[Reprinted from the New York Journal of Gynaecology and Obstetrics 
for April, 1894. 
THE PALLIATIVE TREATMENT OF UTERO-VAGINAL 
PROLAPSE.* 
By John Byrne, M. D. 
About eight years ago, in a paper read before this society, I advo- 
cated and still practice with marked success in suitable cases amputa- 
tion of the cervix by galvano-cautery for uterine prolapse. I stated 
then that, after the removal of the cervix, my custom was to apply a 
firmly-rolled antiseptic tampon, by which the vaginal canal was to be 
kept on the upward stretch and consequently the stump well ele- 
vated. This tampon was to be removed by a careful rotary motion 
and a fresh one applied for two or three weeks, or until the completion 
of granulation and cicatrization. 
I found that in cases so treated, the elevated position of the uterine 
body following such treatment-though noticed by mere accident 
many years previously-gave better promise of permanent relief than 
any plastic operation. 
The appositeness of my allusion to this matter on the present 
occasion will be more apparent when I state that about the period re- 
ferred to, and indeed for some time previously, my confidence in the 
utility of plastic operations for many of these displacements had been 
steadily on the wane. Thenceforth I had been hoping, from time to 
time, to devise some practically useful aid to palliative treatment, con- 
sistent with what I conceive to be the principles of uterine mechanics. 
Besides, a large proportion of the victims of these infirmities-at 
least of those who came under my notice in hospital as well as pri- 
vate practice-manifested a very decided objection to experimental 
whittling of their sexual organs and not a few had already run the 
gauntlet at my own hands or in the serviceof some other hospital surgeon. 
In 1887, therefore, I ventured-though I must say apologetically 
-to call the attention of this society to a form of pessary designed 
for the relief of prolapsus uteri, its action being mainly to counteract 
the sagging of the walls of the vagina. That instrument consisted of 
a properly curved Smith pessary, to which were added two lateral 
arched arms ; and I still continue to use it with marked satisfaction 
in certain cases. 
* Read before the New York Obstetrical Society,February 20, 1894. 2 
John Byrne, M. D. 
Having at that period an experience of many years in the surgical 
treatment of ailments of this class by colporrhaphic operations, I felt 
then, as I feel now, that a due appreciation of our duty toward the 
victims of these infirmities, nay, the very nature of our humane call- 
ing, would seem to demand renewed efforts in the direction of pal- 
liative treatment. 
I am well aware that the advocacy of palliative measures for the 
relief of utero-vesical prolapse is not quite in accordance with the 
trend of gynaecological thought and practice at the present epoch. In 
fact I am almost disposed to think that, in venturing to plead for any 
means other than surgical for the amelioration of such infirmities, one 
would risk the charge of being old-fashioned and behind the times if 
not utterly oblivious to the rapid progress and brilliant achievements 
in gynaecology during the last forty years. 
I maintain however, with regard to palliative treatment of uterine 
and vesical prolapse through the instrumentality of pessaries or other 
mechanical aids, that it is as illogical, unreasonable and unjust to dis- 
credit or discountenance all such means because of their abuse as it 
would be to decry surgical interference because every tyro in gynae- 
cology can not hope to imitate the unrivaled methods of Dr. Emmet 
or aspire to the genius of his revered associate oioneer in this branch 
of uterine surgery, the late Dr. J. Marion Sims. 
1 would have it understood, therefore, that while I question the 
permanent utility of many of the colporrhaphic operations, more espe- 
cially some of European origin, I am far from discountenancing such 
practice in extreme cases by competent hands. For the poor toiling 
woman who has to support herself, and often a whole family, by 
laborious work while suffering from more or less complete procidentia, 
there is, of course, as a rule, no relief to be hoped for except through 
one or more skillfully performed operations. And yet even in such 
extreme cases I have often, by the aid of a pessary such as I now 
show, succeeded in maintaining the displaced organ within the pelvis, 
with great comfort to the patient, and enabling her to pursue her 
arduous labors with comparative ease and comfort. 
During the current half of the present century, uterine flexions 
and versions and utero-vaginal prolapse would seem to have fur- 
nished an almost (if not quite) inexhaustible field for the display of 
mechanical, but too often misdirected, skill. Indeed, so numerous 
and varied have been the devices invented from time to time, but so 
often wholly incapable of effecting the object aimed at, nay, some- 
times more potent for evil than in any manner useful, that gynaecol- The Palliative Treatment of Utero-Vaginal Prolapse. 
