The Reposition of Retro-displace- 
ment of the Gravid Uterus 
by Posture and Atmospheric 
Pressure. 
BY 
PAUL F. MUNDfi, M.D., 
Assistant Surgeon io the New York Stale Woman's Hospital. 
[From the Transactions of the New York Obstetrical Society.] 
Reprinted from, the American Journal of Obstetrics and Diseases of 
Women and. Children, Vol. IX., No. II., June, 1876. 
YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1876. THE REPOSITION OF 
RETRO-DISPLACEMENT.OF THE GRAVID UTERUS 
BY POSTURE AND ATMOSPHERIC PRESSURE. 
DK. PAUL F. MUNDE. 
Mrs. C. S., twenty-eight years of age, mother of two children- 
the first premature at seven months, one and a half years ago, 
the last at some ten months ago-came to me January 3d 
last, complaining of a sensation of weight and drooping 
in the pelvis, hips, and back, which at times increased to 
severe, almost unbearable pain, especially aftei' prolonged 
walking or standing. This condition had lasted about a week, 
and was becoming more distressing every day. Her bowels 
were very much constipated, moving only by means of cathar- 
tics, and each movement aggravated the pelvic and sacral pain ; 
the functions of the bladder were as yet unimpaired, with the 
exception of a desire for frequent micturition accompanied by 
scalding and some tenesmus. Her last menstruation had taken 
place about the middle of October, eleven weeks previously, 
and she thought herself pregnant. A vaginal examination re- 
vealed the uterus in a state of acute retroflexion, the enlarged 
body and fundus occupying the cavity of the sacrum, and firm- 
ly compressing the rectum and the cervix, situated under the 
symphysis pubis. Below the fundus was the enlarged, exquis- 
itely sensitive left ovary. The size of the uterus, and the soft, 
doughy feel of the body, left no doubt on my mind of the exist- 
ence of a pregnancy of about ten weeks ; and the tenderness of 
the organ on pressure clearly showed the necessity for speedy 
interference and reposition of the dislocation. Although the 
symptoms of actual incarceration were neither present nor im- 
minent, that condition generally not arising until towards the 
end of the fourth month, and although the existence of a retro- 
flexion fortunately prevented the compression of the urethra by 
the cervix uteri, and the consequent partial or total retention of 2 
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urine, which would doubtless have been present had the case 
been one of retroversion-still two previous cases of miscarriage 
during the tenth and twelfth weeks, in which the reposition 
of the retroverted uterus and a lever pessary after the com- 
mencement of metrorrhagia proved unavailing, had shown me 
the danger of abortion, even at that early period, unless the 
displacement were soon reduced. I therefore lost no time in 
placing'the patient in the knee-elbow position, and introduced 
two fingers of my right hand into the posterior cul-de-sac of the 
vagina-intending to try this, to the patient, less disagreeable 
and painful method of reposition, before proceeding to the 
more effective manipulation per rectum. Finding, however, 
that the fundus did not budge, I passed the same two fingers 
into the rectum, and endeavored for about five minutes to 
dislodge the body of the uterus, and push it above the brim of 
the pelvis, but without success. The complaints of the patient, 
and the fact that her bowels had not moved for several days, to 
which fact I attributed in a measure the difficult reduction, 
induced me to desist from my efforts for that day, and to send 
her home ^ith directions to thoroughly evacuate the bowels by 
laxatives and enemata, and to return with an empty bladder on 
the following day. She did so, and having found the uterus 
in the same position, I at once again placed her in the position 
d la vache, and renewed my efforts per rectum to push the fundus 
out of the sacral concavity and above the promontory. After 
using as much force as I dared for about ten minutes, and caus- 
ing the patient so much suffering as to require all the influence I 
had over her to permit me to continue my manipulations, I 
found that I had not succeeded in elevating the fundus uteri 
one line from the floor of the pelvis, and that the cervix still re- 
tained its original position above the pubic arch. Whatever 
slight dislodgment was effected by strong upward pressure, 
the hand at the same time pushing up the perineum, was at once 
annulled when the pressure ceased, the fundus instantaneously 
rebounding to its place in the sacral excavation. 
