THE SURGICAL TREATMENT OF 
PROLAPSUS UTERI. 
BY 
HORATIO R. BIGELOW, M. D., 
Washington, D.C. THE SURGICAL TREATMENT OF 
PROLAPSUS UTERI. 
BY t/ 
HORATIO R. BIGELOW, M. D., 
Washington, D. C. 
It is to be regretted that there should be such a multiplication of long 
words descriptive of operations, nearly all of which are based upon the 
same general principles, for the relief of a prolapsus or procidentia due to 
any cause whatever. There are at least ten distinct procedures devised 
for the relief of this condition which may be classed as follows: 
1. Anterior-elytrorhaphy. 
2. Posterior-elytrorhaphy, or posterior colporaphy of Simon, ' 
3. Colpoperineoraphy of Hegar. -V- 
4. Kolpoperineoplasty of Bischoff, of Bale. /J / 
5. Le Fort's median colporaphy. \ ' 
6. Lateral and bilateral elytroraphy. \ . 
7. Episio-perineoraphy or contraction of the vulva and perinethn. 
8. Stricture of the vagina. 
9. Episiorrhaphy or contraction of the vulva. 
10. Obliteration of the vulval ring. 
11. Huguier's operation, or amputation of the cervix. 
Primarily and strictly speaking, prolapsus means the descent of the 
uterus as a whole. But owing to a faulty nomenclature, and to that 
adherence to terminology, a respect for which has been enforced by age, 
we include under one general head; 1. A simple descent. 2. Hyper- 
trophic elongation of the infra-vaginal cervix. 3. Hypertrophic elonga- 
tion of the supra-vaginal cervix. The language is faulty since it disre- 
gards the fundus uteri, and is merely predicated upon the assumption that 
the os tinea are found to be lower down than in the normal condition. The 
simple prolapsus found in old maids of a certain age, due to senile 
atrophy, and to the general decrepitude of advancing years, may also be 
met with in younger women as a resultant of various causes. Since we 
are concerned chiefly with surgical intervention, it is scarcely pertinent 
to the subject, however interesting such a discussion might be, to con- 
sider the patho-an#omy of these three subdivisions. 2 
Surgical Treatment of Prolapsus Uteri. 
Anterior Elytroraphy.-This is the favorite practice of American surgeons 
because cystocele usually complicates procidentia uteri. Marion Sims' first 
operation consisted in a V shaped incision of the mucous membrane of 
the anterior wall of the vagina, the apex being near the neck of the 
bladder and the two arms extending upon the sides of the cervix uteri. 
The two denuded surfaces were then brought together by silver sutures 
passed transversely. He has since modified this plan so that now in 
place of making the suture after having denuded a large oval surface of 
the anterior vaginal wall (as in his first attempts) he dissects off a portion 
of mucous membrane in the form of a trowel, so as to form a true fold, 
the upper ends of which, when brought into contact, form a support for 
the cervix. To remedy the defects of the simple V incision, which con- 
sisted in the formation of a pouch, so that the cervix slipped behind the 
septum into the pouch, and the fundus became fixed in the hollow of the 
sacrum, Dr. Emmet simply denuded the vaginal mucous membrane in a 
line across the cul-de-sac, making a regular triangle with its apex at the 
neck of the bladder and its base at the cervix. Emmet completes the 
triangle by denuding the strip which in Sims' trowel-shaped denudation, 
is left untouched at the upper end of the triangle. Dr. T. G. Thomas 
and Dr. Dawson remove the entire mucous membrane enclosed within 
the triangle. Dr. Dawson catches up an inch or more of the mucous 
membrane with a tenaculum to one side of the cervix, and removes with 
Emmet's curved scissors a piece in the shape of a cone. This serves as 
an outline. After the entire surface within the triangle is removed silver 
sutures are passed immediately below the denuded surface entering and 
emerging about one-fourth of an inch from the edges and introduced first 
at the upper end of the triangle. After these sutures are passed, the de- 
nuded surface is folded with a sound so as to bring its opposing faces to- 
gether. In this way the wire is folded within the tissues so that the su- 
tures act as splints in keeping the vaginal fold in position and the de- 
nuded surfaces in apposition. In 1869 Emmet adopted the following 
method. The uterus is first anteverted and its neck crowded up into the 
posterior cul-de-sac by a sponge probang. He then endeavors to find 
two points, one about half an inch from the cervix on each side and a 
little behind the anterior lip, which can be drawn together in front of the 
uterus by means of a tenaculum in each hand. When two such points 
can be thus brought together without undue tension, the surfaces are to 
be freshened. Then a surface about half an inch square is to be de- 
nuded with scissors about the point of the other tenaculum. Next a sim- 
ilar surface is to be freshened about the point of the first tenaculum, and 
a strip afterwards removed from the vaginal surface, in front of the uterus, 
about an inch long, by half an inch wide. Beneath each of these freshened 
surfaces a needle armed with a silk loop, to which the silver wire is 
twisted, is passed, so that the three surfaces are brought together in front Surgical Treatment of Prolapsus Uteri. 
