cases again, and so far 
as my own personal observation goes I have not seen a single failure 
-that is to say, a single case in which the ligaments were properly 
brought out and attached where the uterus became again retroverted. 
Several of the patients have conceived, carried to term, and been con- 
fined, the uterus retaining its proper position. In some of these in- 
stances several pregnancies occurred, and I had the opportunity to 
satisfy myself that in two cases after the fifth pregnancy following the 
operation the uterus still remained anteverted. While I admit the 
difficulty of finding the ligaments in some cases, I must still contend, 
as 1 have persistently done whenever discussing this point, that an 
absolute failure to find the ligaments is always the fault of the oper- 
ator. Any carelessness in following anatomical landmarks may result 
in such a failure. On the other hand, no one can foretell either the 
thickness of the ligaments or the possibility of drawing them out, since 
they are not infrequently very thin and adherent in the canal and may 
be broken during traction. This is the one drawback, in my opinion, 
to this operation and the only one. I have seen no bad results, no 
death follow it; nothing more, indeed, than now and then some sup- 
puration. Hence I do not think that I can be blamed for speaking 
so highly of the operation, as I have done over and over again since I 
first learned how to perform it. 
2. Owing to the difficulty, in the hands of certain operators, at- 
tending the finding of the ligaments by Alexander's method, and feel- 
ing that with our present surgical asepsis such a course was devoid of 
danger, a number of operators, notably Wylie, Palmer Dudley, and 
Mann, have opened the abdominal cavity, drawn up the fundus uteri, 
and shortened the round ligaments by doubling them upon themselves, 
and stitching them thus doubled to the anterior wall of the uterus. I 
have done this operation but twice and have been fairly well satisfied 
with it. Still I do not think it is justifiable to open the peritoneal 
cavity for this purpose only, except when it is found necessary to de- 
tach the adherent uterus and appendages and in order to be able to 
elevate the fundus uteri. A healthy condition of the appendages in 
spite of their adhesion must be considered essential to this indication. The Present Treatment of Uterine Displacements. 
9 
I have lately had occasion to examine a case of this kind which was 
operated upon by Dudley, in which I found the uterus well anteverted 
but tilted much farther to the right than was normal. Apparently the 
right round ligament had been shortened more than the left. I can 
not quite agree with the latter gentleman, however-provided he 
really made the statement which the patient claims he did-that the 
operation was of so trifling a nature as hardly to be worth calling it 
an operation. I can never consider the opening of the peritoneal 
cavity to be an entirely trifling operation. 
3. Ventral or anterior fixation, hysterorrhaphy or hysteropexy are 
the names given to the attachment of the fundus uteri to the anterior 
abdominal wall by means of sutures, the abdomen having been opened 
in the median line, the fundus uteri and appendages lifted out of the 
pelvis and brought up against the incision. This operation was first 
devised by Sanger, Schroder, and Olshausen, later on modified by 
Howard Kelly, Leopold, and Klotz. I do not pretend to be correct 
in awarding the priority to any one of these gentlemen, since it is 
quite possible that several of them may have adopted the idea simul- 
taneously. Although I have performed this operation twelve times, I 
have never been able to quite satisfy myself that it was justifiable to 
subject a woman to the risk of abdominal section for the cure of an 
entirely harmless affection such as retroversion or retroflexion. I 
lost but one of the twelve patients, it is true, and that from heart fail- 
ure owing to enormous tympanites, the operation having been done 
for prolapsus; but this one death was quite sufficient to deter me 
from a further employment of the method. Of course, when the 
appendages were removed, the uterus being retroverted or prolapsed, 
I have always employed the practice of stitching the pedicles into the 
abdominal wound. These cases I do not include in the twelve of 
true ventral fixation. Only when the appendages are adherent and 
can still be preserved and the uterus is retroverted or prolapsed do I 
consider it justifiable to open the abdominal cavity and stitch the 
fundus to the abdominal wall. I do not think it logical to substitute 
an immovable anteverted uterus for a movable retroverted organ, 
hence I do not think that ventral fixation can in any way be com- 
pared with or substituted for Alexander's operation or any method of 
shortening the round ligaments. Besides, we must consider that if 
pregnancy should supervene with the fundus attached to the anterior 
abdominal wall there may be an interference with the normal devel- 
opment of the uterus and premature delivery may take place. At 
least this did occur in one of my cases, where the woman after the 10 
Paul F. Mundd, M. D. 
fourth month complained of severe pains in the line of the cicatrix 
and finally during the fifth month labor came on. I know that there 
are quite a number of cases reported where pregnancy went to term 
in spite of the ventral fixation of the uterus; I do not, therefore, in- 
tend to deny that this may occur, but it is logical to fear premature 
delivery in such cases. Such a fear is not justified in shortening of 
the round ligaments by Alexander's or the internal methods, since 
during the growth of the uterus in pregnancy the ligaments adapt 
themselves to the increasing elevation of the organ. Many of our 
best operators in this country are, I think, gradually receding from 
their former preference for ventral fixation and returning to the ranks 
of the supporters of Alexander's operation or its modifications. 