Having, in a number of cases of retroflexion or version of 
the gravid uterus, succeeded, without difficulty, in replacing 
the organ in the manner indicated, I thought that there must 
be some special reason for my want of success in this case- 
perhaps adhesions, which were possible, since the patient could 
not date the displacement to any sudden accident; and it might 
therefore have existed for some time before the present im- 
pregnation took place. I determined, however, to try first, 
whether, by drawing the cervix away from the pubis and 
towards the floor of tlie pelvis, I could not dislodge the fundus 
and reduce the dislocation by simultaneous digital pressure per New Yorii Obstetrical Society. 
3 
rectum. This I had already tried with the finger, but without 
avail. The patient still being in the knee-elbow position, I 
introduced Sims' speculum into the vagina, and pulled up the 
perineum sharply, intending to seize the cervix with the double 
tenaculum, when I suddenly noticed that the vagina was dis- 
tended with air like a balloon, in the middle of which appeared 
the cervix. On looking for the body of the uterus, I found, to 
my surprise, that it had disappeared, that the sacral excavation 
was empty, and that the obstinate retroflexion of the gravid 
organ had been unwittingly and painlessly reduced. The 
patient immediately expressed her sudden and entire relief 
from the previous distressing symptoms, and I hastened to 
secure the uterus by introducing a proper Albert Smith pes- 
sary, which the patient has since worn with perfect satisfaction 
and comfort. [It was removed at the beginning of the fifth 
month.] 
The explanation of this phenomenon is perfectly simple and 
obvious: The position of the patient produced a slipping of 
the moveable abdominal viscera away from the pelvis, and a 
suspension of the intra-abdominal pressure, or vis-d-tergo, its 
place being indeed supplied by a greater or lesser amount of 
suction or traction away from the pelvic organs, a certain vis- 
a-fronte, so to speak. The forcible elevation of the perineum 
opened the introitus vaginae, and gave entrance to a volume 
of air, the pressure of which had already been pushing up the 
perineum, slightly drawn inwards by the downward gravitation 
of the abdominal viscera, and the pressure of which, when ad- 
mitted, instantaneously distended the vaginal pouch, and re- 
placed the uterus-a mechanism identical with that on which 
the action of Sims' speculum is founded. Thinking the mat- 
ter over, it occurred to me that it was a case of acute (sudden) 
retroflexion of the non-impregnated uterus which afforded Sims 
the occasion for discovering his invaluable speculum. The 
unexpected reposition of the retroflexed uterus by the disten- 
sion of the vagina with air, which had rushed into the canal 
under the volar surface of his two fingers, while he was 
endeavoring, in the knee-elbow position, to lift up the fundus, 
first gave him, as we all know, the idea of the duck-bill specu- 
lum. But I did not remember seeing this method of reposition 
of the retro-displaced uterus, gravid or unimpregnated, recom- 
mended in any of the works on obstetrics or diseases of women 
with which I am familiar. Could it be possible that, among 
the great benefits which this lucky accident has conferred on 
humanity, this smaller but still estimable benefit had been 
overlooked ? It seemed scarcely probable. However, on 
looking over all the modern works on obstetrics and gynecology 4 
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at my disposal, such as Scanzoni, Schroeder, Byford, Cazeaux, 
Leishman, Thomas, Barnes, Hewitt, I found that, while all 
recommended the usual manipulations for the reduction of 
retroflexions and retroversions of the unimpregnated and gravid 
uterus, as by fingers in the rectum or vagina, or by air or water 
bags in these passages (Favrot) ; or by pressing the fundus up 
with a drumstick or ivory-headed cane in the rectum (Byford); 
or by drawing down the cervix with one hand, while the other 
pushes up the fundus, the patient generally being in the knee- 
elbow or semi-prone position; and, while all these authors 
agree that the reposition of the uterus with the sound is always 
attended with more or less danger and pain, still not one even 
as much as hints at the employment of atmospheric pressure for 
this purpose. Even Sims himself, whose attention might 
naturally have been supposed to be directed to this manner of 
replacing retro-deviations, from the case mentioned above, 
entirely ignores the minor lesson taught him by that case, and 
recommends the reposition of the retro-displaced uterus by the 
fingers and three sponge-holders, or by the uterine elevator. 