3 
of the cervix forming a fold. Courty depresses the posterior wall and 
perineum by a Sims' speculum, and fixes in the anterior lip of the cervix 
the two terminal ends of a catheter, the convexity of which depresses the 
anterior vaginal wall toward the bladder-the curve of the catheter is 
buried under the lateral folds formed by the mucous membrane, where 
they meet in the median line. He then passes a solution of nitrate of 
silver over these folds and afterwards one of salt, which whitens them 
and allows him to make out exactly the surface to be denuded. The ar- 
tificial support of the uterus is not secured so satisfactorily by anterior as 
by posterior elytroraphy or the colporaphy of Simon. Then, too, the 
operation is by no meaps an easy one and requires exceedingly delicate 
manipulation. 
Posterior Colporaphy.-Devised by Simon of Heidelberg. He dilates 
the vagina by means of a broad fenestrated speculum, and then removes 
with scissors or bistoury, a portion of the mucous membrane and sub- 
jacent tissue to within about an inch of the vaginal insertion of the neck. 
The upper extremity of the denuded surface should be almost square, 
and not pointed, so that after cicatrisation has taken place, there is a kind 
of bag above the cicatrix which receives and retains the cervix, without 
this precaution, as stated by Courty, "the cervix would penetrate into 
the narrowed canal, would insinuate itself like a wedge, and by grad- 
ually dilating it would eventually make its way through it and reproduce 
the prolapsus." Below, the posterior portion of the labia must be de- 
nuded, so that by uniting them, the elongated perineum is produced 
forward "forming a curve terminated by a spur which forms an ex- 
tended point (Pappui. The opposite edges are brought together by 
sutures, and thus a firm cicatrical band is formed which occupies 
almost the whole length of the posterior vaginal wall. Prof. Simon 
claims for his operation ; That it forms a pouch in which the cervix 
rests; that a firm barrier is by it opposed to the exit of the uterus at 
the point toward which that organ naturally gravitates, and that the 
vagina is made narrower and more rigid. In addition the uterus is 
not drawn down by the contraction of the cicatrix as occurs in Sims' 
operation. (Barnes). 
Colpo-perineoraphy (Hegar).-Hegar narrows the vagina by removing 
a V-shaped fold of mucous membrane from the posterior vaginal wall, 
the apex reaching nearly to the cervix, the base ending at the vulva, 
which it includes, as in rupture of the perineum. The paring has 
to be done very carefully, and it is sometimes difficult to decide just 
how . much mucous membrane from the posterior vaginal wall should 
be taken off. Hegar gives six to seven centimeters in one direction, and 
seven centimeters in the other. He also uses the radiating stitch. 
Kolpoperineoplasty of Bischoff.-A tongue shaped flap is separated in 
the direction upward, and each edge of it is united by sutures to the 4 
Surgical Treatment of Prolapsus Uteri. 
posterior edge of the ordinary lateral denudation, after healing of the 
wound the lower part of the vagina is considerably narrowed, and the 
vaginal axis is broken so as to form an angle with the axis of the uterus. 
The two factors, it is claimed, prevent the womb from protruding through 
the vagina. 