4. Following the practice very recently introduced by some Con- 
tinental operators-Jacobs, of Brussels, and Pean, of Paris-of doing 
everything through the vagina that can possibly be done through that 
passage in preference to the abdominal wall, Polk chief of all has re- 
cently reported a number of cases in which he has opened the pos- 
terior vaginal and peritoneal pouch, detached the adherent uterus and 
the appendages with his fingers, drawn the appendages into the vagina 
for examination, and finding them sufficiently normal to warrant their 
retention, has elevated them and the uterus and retained them by 
shortening the round ligaments according to Alexander's method ; he 
then closed the opening in the posterior cul-de-sac and vagina. I am 
not sure who else has done this operation and therefore do not men- 
tion names, but am under the impression that it has been done in 
New York by other gentlemen with decided success ; and I must say 
that I think it exceedingly ingenious and practical and far preferable 
to the detachment of the uterus and appendages through the usual an- 
terior abdominal incision. I especially commend the retention of the 
uterus and appendages in their normal position by the shortening of 
the round ligaments through the inguinal canal rather than by attach- 
ing the fundus to the anterior abdominal wall as is the practice in 
hysterorrhaphy. I shall certainly take the first opportunity to test 
the merits of this new procedure. 
5. Schticking a number of years ago recommended anteflexing a 
retroflexed uterus by carrying a needle armed with a silk thread 
through the previously manually anteflexed uterine canal and fundus 
and between uterus and bladder into the vagina. The two ends of 
the silk were then tied and the uterus thus kept in this new position 
until the adhesion between the anterior peritoneal surface of the fun- 
dus uteri and the vesico-uterine pouch took place. He reported a The Present Treatment of Uterine Displacements. 
11 
number of successful cases, but the profession has never taken up this 
method, simply for the reason that it seemed not only risky but also 
mechanically illogical, in that an immovable anteflexion was substi- 
tuted for a movable retroflexion-certainly not a very desirable sub- 
stitution. 
6. More recently Mackenrodt, of Berlin, has devised and enthu- 
siastically recommended another method based on a similar mechan- 
ical principle, but differing in its execution, which consists in opening 
the anterior vaginal pouch, pushing up the bladder, bringing the 
fundus uteri down into the space thus made between bladder and 
uterus, and attaching it there by deep stitches passed through the 
vaginal walls. The same logical objection of a substitution of an im- 
movable anteflexed uterus for a movable retroflexed one applies to 
this operation. While I have never performed it, any more than that 
of Schiicking, I still feel myself justified in condemning it, if on the- 
oretical grounds only, as anatomically bad and illogical. If I am 
criticised for condemning what I have not myself performed, I can 
only say that I might as well be condemned for. opposing decapitation 
for a headache or amputation of the penis for a gonorrhoea. Both of 
these latter procedures I certainly have never performed and never 
shall perform for the conditions named, any more than I propose to 
do either Schticking's or Mackenrodt's operation for retroflexion. 
7. There have been other plastic operations invented for the cure 
of retrodisplacements of the uterus which were based on the principle 
of stitching the cervix to the posterior vaginal wall with the object of 
thereby throwing the body of the uterus forward. The late Dr. James 
B. Hunter proposed such a method, but it was found impracticable 
thus to antevert the uterus and these methods were abandoned. 
So far as our present status on these operative measures for the 
cure of backward displacements of the uterus goes I think that the 
opinions between the shortening of the round ligaments and ventral 
fixation remain about evenly divided. The new method of vaginal 
detachment of adherent uterus and appendages and Alexander's oper- 
ation seems to me to be the coming one for those cases where the 
organs are adherent. 
Now to come down finally to prolapsus uteri, which is almost in- 
variably associated with a descent of one or both vaginal walls, to- 
gether with more or less hypertrophy of the supravaginal portion of 
the cervix, the operations for these conditions are of much greater age 
than those for retrodisplacements. I will not go back to ancient his- 
tory, but will merely refer to the plastic operations of Carl Braun in 12 
Paul F. Munde, M. D. 