During a discussion, likewise, on a paper by Dr. Gervis,' on 
" Retroversion of the Gravid Uterus," in the London Obstetri- 
cal Society, at its meetings in November and December, 1874 
{Obst. Jour. Gr. Bt. d? Irei., Dec., '74, and Jan., '75), which 
is probably the latest published general discussion on the sub- 
ject, Drs. Barnes, Wynn Williams, Ayeling, Galabin, Braxton 
Hicks, Palfrey, Godson, Edis, Hayes, and others, related their 
experience in forty-eight cases, eight of which were fatal, and 
the treatment employed and advocated by them ; but not one 
word of air-pressure as a repositor do I find among all the 
various methods recommended. It is evident that none of the 
gentlemen named had ever heard of it in that connection. 
On January 6th, that is, two days after the reposition of the 
displacement, as above described, the latest number of the 
Berlin Beitrage zur Geburtshulfe und Gyndkologie (Vol. IV., 
No. 1), came into my hands ; and, looking it over, I noticed an 
article, entitled "A Hitherto unrecognized Obstacle to the Re- 
position of the Retroflexed Gravid Uterus," by Dr. Solger 
of Berlin, read before the Berlin Obstetrical Society, May 11, 
1875, in which the author, after enumerating the various well- 
known obstacles to the reposition of the retro-displaced impreg- 
nated organ, such as distension of the bladder and rectum, pro- 
jection of the sacral promontory and impaction of the fundus 
in the sacral excavation, and retro-uterine adhesions, mentions a 
a new, hitherto not recognized impediment, viz., the normal 
intra-abdominal pressure, and relates his experience in a case 
of difficult reposition, in which he made exactly the same New York Obstetrical Society. 
5 
observation as now reported by me, although in a slightly dif- 
ferent manner, identical with the original observation of Dr. 
Sims. In one case of irreducible retroflexion of the gravid 
uterus, at the end of the fourth month, in which Solger vainly 
endeavored to replace the organ by the fingers and the col- 
peurynter, in the knee-elbow position, he seized the cervix with 
a double tenaculum, to draw it away from the pubis, and, 
while examining with the finger, to see whether the tenaculum 
was in the right place, the cervix and tenaculum suddenly 
made a spontaneous evolution, and the cervix was found high 
up in the sacral excavation, from which the fundus had disap- 
peared. After some deliberation, Solger finally concluded 
that this voluntary reduction was owing to the influence of the 
negative intra-abdominal pressure in the knee-elbow position, 
and was reminded of a case of severe incarceration, in which 
violent emesis, in the prone and knee-elbow positions, brought 
about the spontaneous replacement of the uterus. Still, he 
was not completely satisfied with this explanation, and it was 
not till about a month previous, that a new case afforded him 
the opportunity for ascertaining the true rationale of this phe- 
nomenon. After repeated unsuccessful attempts to replace the 
retroflexed uterus of 3^ months, in the knee-elbow position, 
with the fingers in the rectum and vagina, Solger again intro- 
duced his fingers into the vagina, for the purpose of drawing 
the cervix away from the symphysis, when he heard and felt 
the air rush into the vagina between his fingers, which at once 
found themselves in a large balloon-like space, bounded above 
and behind by the sacrum. The retroflexion was completely 
replaced ! This, to him (as to me) unexpected and surprising 
result, Solger attributes to the overcoming of the intra-abdo- 
minal pressure (equal to at least 100 pounds) by the atmospheric 
pressure (which, taking the antero-posterior diameter of the 
superior pelvic strait only as high as 8 ctm., or 3", at 15 lb. to 
the square inch, amounts to more than 100 pounds), aided by 
a negative intra-abdominal pressure, not exceeding, according to 
Schatz, 10 ctm. hydraulic pressure, and the weight of the 
uterus itself. Solger recommends to replace all retroflexions 
of the gravid uterus by placing the woman in one of the posi- 
tions which annul abdominal pressure (the other obstacles re- 
sulting from distension of the bladder and rectum having been 
removed), and then lifting up the lower two-thirds of the pos- 
terior vaginal wall with one or two fingers, so as to permit the 
free ingress of air to the vagina. Only in case of this manipula- 
tion failing to be successful, is the employment of manual or 
instrumental pressure justifiable. 