Median Colporrhaphy. (Le Forts' Operation.'}-The uterus being out- 
side of the uulva, a portion of mucous membrane is dissected off each 
of the vaginal walls from the middle part (six centimeters long and two 
wide, according to Courty) the uterus is reduced sufficiently to bring into 
contact the uterine extremities of these two denuded surfaces, and three 
sutures are applied to this transverse border, uniting the anterior and 
posterior vaginal walls in a linear direction. The union of the lateral 
borders is effected afterwards by forming a metallic thread on each side, 
first through the border of the anterior denuded surface, and then through 
the corresponding border of the posterior surface; a thread being placed 
in the same way on the opposite border and at the same height, it suffices 
to fasten these two sutures, in order to increase the reduction of the 
uterus by bringing the opposite vaginal walls together. 
Eustache of Lille modifies this operation by removing the mucous 
membrane at least four centimeters in length and as much in width so 
that the wound may be nearly square. He also uses catgut instead of 
silver wire for sutures. 
Dr. A. H. Smith uses long deep stitches of silver wire inserted in 
sound tissue on one side of the anterior denuded surface completely 
under the latter, then out and under the posterior denuded surface 
in the same way. The loop of the stitch is now passed through a per- 
foration in a soft metal bar and'shotted. The remaining "stitches are 
passed in a similar manner, the loops of each being passed through a per- 
foration in the bar and shotted. The ends of the sutures are twisted and 
left long. 
Hewitt's Operation. -One plan of Dr. Hewitt's is to remove a triangu- 
lar strip of mucous membrane about two inches broad below, and about 
half an inch broad above, from the floor of the vagina, the upper end and 
apex of the triangle being quite close to the os uteri. The ordinary peri- 
neal operation is then performed. His other plan is to remove two tri- 
angular strips from the vaginal canal, one on each side of the vagina, 
then follow it with the perineal operation. The edges are brought into 
apposition by means of silver wire, an ordinary short curved needle such 
as is used in vesico-vaginal fistula being used to carry it. He uses the 
ordinary post mortem stitching which acts'as a splint stitch. 
The Method of Dr. Savage.-Dr. Savage entered the perineal cavity by 
removing the mucous membrane upward along the floor of the vagina, 
but he relies on deep sutures for securing coaptation. This only differs 
from Simon's operation in the stitching-Simon using the ordinary stitch. Surgical Treatment of Prolapsus Uteri'. 
5 
Dr. Gillette has operated successfully by passing stitches under the 
mucous membrane without denuding it, by simply condensing the walls 
of the vagina. 
Dr. Schroder denudes the whole surface of mucous membrane within 
an oval, and buries the sutures in the submucous tissues across the whole 
face of the wound. 
Mr. I. Baker Brown's Operation was devised to meet those cases in 
which there was a deficiency of perineum from laceration. He denuded 
the posterior wall of the vagina an inch above the raphe of the perineum, 
and up the sides of the orifice two-thirds of the inner surface. 
Lateral and Bilateral Elytroraphy are indicated, perhaps, in an excep- 
tionally broad vagina. 
Episiorrhaphy or contraction of the vulva, is done by uniting the pos- 
terior three-fourths of the labia majora -the labia minora being removed, 
the vivified edges are united by wire sutures. 
Obliteration of the Vulval Ring.-This may be done by infibulation as 
practiced successfully by Schieffer in 1856, Aran did four cases in 1859, 
result not known. 
Martin's Operation.-Martin aims at restoring the posterior columns of 
the vagina. He makes raw surfaces on the posterior wall, and a raw sur- 
face around the introitus. The opposing edges are united in the vaginal 
wall. The denudation resembles an anchor with a double stock. The sur- 
faces on the stock being brought into apposition on each stock separately. 
Huguier's Operation.-Marion Sims has said, that, as a rule conoid 
amputation should only be made when there is hypertrophic elongation 
of the intra vaginal portion of the cervix as well as procidentia and supra- 
vaginal hypertrophy. Courty holds the same opinion. The operation 
consists in removing a part or the whole of the cervix with the upper ex- 
tremity of the vagina, by scooping it out from without inwards, after hav- 
ing previously detached the bladder from the part which is to be removed. 
