THE TREATMENT 
OF 
PROLAPSUS UTERI 
By ERNEST F. TUCKER, M. D. 
Lecturer on Clinical Gynecology at the Medical Department of Oregon 
State University; Attending Gynecologist at St. Vincent's 
Hospital, Portland, Oregon. 
fRead before the Portland Medical Society in March, 1894.] 
[Reprint from Medical Sentinel of May, 1891. 
Portland, Oregon. THE TREATMENT 
OF 
PROLAPSUS UTERI 
ERNEST F. TUCKER, M. D. 
Lecturer on Clinical Gynecology at the Medical Department of Oregon 
State University; Attending Gynecologist at St. Vincent's 
Hospital, Portland, Oregon. 
[Read before the Portland Medical Society in March, 1894.] 
[Reprint from Medical Sentinel ot May, 1894. 
Portland, Oregon. THE TREATMENT OF PROLAPSUS UTERI. 
Ernest F. Tucker, M. D. 
Lecturer on Clinical Gynecology at the Medical Department of Oregon 
State University; Attending Gynecologist at St. Vincent's 
Hospital, Portland, Ore. 
In a condition of perfect health and a normal condition of 
the female pelvic organs; that is, with the uterus in physio 
logical anteversion, the cervix drawn well backward by the 
sacro-uterine ligaments, the posterior wall of the vagina drawn 
upward and forward by the levator ani muscles and kept well 
in contact with the anterior wall, thus preserving an acute angle 
between the axis of the uterus and the axis of the vagina, it is 
impossible for the uterus to escape from the pelvis. The few 
scattering cases that have been reported of prolapse occurring 
in virgins after some violence resulting in great and sudden 
increased abdominal pressure do not disprove the above state- 
ment, unless it could be conclusively shown that in these cases 
a perfectly normal state of affairs existed before the accident. 
In order, therefore, to render the escape of the uterus pos- 
sible, the angle between it and the vagina must be obliterated; 
this can only come about by retroversion or such a stretching of 
the sacro-uterine ligaments as will allow the cervix to drop 
downward and forward toward the pubic arch, carrying the 
anterior vaginal wall with it; particularly is this the case where 
the levator ani muscle has been torn or stretched and thus fails 
to keep the posterior vaginal wall in its proper position. 
Increased weight of the uterus, I believe, has very little to 
do directly with prolapse, although indirectly it may have a 
great deal to do with it when all the supports of the uterus have 
received serious injury, whereby they are rendered lax and weak 
and over-stretched. Increased abdominal pressure likewise may 
become a very important factor, after the damage has already 
begun, and, therefore, should receive serious consideration in the 
treatment of these cases. 
[Read before the Portland Medical Society in March, 1894.] 2 
Child-bed seems to offer just the necessary conditions to 
favor prolapse; here all the pelvic organs have undergone a 
severe stretching process; so that for a time all the tissues and 
supports of the uterus and vagina are weak, lax and devoid of 
their normal amount of tonicity; the cervix and perineum have 
possibly been torn, so that the process of involution is being 
greatly interfered with. In fact, 1 think I am safe in saying 
that all cases of prolapse are due to the accidents of parturition, 
which, in a large majority of cases, are entirely avoidable. I do 
not make this last statement to throw any blame on the obstet- 
rician, for I know only too well that often when he has done his 
duty most conscientiously, the patient refuses to,or perhaps cannot 
follow out his directions, and so the first step begins in a chronic 
process which may end in complete procidentia. 
Before speaking of the treatment of these cases I cannot 
help but say a few words in regard to prophylaxis. In the first 
place I should do away with the abdominal binder after labor, 
for if this is used in a way to exert any influence on the uterus 
it cannot help but increase the intra-abdominal pressure, thereby 
forcing the uterus lower down in the pelvis, and therby still 
further stretching its already weakened supports. In the second 
place, any injury whatever done to the pelvic floor should be im- 
mediately repaired, whenever the injury is apparent. Care 
should be taken to see that the uterus is kept anteverted; this 
can be greatly aided by seeing that the patient is not allowed to 
lie constantly on her back, but is induced to lie on her sides. 
She should remain in bed absolutely until involution is well 
under way, and should not attempt to do any work until it is 
complete. Any injury to the cervix should be repaired so soon 
as convalescence sets in, for at this time the operation would be 
much simpler, as the extensive tissue changes which take place 
in lacerated cervix have not yet occurred. 