3 
ogists of experience are apt to accept anything new or useful in this 
line with a shrug of incredulity. Nor is this to be wondered at when 
I, as doubtless also many of those 
present, reflect on the numerous and 
viciously constructed so-called sup- 
ports which I have been called upon, 
from time to time, to excavate and 
which even now are daily resorted to 
with irretrievable injury to patients. 
Truly if the shades of the distin- 
guished professors, Hodge and Meigs, 
could arise and see the extent to 
which the principles underlying their simple, safe and so often useful 
pessaries and rings had been ignored or tampered with, they would 
shudder at the perverse ingenuity of some of their successors and 
retire in disgust. 
Thus, in the treatment of simple retroversion, how often do we not 
meet with cases of almost incurable retroflexion brought about by the 
injudicious application of a viciously shaped pessary or an anteflected 
uterus which some one has attempted to prop up by a contrivance 
which, even to contemplate, is suggestive of vesical destruction and 
which would bore its way through tissues as dense and resisting as car- 
tilage ! To the first of these evils may be attributed false teaching as 
to the manner in which a properly shaped pessary ought to, and as a 
matter of fact does, relieve rectal pressure and other disagreeable 
symptoms. As to the general run of anteflexion instruments in vogue, 
they are, to say the least (with one exception and that is the Gehrung), 
as useless as they are dangerous, and the principles on which they 
have been devised, though perhaps clear to their inventor, are cer- 
tainly beyond my limited comprehension. 
From these considerations, therefore, it is quite evident that to a 
lack of mechanical skill and a failure to duly consider and comprehend 
the relation of parts and organs involved, and the object and kind of 
mechanical treatment to be adopted for each particular case, is due 
the disrepute attached to the use of pessaries. 
To the failure to obtain benefit from the many mechanical con- 
trivances obtainable, especially for the relief of utero-vesical pro- 
lapsus, is doubtless to be attributed the favor with which numerous 
and oftentimes useful plastic operations have been viewed and resorted 
to in the last twenty years or more. During this entire period, in fact 
soon after the publication of Dr. Sims's bold but unsuccessful attempt 
Dr. John Byrne's Cystocele and 
Prolapsus Pessary. 4 
John Byrne, M. D. 
to excise the anterior wall of the vagina, I have conscientiously, and 
with as much skill and care as I am capable of, operated for the rad- 
ical cure of these infirmities and followed as near as possible the lines 
laid down by our best operators, both here and in Europe. I have 
also had opportunities of noting the subsequent history and condition 
of patients operated upon by myself and many others, and I can safely 
say that in the very large majority of cases the relief obtained was not 
only inconsiderable and in unfavorable contrast with the sacrifice 
made but of very temporary duration. In making this declaration it 
is needless to remark, as I have already intimated, that I do not in- 
clude in this qualified censure certain operations universally conceded 
to be essential and imperatively demanded as a sine qua non to the 
success of any intravaginal mechanical device. Such, for example, as 
a very thorough colpo-perineorrhaphy extending beyond the plane of 
the levator muscles, as well as certain ingenious operations devised 
by Dr. Emmet for urethrocele, etc. But, from what I have observed 
myself, from the verdict of others of equal experience, and, without 
wishing to detract in the slightest degree from the great skill and 
operative dexterity of members of this society and others for whose 
versatile chirurgical ability I have the most profound admiration, I 
have long since, i. e., during the period of six or seven years, ceased 
to urge or even encourage plastic operations for the cure of cystocele 
and prolapsus uteri merely. 
A good perineal rest for the pessary here shown is all that I have 
found called for. 1 am also of the opinion that if it were possible to 
obtain all the facts touching these colporrhaphic operations, not so 
much as regards immediate results which, it must be admitted, are, 
when not " total failures," satisfactory and for the time attractive and 
promising, but if the condition of the parts at the expiration of a 
reasonably long period, say two or three years, are carefully exam- 
ined, they would fully warrant the foregoing conclusions. 
In this connection I may quote Dr. Emmet's statement in con- 
cluding his chapter on Prolapsus of the Posterior Wall of the Vagina. 
He says : 
" In my practice previous to 1878, I found it necessary to operate 
on the rectocele and close the vaginal outlet of one hundred and fifty- 
four women of the number who suffered from the different degrees of 
procidentia. To impress this fact I will state that of one hundred 
and eighty women having rectocele, cystocele or complete procidentia, 
I diminished the vaginal entrance in addition to other operations in 
all but twenty-six cases. Where the operation was deemed not neces- The Palliative Treatment of Utero - Vaginal Prolapse. 