Courty says: The object of the operation is not merely to amputate the 
subvaginal portion of the cervix, but also to remove that extending be- 
tween insections of the vagina and the body of the organ, which is the 
principal seat of hypertrophy." The dangers to be avoided are lesions 
to the perineum and to the bladder. When the malady is preceded by a 
rectocele or cystocele, or by both, it may be necessary to operate upon 
the herniae of the rectum and bladder separately. Huguier has devised 
an interesting operation for this, which 1 take from Courty. "For 
cystocele, after having previously dilated the urethra with prepared 
sponge, he introduces the little finger by this canal, and if possible, the 
index finger of the left hand into the bladder. He seizes the tubercle 
and the anterior wall of the vagina with a small pair of Museux's forceps, 
making an assistant draw them downward and forward, so as to stretch 
them and separate them, if possible, from the corresponding wall of the 6 
Surqical Treatment of Prolapsus Uteri. 
bladder. Then he passes, at the base of the fold formed by the part of 
the vaginal wall which he wishes to remove, a long pin, or several pins 
crossed, for example four, forming two crosses, taking care that the pins 
traverse the cellular tissue lying between the vagina and bladder without 
touching the walls of this organ, of which he is warned by the finger in- 
troduced into the vesical cavity. He throws a loop of thread behind 
each cross formed by the pins, forms a pedicle of the whole with a triple 
thread and applies the ecraseur." 
Episio-perineoraphy consists in the greatest extent of juxtaposition by 
extending the excisions from the vulva to the perineum, and in the in- 
crease of the depth and resistsnce of the cicatrix which contracts the 
vulva behind, a portion of tissue in the shape of a horse-shoe is removed, 
and two sides united by a double set of sutures, three deep and three 
superficial. 
Critical Examination.-Savage says : Experience has shown the futile 
character of these and such-like plastic operations. The great susten- 
sibility of the vagina defeats their, object sooner or later." This very 
sweeping assertion is not sustained by the results of to-day. Gynecolo- 
gists all over the world are operating for prolapsus, with a success more 
or less favorable. Some cases fail in toto, others are only partially suc- 
cessful, while another class are permanently benefited in every particular 
for which surgical interference was demanded. Discrimination in the 
choice of an operation, a proper consideration of the conditions enjoin- 
ing it, with a just appreciation of etiological factors are as necessary here 
as in the larger operations. Anterior-elytroraphy is pre-eminently suited 
to some cases,.while Simon's and Hegar's operation will be followed by 
better results in another. Huguier's operation is a difficult and danger- 
ous one, but when carefully performed for the relief of certain conditions, 
is usually followed by happy results. Not even the majority of instances 
of complete or incomplete prolapsus is attended with perineal laceration, 
and I very much doubt if a prolapsed uterus has the power of lacerating 
the ano-perineal tissue, a prolapsed uterus follows the same general 
course as a foetal presentation, that is, the curve of the sacrum. If, the 
prolapsus prior to making its final turn under the pelvic arch, has pressed 
for a long time upon the perineum, the perineal body becomes distended, 
and the perineum itself thin and patulous. If, once escaped, it has re- 
mained unreduced for some time, the perineum becomes a thin edge of 
"atrophied recto-vaginal septum" the space between the rectum and 
vagina being lessened. Another case, is a prolapsus complicating a 
lacerated perineum from parturition in which, of course, the double 
operation is demanded. The long continued pressure of a prolapsed 
uterus upon the anterior perineal triangle, produces, in time, many of the 
changes incident to child-bearing, but never a laceration. The object 
aimed at is to secure a sufficient support for the uterus, in which the Surgical Treatment of Prolapsus Uteri. 