If these precautions could always be enforced and faithfully 
carried out, I am sure we would rarely see any cases of prolapse, 
except those lesser of degree which occur in nulliparous women 
and are the result of retroversion and chronic inflammatory proc- 
cesses. As to the treatment of this condition when it has oc- 
curred, it should have for its aim the repair of the injuries which 
have brought about the prolapse in the first place. 
Alexander's operation, which has been more or less popular, 
does not seem to me to cover the ground. The round ligaments 
in the normal condition have nothing to do with the support of 
the uterus, and, therefore, it does not seem to me to be good 
surgery to throw work on these ligaments for which they are 
not prepared by nature. Besides, the most ardent advocates of 3 
this operation urge the necessity of first repairing injuries to the 
pelvic floor, to which, if they added reduction of the weight of 
the uterus and rest in bed, shortening of the round ligaments 
would be unnecessary, providing their plastic surgery was of the 
right kind. 
In the supplement to the Refererence Hand-Book of the 
Medical Sciences there is an article by Dr. F. W. Johnson on 
this operation, with a report of 152 cases, which, however, were 
mostly cases of retroversion, but as retroversion rarely exists 
without prolapse, it is fair for us to consider results from this 
point of view. Out of these 152 cases he reports the results.of 
131 as perfect; in another column of his statistical table, under 
the head of "Relief of Symptoms," only 50 cases are asserted to 
have obtained relief; that is 87.4 per cent with a perfect result 
and 33 per cent with relief of symptoms, the object, 1 take it, 
for which the operation was performed. 
These observations, too, were probably made within a few 
weeks of the operation, so that if the ultimate results in these 
cases could be obtained, I am afraid the percentage of his re- 
lieved cases, would fall still lower. 
On page 37 of volume IV. of The New York Journal of 
Gynecology and Obstetrics is an article by Dr. Arthur Bird, 
from which I quote the following: "The disadvantages are, 
first, that shortening the round ligament does not relieve the 
condition causing the displacement; that it is directed to the 
relief of a symptom and not to the cause; secondly, that it does 
not restore the uterus to its normal position, or plane, in the 
pelvis, and that the obstruction to the circulation is not relieved, 
but, on the contrary, the obstruction is often increased." 
This expresses my views regarding the operation, although 
my personal experience is limited to the observation of only six 
cases, in all of which the ultimate results were bad. 
As to ventro-fixation, I think it should be condemned for 
the same reasons as Alexander's operation, as it merely substi- 
tutes one pathological condition for another, besides being a 
much more serious operation. 
As to hysterectomy, or rather the total ablation of the gen- 
erative organs, for the relief of prolapse, I can look at it in no 
other light than that of its being an act of barbarity, in spite of 
some of the eminent authorities who have performed the opera- 
tion with this end in view. At the meeting of the American 
Gynecological Society last May, after the reading of a paper by 
Dr. Edebohls of New York on this subject, Dr. Emmett, who 
has certainly had more experience in the treatment of these cases 
than any other man, said: "I have seen very few cases of pro- 4 
cidentia that could not be relieved by plastic surgery, * * * 
but I have never yet failed to keep the uterus within the vagina." 
It seems to me as if this were almost criticism enough on 
this subject. But, to go further, at a meeting of the Berlin Gyne- 
cological Society last April, Veit reported a case of vaginal 
enterocele that had been published by some one else as an in- 
stance of cure, after long observation, of prolapsus uteri by total 
extirpation; the woman had more serious symptoms than ever 
before. Duvelius stated that he had seen several cases of relapse. 
Mackenrodt had also observed the same unsatisfactory results 
following total extirpation of the uterus. 
Hysterectomy is not then a universal panacea to the suffer- 
ings of womankind. 
The treatment which I consider rational in these cases is 
that which, as I have said above, is directed against the causes 
which have brought about the prolapse, and this will apply, I 
think, to all degrees of the condition. 
In the first place, the patient should be informed that it 
will take time, and perhaps a long time, to effect a total cure of 
her symptoms, but with perseverence on her part and a strict 
compliance with the rules laid down for her, she may expect to 
get well without undergoing any serious operation or losing any 
of her sexual organs. She should be instructed not to under- 
take any work which brings her abdominal muscles into strong 
contraction; if it were possible, in cases of complete prolapse, rest 
in bed would be to her great advantage; the clothes about her 
abdomen should be as loose as possible; if they could hang en- 
tirely from the shoulders, so much the better. Any faulty di- 
gestion or assimilation should be looked after and prescribed for. 