Vienna twenty-five years ago, and those of Simon, of Heidelberg, of 
about the same date-two surgeons who were the Nestors of plastic 
gynaecological surgery in Germany at that time. Since then the 
operations for prolapsus uteri et vaginae have become so numerous 
that it may be said that almost every operator of prominence has a 
method of his own: Bischoff, Fritsch, Martin, Hegar, Freund, among 
the Germans ; Lefort, Pozzi, Doleris, among the French ; and Thomas, 
Emmet, Wylie, Polk, and myself, among the Americans. I really can 
not give the names of all those who have invented or claimed to have 
invented peculiar methods for the cure of prolapsus. Practically they 
all mean the same thing and are all based on similar principles- 
namely, reduction in size of the uterus, retention of the uterus in its 
normal position in the pelvis, and, finally, constriction of the vaginal 
walls and restoration of the perinaeum-therefore either amputation 
of the cervix if it is elongated, or trachelorrhaphy if it is torn and 
hypertrophied, ventral fixation or Alexander's operation, constriction 
of the anterior vaginal wall by Stoltz's, Emmet's, or Sims' method, 
and of the posterior vaginal wall by Hegar's or Emmet's method, 
which latter implies also restoration of the perinaeum-this is, in brief, 
the combination of operations which, more or less modified according 
to the ideas of different operators, is nowadays employed for the radi- 
cal cure of prolapsus uteri et vaginae. These plastic operations, while 
constricting the vagina, do not, however, propose to completely close 
that canal, and are therefore applicable to women who are still in the 
childbearing period and who are subject to their marital duties. 
Unfortunately these very conditions in many instances prevent a per- 
manent cure, no matter how perfect the result of the plastic operations 
may have been when the stitches were removed, since coition and 
subsequent parturition are more than liable to bring about a return 
of the dilated vagina and the prolapse of its walls and of the uterus. 
It is therefore one of the rules to be inculcated upon such women 
as strenuously as possible that pregnancy should not again take 
place. 
It has remained for one of the younger gynaecologists to devise 
within the last two years a most ingenious operation for the complete 
cure of prolapsus, which operation is, however, restricted to women 
who have passed the childbearing period or by whom at least the 
marital function is no longer to be performed. This operation con- 
sists in encircling the vaginal walls, beginning as near the cervix as 
possible, by stout silver-wire sutures which are inserted at the median 
line of the posterior vaginal wall and carried entirely around until The Present Treatment of Uterine Displacements. 
13 
they meet in front, a needle at each end of the wire being used. The 
suture is then twisted as tightly as it can be without tearing out, and 
the ends are turned down and cut short. The next suture is intro- 
duced about half an inch below the first, proceeding from within out- 
ward, and twisted in a similar manner. Stitch after stitch is thus 
inserted and twisted until the whole vaginal canal is narrowed down 
to the vulva, care being taken to so place the stitches that their ends 
will not irritate the neighboring parts. The last stitch practically 
closes the vulvar orifice, leaving only a small canal about the width of 
an ordinary lead pencil for the exit of secretions. It must be remem- 
bered that the sutures must be applied with the vagina and uterus 
replaced, not prolapsed, although the first two stitches may be intro- 
duced for convenience' sake around the external os with the uterus pro- 
lapsed ; but before twisting the first stitch the uterus must be returned 
into the body. The patient is then put to bed and kept there for 
a few days until any possible chance of reaction has passed away, and 
then is allowed to get up. Her confinement to bed scarcely exceeds 
a week, and need not even reach that. The stitches are, of course, 
to remain, and that is the novel and ingenious part of the scheme. 
They remain as permanent splints. I have performed this operation 
three times within the last twelve months-twice at the Mount Sinai 
Hospital and once last summer in Hanover, N. H.-in all with per- 
fect success. In the Hanover case I was obliged to use strong copper- 
plated iron wire, there being no sufficiently strong silver wire on hand. 
This made the introduction of the sutures very much more difficult 
and entailed some laceration of the tissues which otherwise would not 
have taken place. Still the patient was up within one week after the 
operation and went home at the end of the second week, claiming that 
she had not felt so comfortable for ten years, since which time she 
had the prolapsus. In two of the cases I found that after a time some 
of the lower stitches cut a little and required retwisting and shorten- 
ing of the twisted ends. There was absolutely no reaction in any of 
the cases. I consider this to be the ideal operation for prolapsus, but 
unfortunately, as I have stated, it is restricted to a comparatively 
limited number of cases. We shall therefore always be obliged to 
perform the combination of operations which I have described in 
women who are still in the childbearing period. The perfectly ideal 
operation for the cure of prolapsus uteri et vaginae, which will enable 
the woman to bear children afterward, precisely as though she never 
had a prolapsus, has still to be invented. 
Removal of the entire prolapsed uterus has been performed a num- Paul F. Munde, M. D. 
14 
ber of times and may be perfectly justifiable if it seems to offer the 
only reasonable prospect for a cure. It will usually be necessary to 
remove also the larger part of the prolapsed vagina. I have not yet 
met with a case where I considered it imperative to perform this oper- 
ation. Inversion of the uterus is not in the scope of this paper.