7 
vaginal walls shall act as natural pessaries, to strengthen the perineum 
and to increase its saggital dimensions. These are the primary points of 
consideration in instances of simple prolapsus complete or incomplete, 
we desire to arrive at a position in which the final descent from under the 
pubic arch may be anticipated. If cystocele or rectocele or both shall 
accompany the prolapsed uterus, such an operation must be chosen as 
shall best meet these indications If the perineum be lacerated from 
any cause, the operation upon the vaginal walls must follow that of the 
reservation of the perineum, and here the incisions may be prolonged so 
as to narrow the vaginal outlet. Preservation of the perineum in what- 
ever way it may be done will not of itself prevent extrusion, and is useful 
only as affording a more permanent support for a pessary. The pro- 
lapse may be due to hypertrophic elongation of the infra-vaginal cervix 
or to elongation of the supra-vaginal cervix. In the former we have a 
"prolapse without locomotion of the fundus," for while the fundus may 
be slightly dragged down, it is the exaggerated nutrition of the cervix 
which causes such an elongation as to bring the os tinea near the orifice 
of the vulva. Here, too, we are apt to meet the conical cervix so often 
associated with sterility and dysmenorrhcea, or the tapiroid, an acquired 
form of hypertrophy due to defective involution, or to the "traumatisms 
of labor." (Goodell). For the relief of such conditions the redundant 
portion must be removed by the galvano-cautery or ecraseur, or by 
Hegar's operation, which consists in exsecting a wedge-shaped piece 
from the redundant tissue, and bringing the flaps together by deep 
stitches passed through the whole substance of the cervix; or the 
whole rim of the os may be stitched to the vaginal mucous membrane. 
Where infra or supra-vaginal hypertrophy are associated, Huguier's 
operation has met with success. 
Now, since neither form of these hypertrophic elongations constitutes 
a true prolapsus, if the plan of Huguier is to be resorted to only when 
procidentia accompanies both forms of hypertrophy, the cases will be 
exceedingly rare, since the occurrence is excessively infrequent. The 
fundus is always dragged down somewhat in these elongations, but there 
is no true prolapse, no descent of a fundus as a whole, and on the only 
part usually appearing outside the vulva is the elongated cervix of supra- 
vaginal hypertrophy. 
I do not intend to convey the impression that procidentia may 
not occur with elongations of both infra- and supra-vaginal cervix, but 
that such instances are extremely rare and are pathological curiosities. 
Veit (Zeitschrift f. Geburtsk., Bd. i, S. 144) believed that primary hyper- 
trophic elongation was very rare, and that this kind of hypertrophy was 
usually consecutive to prolapsus. The fact is just the reverse. It is the 
hypertrophy that simulates the prolapsus. Partial hypertrophy of the 
cervix may exist in the peripheric parts or in the parts which form the 8 
Surgical Treatment of Prolapsus Uteri. 
walls of the cervical cavity. Courty, who read a most interesting paper 
on this subject before the Academy of Medicine, May 22, 1877 (quoted 
by him in "Uterus, Ovaries and Fallopian Tubes," p. 616), says: "It 
exists most frequently in the median line. It is often congenital, de- 
pending on arrested absorption of the partition which separates primi- 
tively the two uteri, and of which the columns of the arbor vita are the 
vestiges." 
Anterior elytroraphy seems to have originated in the desire to rectify a 
cystocele which usually attends procidentia uteri. It may be objected to 
this operation. 1. That it is a delicate one, and 2. That it gives an 
insufficient artificial support to the uterus. The chief object is to make a 
proper support for the womb and for the anterior wall. If the uterus 
be prolapsed, and there is no rectocele dragging it down, if there be no 
hypertrophic elongation or perineal laceration, the operation of Sims or 
Emmet is probably the best. If the perineum be much dilated, if there 
should be a rectocele, colporraphy will be resorted to, or the colpo- 
perineoraphy of Hegar where the perineo plastic operation is demanded. 
Banga (American Journal of Obstetrics, July,'1882, "The operation for 
prolapsus uteri of.Simon-Hegar vs. that of Bischoff"), says: "I deem it 
my duty to revoke the statement made in my former article as to the 
feasibility of Bischoff's Kolpoperineoplasty in every case of prolapsus, 
however complicated. More extended experience has shown me that 
this more justly applies to the Simon-Hegar mode of operating." And 
again he says; "I always thought that anterior elytroraphy was essential 
to secure a good result in any severe case of procidentia. However, the 
two last reported cases go far to show that the assistance to be derived 
from such a primary operation had been greatly overrated. Anterior 
elytroraphy. had failed, and yet after colpoperineorraphy the prolapse 
was cured. Nevertheless, I shall continue to make anterior elytror- 
haphy, especially where the bladder descends very low." 