The uterus, if outside of the vagina, should be replaced and 
maintained at its proper plane, in order to restore perfect circu- 
lation through it. This can be done by intelligently applied 
cotton tampons, and if the gaping of the vulva is such that these 
tampons cannot be retained, they may still further be held in 
place by a napkin and a pad worn as during menstruation. 
If these tampons are soaked in glycerine and iodoform they 
have a still further beneficial effect on the hypertrophied uterus. 
Where the uterus is only prolapsed in what the text-books gen- 
erally call the first degree, and is retroverted and adherent, the 
same treatment should be carried out, with the tampons applied 
while the patient is in the knee-chest position. 
Adhesions will yield to pressure, and with properly ap- 
plied tampons we can maintain an almost constant pressure. 
To this can be added pelvic massage, which, in several cases 
in my hands, has seemed to be of the greatest benefit. At the 5 
same time, tr. of iodine may be applied to the vault of the vagina, 
and hot water douches thoroughly applied. 
When the uterus has begun to diminish in size and can be 
anteverted, the process can be still further hastened and main- 
tained by closing the laceration in the cervix, and no operation 
for prolapse can be successful without it. Amputation of the cer- 
vix is very seldom necessary and, I believe, results in more harm 
than good; but the operation for the laceration should be per- 
formed in such a way as to remove all the diseased tissue and 
should be carried up as far as where the original tear commenced. 
Scarifications applied to the cervix during treatment, before op- 
eration, often materially assist in relieving the local congestion 
of the parts. 
Next, any cystocele or urethrocele or tendency thereto should 
be corrected by an appropriate operation on the anterior vaginal 
wall; and, lastly, the perineum should be restored very thoroughly. 
I would always advise the performance of these operations at 
separate sittings, as to do any one of them conscientiously takes 
considerable time; besides, in this way the patient is obliged at 
intervals to keep her bed, which, I believe, is of the utmost im- 
portance, as it gives the natural uterine supports a complete 
rest, thereby allowing them to regain their strength and tone 
and putting them in a state to do their physiological work. As 
to this question of rest in bed, I have found it of great advant- 
age to have the foot of the bed raised, so as to take all pressure 
off the pelvic floor and also to assist in allowing the blood to 
flow out of the uterus as easily as possible. Patients readily be- 
come used to this position, and in a day or two hardly notice it. 
As to the selection of operation on the anterior wall, it is 
impossible to lay down any rules, as different cases have differ- 
ent requirements; as far as the perineum is concerned, Dr. Em- 
met's seems to me by far the most efficient. Tait's operation 
seems to have gained some popularity in the last few years, 
although I think now it is losing ground again; why it should 
ever have been taken up I cannot see, as it is self-confessedly 
almost useless, for in his work on "Diseases of Women and Ab- 
dominal Surgery," Vol. I., p. 144, speaking of prolapse, he says: 
"For a radical cure the operation for extending the perineum, 
which I have already described, is by far the best means, but it 
is useless to perform it on a woman likely again to become 
pregnant, as parturition will surely undo it." As operations 
for the repair of the perineum, in the majority of cases, take 
place during the child-bearing period, some other operation not 
possessing these defects had better be employed. 
In the performance of these operations, I must say before 6 
closing that the use of silver wire for sutures is preferable to 
me than any other materials, for the reasons that it is perfectly 
bland and unirritating, non-absorbent, aseptic, and, when prop- 
erly applied, does not bind the edges of the wound together but 
merely holds them in apposition in much the same way as might 
be done by a firm splint; a number of them acting together like 
a scaffolding, as it were. Dr. Emmett, whose success in plastic 
work has been almost phenomenal, attributes a great part of his 
success to the use of silver sutures. In the Berl. Klin. Wook., 
Nos. 37 and 38 for last year, Kehrer discusses the subject of 
prolapse at some length and is an ardent advocate of the plastic 
operations for its relief, and also advises performing these opera- 
tions at separate sittings and strongly urges the use of silver 
wire. 
It is a pleasure to me to quote these German authorities as 
gradually coming around to our American views on the value of 
plastic surgery in gynecological operations. 
It has seemed to me sometimes in perusing current med- 
ical literature of the last few years that the aim of surgery has 
been more in the line of accomplishing brilliant and daring op- 
erations than in that of relief to the patient. 
I do not wish in the least to detract from the glorious ad- 
vances that we have made in the treatment of abdominal cases, 
which previously had been regarded as incurable, but I do not 
think that we should go too far and believe that the only glory 
to the operator lies in performing wonderful operations, for I 
sincerely believe that the best surgeon is he who gives the most 
relief with the least mutilation.