Several of the members of the Berlin Obstetrical Society, 6 
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such as Drs. Louis Mayer, Korte, and Von Haselberg, expressed 
their doubts as to whether the mere pressure of air in the 
vagina could replace a retrofiexed gravid uterus with greater 
facility then could be done with the fingers; and the last-named 
gentleman referred to several cases observed by Martin, Fuhr- 
mann and himself {Monatschr. fur Geb. u. Frauenkrankh., 34, 
p. 173), in which air entered into the vagina in the dorsal decu- 
bitus, in which position the idea of traction on the vagina by 
negative intra-abdominal pressure must be excluded. Ue was 
therefore inclined to lay less stress on the influence of intra- 
abdominal pressure as an obstacle to reposition, than of the 
projecting promontory. 
These doubts as to the power of air-pressure in the vagina cer- 
tainly confirm the impression I had gathered touching the 
ignorance or want of appreciation of the profession of this sim- 
ple, but nevertheless powerful instrumentality. 
As regards Dr. Von Hasselberg's objection, it is refuted by 
Dr. Adolph Rasch, in a paper on "Air in the Vagina" {Trans. 
Lond. Obstet. Soc., vol. xii, 1871), the conclusions of which read 
as follows: 
" 1. No air enters the vagina of a female placed on her back. 
" 2. In the prone position, the abdominal walls fall outward, 
and cause a diminished pressure in that cavity. If the vaginal 
orifice be open, air will enter and so compress the expanded 
intestinal gases to their previous volume. 
" 3. The force with which it enters and consequently the 
quantity which distends the vagina, varies with the resistance 
offered by the abdominal walls to the gravitation and the de- 
gree of mobility of the viscera. 
" 4. In replacing the female on her back, the abdominal con- 
tents fall inwards and expel the air again from the vagina. 
" 5. In the position on the back we have an efficient means 
of keeping the air out of the vagina and uterus, and so prevent- 
ing the deleterious consequences ascribed to its action on the 
vaginal and uterine contents." 
Dr. Rasch also denies the power of sucking up the air by 
spasmodic contraction ascribed to the vagina by Hadley, Hew- 
itt, Routh, Braxton Hicks, and others, and shows that the ab- 
dominal cavity also possesses no suction power. The incorrect 
observations of the gentlemen mentioned must be attributed to 
a lack of appreciation of tire time when the air entered the va- 
gina, which certainly must have taken place at some previous 
time in some other position than on the back, and was not ex- 
pelled until she occupied the latter position. 
While looking, a few days ago, over the numerous periodi- 
cals accumulated in my library during the past year, for the New York Obstetrical Society. 
7 
purpose of preparing my annual report on Gynecology, I came 
across another paper bearing on my subject, entitled " Position, 
Pneumatic Pressure, and Mechanical Appliance in Uterine 
Displacements," by Dr. Henry F. Campbell, of Augusta, Ga. 