5 
sary, it was found to be almost entirely among those who had 
cystocele only and in whom the change of life had already taken 
place. For over twenty years I have been in a position to observe 
the value of such surgical procedure devised for the relief of this 
class and to appreciate the changes brought about by time-the most 
valuable test of all. This experience has taught me that whenever 
the procidentia has been complete, if the change of life has not 
already taken place, the displacement will reoccur in every instance 
after the operations on the anterior wall, if the proper procedure on 
the posterior one has been neglected. With all the cases under my 
observation, where a support of the posterior wall was wanting, four 
years was the longest interval before the recurrence of the procidentia. 
I have found that even after carefully performing the final operations 
on the posterior wall and vaginal outlet the procidentia would soon 
return if the uterus was left retroverted unless it happened that the 
organ had become bound down by adhesion." (Principles and Practice 
of Gynaecology, 3d ed., p. 377, et seqf 
These statements are of great practical value and entirely in ac- 
cordance with my own experience and observation. They more than 
emphasize the necessity for the use of some reliable mechanical sup- 
port in all cases of procidentia, whether vesical or uterine or both, 
and however perfect the posterior wall may be naturally or as a result 
of colpo-perineorrhaphy. It is to be regretted, however, that still 
further information can not be obtained regarding the period of im- 
munity from relapse after colporrhaphic operations. Indeed, statis- 
tical reports on this, as upon many other subjects, are few and un- 
satisfactory, so far at least as my opportunities of research have 
led me. 
The reports of operations of this class and the papers read and 
discussed before the various societies, more especially in Germany, 
are singularly reticent on the subject; the leading object of members 
seemingly being to vie with each other for surgical notoriety and the 
distinction of novelty in the art and methods of vaginal whittling and 
stitching-for example : 
A prominent exponent of radical operative gynaecology * and of 
course opposed to all palliative treatment, which he thinks "is uni- 
versally admitted to be ineffectual," thus summarizes his exploits 
in sixty prolapsus operations, one only having died from septicaemia, 
viz.: 
* A. Martin in Amer. Jour, of Obst., vol. 13, p. 209. 6 
John Byrne, M. D. 
" Fifteen times anterior colporrhaphy with three complete failures, 
four complete successes, and eight cures, but with subsequent stretch- 
ing of the cicatrix ; twenty times colporrhaphy after Hegar. Of 
these only twelve healed. Of these twelve, seven patients per- 
manently improved ; of the other five clinical patients, three have 
now, less than one year after, again symptoms of prolapsus. Five 
were operated after Bischoff's method; two were cured, but in three 
the flaps became gangrenous. After his own method five were oper- 
ated upon ; in one, no result was obtained; in three there was a 
complete cure, now of nine months' duration. In one the episior- 
rhaphy did not heal but the well-consolidated vaginal cicatrices have 
held the prolapsus back in a satisfactory manner up to the present 
time-over nine months." 
In this not very lucid, if veritable, contribution to the science of 
statistics it will be observed that out of sixty operations forty-five 
only, exclusive of one death from septicaemia, are deemed worthy of 
special note. In other words, of the fate of twenty-three and one half 
per cent, of the whole number it would appear as if it were prudent 
to say nothing. There is surely no rule in the science of surgical 
record-making that dooms to utter oblivion patients who have been 
removed to another, if not a better, world ; or, can the maxim of some 
statisticians, notably gynaecological, be " de mortuis nil nisi bonum " ? 
Possibly this problem may be solved in the hereafter, or at least 
a suggestion is pertinent to the effect that after all it may be that 
forty-six and not sixty patients have been subjected to sixty surgical 
efforts. Just here, however, we encounter other difficulties, for in 
the first series of fifteen patients, though three complete failures are 
admitted, there were four complete successes and eight cures ! Here 
we have either a distinction without a difference or a distinction in- 
capable of being distinguished. Again, in the second series of twenty 
patients, we are informed that not less than eight refused to heal. 
Now, why these eight perverse cases should be exempt from the plain 
designation of "complete failures" as well as their neighbors is also 
difficult to understand. But seven were improved, though five re- 
lapsed quickly so that in this batch there is not much to glorify over. 
In the third series of five, two are noted as cured ; but in three of 
these five patients (that is, sixty per cent.) the flaps became gangre- 
nous, so the subsequent condition of these patients can be imagined 
but can not be said to be "improved." In the fourth and last series 
of five, two were cured up to nine months, one did not heal, and one 
had "no result." The Palliative Treatment of Utero - Vaginal Prolapse. 