As a general rule I think the Simon-Hegar operation is to be preferred- 
bo'th because it is more easily carried out and meets more fully the require- 
ments. Again there are conditions of the posterior vaginal wall which ren- 
der Bischoff's method utterly impracticable. Anterior elytroraphy may 
be resorted to for the cure of the cystocele, and later on it may be fol- 
lowed by colpoperineoraphy. Cases of supra-vaginal hypertrophy of the 
cervix are best treated by Huguier's method, which seems to offer the 
shortest road to a permanent cure. Great caution must be used against 
wounding the bladder or the peritoneal reflection behind. The exposure 
of the cervix is attended with considerable difficulty, and its retraction, 
after being severed, must be guarded against by transfixing the uterus 
above that point. Le Fort's operation is an exceedingly ingenious one, 
and is preferable to either lateral or bi-lateral elytroraphy. It has the 
merit, too, of not interfering with coitus, while placingwithin the vagina an Surgical Treatment of Prolapsus Uteri. 
9 
obstacle "which, from its position, ought to prevent a return of the pro- 
lapsus better than any other operation." This operation may be supple- 
mented by perineoraphy if we desire to give more strength and re- 
sistance. 
Courty says: "Posterior colporaphy seems to me theoretically prefer- 
able, and my practice has justified this theory; I should therefore advise 
it when there is reason for attempting a radical cure of these maladies. 
If the cystocele has not yielded to this operation, anterior colporaphy 
may be added." 
Barnes states his conclusions as follows: "i. When there is prolapsus 
without marked elongation of the cervix, remove a portion of the mucous 
membrane of the anterior wall of the vagina on Sim's plan. 2. If there 
be considerable elongation amputate a portion of the redundant neck, 
and at the same time remove a triangular piece of the mucous membrane 
just in front of the cervix, the base of the triangle merging in the stump 
of the cervix, and bring the sides of the triangle together by sutures. 
3. If there be considerable rectocele, with impairment of the perineum, 
perform the perineal operation, or posterior colporraphy. 4. Where the 
three conditions co-exist, all three operations should be performed. It 
will generally be best to do this in successive operations." 
Mr. Whitehead (Manchester Medical and Surgical Reports, 1871, 
cited by Barnes), thought that to cure prolapsus we must aim more 
Plate I.-This drawing, from Hart and Barbour, shows the various 
forms of raw surfaces made on the posterior, vaginal wall. I I i i, 
Hegar's. 2222, Bischoff's. 3333, Simon's. 4 4 4 4, a b, 
Winckle's. 10 
Surgical Treatment of Prolapsus Uteri. 
to relieve the pressure from above than to diminish the weight of the 
uterus or to increase the strength of its supports. Consequently he made 
two triangles, the posterior one with its apex towards the os uteri, and 
the anterior one with its apex downwards-he also amputated the 
cervix. 
Hart and Barbour say: " Of all the raw surfaces recommended He- 
gar's is probably the best and simplest." 
Plate II.-Also from Hart and Barbour, shows Martin's operation. 
1234, raw surfaces on posterior vaginal wall. I. II, raw surface 
around introitus. The surfaces 1-4 are united., A to A., B to B. 
The edge 4B., is turned in with the corresponding one of opposite 
side, along the line a. The surface I. II is united by sutures, so 
that the English and Greek letters are in apposition. 
Plate III.-From Courty, shows the Colpo-perineoraphy of Simon 
and Hegar : C. P. R., juxtaposition of the right and left bleeding 
surfaces of the vagina and perineum kept in contact by alternate 
sutures; at the upper part a projecting fold of the vagina makes a 
supporting surface for the cervix ; E. vagina; C. U. vaginal portion 
of the cervix ; V. bladder; R. rectum. 
Reprint from the Obstetric Gazette, November, 1883.