{Atlanta Aled, and Surg. Jour., May, 1875), which I remem- 
bered receiving, but had laid aside unread fora future occasion. 
This paper may have met the eyes of some of the gentlemen 
present, and a detailed repetition of its contents is therefore 
unnecessary ; still a brief review of the main features of Dr. 
Campbell's extensive experience on this topic may not prove 
uninteresting or tedious. 
Ue says that although the knee-and-breast (not knee-elbow) 
posture has been known and practised in uterine displacement 
for many years, it is still but little appreciated; and only two 
modern works-Thomas's and Barnes's recommmend it as a 
means for reducing uterine dislocations. Not one mentions 
" the indispensable condition of power and the real instrumen- 
tality and sine gua non in the process of replacement," the pneu- 
matic pressure, without which the posture alone is almost 
useless. He recommends the employment of the knee-breast 
position and pneumatic; pressure together, in all varieties of 
uterine displacement, not only to aid the diagnosis and re- 
place the dislocated uterus, preparatory to introducing a pessary 
in the same position, when it can be gently laid on the posterior 
vaginal wall without forcibly pushing up the displaced organ 
(the only way in which a pessary should be applied), but chiefly 
for the purpose of enabling the patient to reduce the disloca- 
tion herself every evening before retiring to bed, and thus secure 
an unimpeded uterine circulation with unstretched uterine 
ligaments during the whole night, a process which, if regularly 
repeated for some time, will, he asserts, "go far in favoring a 
restoration to a permanently normal position of the organ." 
This self-replacement is rendered practicable by means of the 
"pneumatic self-repositor," a glass tube with slightly curved 
bulbous extremity, made of different sizes, which the patient 
introduces every night in the knee-breast posture, only for a 
moment, when " the air rushes in, the suction is broken, and 
immediately, whatever may be the displacement, unless there 
is adhesion or impaction, self-replacement is completely and 
instantly accomplished." Sims' speculum was originally used, 
but proved too exprensive and inconvenient to the patient. 
Dr. Campbell also advises the postural and pneumatic-pressure 
treatment in the various forms of displacement of the gravid 
uterus, which "are not only incident to but are almost normal 
attendants of the earlier months of pregnancy ; and is confident 
that many of the discomforts and dangers accompanying these 8 
Transactions of the 
conditions will be alleviated or removed by "nightly self-re- 
placement." Rectal inflation has also been employed by Dr. 
C., and is recommended as serviceable in some cases " to dis- 
lodge the fundus from the hollow of the sacrum, thereby making 
restitution by vaginal inflation and inverted gravity easier and 
more certain." A case confirming this conviction of Dr. 
Campbell's is reported by Dr. Aveling in the Obst. Jour, of 
Grt. Br. cb Irei, for Jan. 1875, in his article on " The Influence 
of Posture on Women," of a lady afflicted with retroversion, 
who found her suffering alleviated whenever she knelt with 
bowed head at her confessional. 
A very important, distressing, and peculiarly obstinate class 
of cases, in which postural treatment alone is of marked benefit 
(Rigby, ride Aveling 1. c.) are those in which one or both of the 
normal or enlarged and congested ovaries have slipped down 
behind the uterus, and produce the most agonizing torture at 
almost every movement of the patient. Dr. Campbell entirely 
omits all mention of these displacements, although they are 
very common in connection with those of the uterus. I am 
confident that the knee-breast position, particularly if reinforced 
by atmospheric pressure, will prove very soothing and beneficial 
in these cases. 
While Dr. Solger's observation differs from mine in that he 
did not recognize the advantage offered him by the employ- 
ment of Sims' speculum for the admission of air to the 
vagina (and this is by no means a mere nominal advantage, as 
I have recently ascertained, while experimenting on a number 
of patients, for it seems almost essential to a complete disten- 
tion of the vagina to lift up the perineum, which latter, I 
ought to state, should be lax and distensible, as in multiparse, 
with a gaping vulva), it will be seen that Dr. Campbell has 
covered all the ground (with one exception) and infinitely more 
than I had expected to occupy when I first made the indepen- 
dent observation which forms the basis of this communication. 