7 
Reports like these, so strikingly ambiguous and misleading, smack 
so suggestively of the statistics of the vaginal hysterectomy for uterine 
cancer, one might almost imagine that the same evil genius presided 
over the compilers' deliberations in both cases ; they are as difficult 
to interpret as the oracles of Delphi. 
The following cases, each being typical of a class and taken from 
my record of a large number, will illustrate the benefits derivable from 
the use of my utero-vesical support. 
December 12, 1888, I was consulted by Mrs. D., a widow, aged 
fifty-nine, and the mother of five children ; the youngest, twenty years 
of age. She suffered since three or four years after her last confine- 
ment with an involuntary escape of urine on much exertion, as in the 
act of sneezing or coughing, but withal a constant desire to urinate 
yet inability to completely empty the bladder. For the past two years 
she had noticed what she supposed to be her "womb coming down " 
when in the erect position or in the act of moving the bowels, which 
latter function has been difficult and incomplete by reason of " a feel- 
ing as if something were in the way." 
On examination in the dorsal position, the anterior vaginal wall 
was observed to protrude to the size of a lemon, but the perinaeum 
was fairly good. On introducing the finger it came in contact with 
the cervix uteri immediately but barely within the introitus and look- 
ing forward. Though the fundus was reflexed the entire organ was 
quite movable. A Gehrung pessary, such as I had been using for 
some years previously with excellent effect for cystocele and anteflex- 
ions, was applied. One week after, she reported that for some days 
following the application of the pessary she experienced the greatest 
possible relief so far as being able to retain urine. 
On examination at the expiration of the week, I found that the 
pessary had turned about half round and was in a fair way of serious- 
ly injuring the soft parts. Having removed it, I sponged with a solu- 
tion of tannin in glycerin, containing two and a half per cent, of car- 
bolic acid and requested her to call in the course of a week when I 
hoped to have something more suitable to her condition. This was 
the first trial of a pessary in all respects similar to that now exhibited. 
Without going into details I will merely add that this patient has been 
wearing it constantly, with the exception of two weeks, up to the pres- 
ent time with perfect comfort. The cause of its suspension for the 
said two weeks will be understood when I state that this patient, con- 
Cystocele. John Byrne, M. D. 
8 
sidering herself perfectly well and free from all her former distress, 
did not call upon me or have the pessary removed for nearly eleven 
months. On removing it then I found the parts in a wonderfully 
good condition, all things considered, but deemed it best to sponge 
the vagina as before and substitute a firmly rolled tampon, soaked in 
an astringent and antiseptic mixture to be worn for forty-eight hours. 
This treatment was repeated several times during the two weeks when 
the pessary was replaced and has now been worn without change for 
four months. 
Complete Procidentia. 
Mrs. S., aged forty-one, stout, the mother of eleven children; the 
youngest now four years old. She says she has never had any trouble 
in her confinements and now menstruates regularly ; that, except when 
in bed at night, her womb has been entirely outside for the past two 
years. In reply to my question as to the size of the protrusion she 
said : " It could only be compared to a moderately sized football." 
A mere ocular examination sufficed to confirm her statement as re- 
gards the voluminous character of the protruding mass which con- 
sisted of the bladder, the uterus and ovaries and the entire rectal 
wall. Though the muscular tissue of the perineal floor had under- 
gone atrophic changes, yet the mucous as well as the integumentary 
covering seemed to have escaped injury ; the most depending part 
marking the seat of the cervix, was deeply ulcerated and, on being 
sponged, bled freely. The whole having been returned without dif- 
ficulty, a utero-vesical support of unusually large size was temporarily 
adjusted, the antiseptic styptic freely applied to the ulcerated surface, 
and the patient directed to use a warm boric-acid douche twice daily 
for a week. At the expiration of this time she returned, stating that 
she never felt more comfortable in her life than she did then and 
hoped I might find it unnecessary to remove the support. To be 
brief-the course which I have always pursued in cases like the above 
was carried out in the present one. 
1. For the first few weeks, or until the restored organs approach 
their normal size and weight through better return circulation, a 
weekly inspection is necessary. 
2. A slight and gradual decrease in the size and, if called for, in 
the shape of the pessary, until the one for permanent use is decided 
on and, 
3. A monthly inspection for two or three times, after which the 
patient may be allowed to remain away as long as she feels comfort- 
able, but always with strict injunctions regarding antiseptic douching.