I must say that, having since replaced a number of retroverted 
non-gravid uteri by the postural and atmospheric-pressure me- 
thod, I am very much impressed with the truth and force of 
Dr. Campbell's statement; and, while the subject of " nightly 
self-replacement " may perhaps meet with some opposition on 
aesthetical and moral grounds, I do not hesitate to express my 
unqualified support of the principles of treatment advocated by 
Dr. Campbell, and my belief that its universal appreciation and 
adoption will be of great benefit to the suffering female sex. 
My object in preparing this short paper is to call attention to 
the value of atmosphericpressure conjointly with the old-estab- 
lished postural treatment in reduction of retro-displacements New York Obstetrical Society. 
9 
of the gravid uterus, even of a severe degree, where the 
employment of an amount of force such as would be perfectly 
justifiable in case of adhesion of the unimpregnated womb, 
would surely be productive of metritis or abortion. 
This particular class of cases is not referred to by Dr. Camp- 
bell ; indeed he excepts displacements, where there is adhesion 
and impaction, as not amenable to the beneficial influence of 
posture and air-pressure. Solger's and my cases both prove 
that the latter condition in its commencing stages, may readily 
be relieved by this method. I need scarcely mention, there- 
fore, that all the milder cases of this accident are, as a matter 
of course, controlled with correspondingly greater facility; and 
that I entirely concur with the advice given by Dr. Solger, that 
only after posture and atmospheric pressure (employed in the 
manner described by me-knee-breast position and elevation of 
perineum with Sims' speculum)-have failed to reduce the dis- 
location, are the usual infinitely more difficult and painful 
manipulations to be resorted to. 
Dr. Peaslee said that he thought the power of air to replace 
a displaced uterus was liable to be overrated. The air will 
replace the uterus only as far as the vagina reaches, and a re- 
troversion will then be found reduced from one of the third to 
one of the second, perhaps from one of a second to a first 
degree ; but the sound will still be felt to pass into the uterus, 
with its concavity turned slightly backward. He does not 
think that even a pessary will change a retroflexion into an 
anteflexion; only the sound or repositor will do that. 
Dr. Chamberlain made the following remarks on the sub- 
ject : 
Mr. President : I would like to ask Dr. Peaslee if, provided 
the vagina be sufficiently extensible, the pressure of an instru- 
ment in the commissure behind the uterine neck, applying, as 
it does, upon the lower portion of the fundal zone, must not 
carry the fundus, first, against the cavity of the sacrum, and, 
if further continued, upward along the curve of the sacrum, 
until it emerges from the true pelvis in a perpendicular to the 
plane of the brim. Now, this perpendicular is substantially 
the axis of the superior strait, and it is in that axis that the 
normal position of the uterus lies. That the pressure of which 
I speak will compel the uterus to assume this position I have 
several times verified upon the cadaver. 
If Dr. Peaslee's statement be that the uterus cannot be 
positively anteflexed, except by an instrument within its cavity, 
I may say that I think that, when sustained above the brim of 
the pelvis and prevented from retroverting, the combined influ- 
ence of the round ligaments, the weight of the organ and the 10 
Transactions N. Y. Obstetrical Society. 
pressure of the viscera will sometimes positively antevert it; 
but, at any rate, I have not doubted that substantial restoration 
to its natural position can be attained by a pressure from below 
and without, and that the knee-and-breast position is a most 
valuable aid to restoration. 
Dr. Lee asked Dr. Peaslee whether there is not danger from 
replacing an endometritic uterus with the sound '? 
Dr. Peaslee said that he had never had any trouble, unless 
pelvic adhesions were still or had recently been present, lie 
thought the sound could generally be used without danger in 
such cases.