COMPLIMENTS OF THE AUTHOR.

THE OPERATIVE TREATMENT OF COMPEETEPROLAPSUS UTERI ET VAGINAE 1

Georgk M. Edkbohhs, A.M., M.D.Professor of Diseases of Women at the New York Post Graduate Medical School and Hospital;

Gynecologist to St. Francis’ Hospital, New York.

Reprinted from thf. American Journal of Obstetrics,Vol. xxviii., No. i, 1893.

One purpose of this communication is to call renewed attentionto, and to emphasize, the fact that prolapsus of the uterus, evenin its severest forms, is readily, speedily, and permanently cura-ble by modern gynecic surgery.

My second object is to elicit, in the discussion to follow, yourindividual experiences and methods in the operative treatment ofcomplete prolapse of the uterus and vagina. For although wemay all agree that prolapsus is curable by operation, yet will weprobably differ considerably both in the kind and in the techniqueof the operations we employ.

Personally I am not wedded to any routine line of operativetreatment, but am inclined to be eclectic, and try to differentiatethe indications as presented in individual cases as far as I amable. And this notwithstanding a satisfactory degree of successin the employment of ventrofixation of the uterus combined withthe various plastic operations called for by the condition of theuterus, vagina, and pelvic floor, all required operations beingperformed at one sitting.

I have limited myself in this paper to complete prolapsus of theuterus and vagina—i.e. , to the consideration of those cases onlyin which the entire uterus and vagina are outside of the vulva.It will be readily granted that, provided we can deal successfullywith these extreme cases, the lesser degrees of prolapsus shouldoffer no special difficulties.

1 Read before the annual meeting of the American Gynecological Society1893-

2 EDEBOHES : THE OPERATIVE TREATMENT OP

The first question that arises in connection with the operativetreatment of complete prolapsus of the uterus is one of principle:Shall we endeavor to preserve the uterus, or shall we removethe prolapsed organ by total extirpation ? Until such time as itcan be shown that the results achieved by total extirpation of theuterus for prolapsus are better and more lasting, as well as thatthe operation is no more dangerous than the rivpl procedure, Ishall adhere to ventrofixation of the uterus combined with thenecessary plastic operations as the rule, practising total extirpa-tion only on exceptional indications.

Such exceptional indications, to my mind, are ;

i. A uterus so large and heavy that it cannot be reduced to anapproximately normal size and weight by amputation of thecervix.

2. A uterus presenting either positive evidence or strong sus-picion of malignant disease.

3. A uterus with appendages so diseased that the condition ofovaries and tubes calls for their removal, apart from other con-siderations.

It must be remembered, also, that total extirpation of theuterus is in itself not sufficient to cure complete prolapsus of theuterus and vagina, but that plastic operations, of one kind oranother, upon the vagina and the pelvic floor are required inaddition.

The only method of total extirpation for prolapsus claiming todispense with the necessity, in some cases at least, of these addedplastic procedures, is that advocated and practised by Dr. W. M.Polk. Dr. Polk opens the abdomen, removes the uterus fromabove, and attaches the cut end of the vagina to the abdominalwall in closing the wound of the latter. The ingenuity, origi-nality, and plausibility of the procedure recommend it strongly,even without the crucial test of its successful use by such a re-liable observer as Polk. Although I have no reason to be dis-satisfied with my experience, limited though it be, in the com-bination of vaginal hysterectomy with operations upon vaginaand perineum, I shall, in the next case of total prolapse calling,in my opinion, for total extirpation of the uterus, give the methodof Polk a trial.

My objections, then, to the routine practice of total extirpa-tion of the uterus for prolapsus of that organ and the vagina arebased on two grounds mainly. Firstly, because the practice isopposed to that rule of conservative surgery which calls for the

complete prolapsus uteri et vaginae. 3

preservation of all organs which by their presence menaceneither life nor health. Secondly, because total extirpationneither lessens the danger nor simplifies the operative technique,except, perhaps, when practised after the method of Polk.

On the other hand, with healthy tubes and ovaries, ventrofix-ation of the uterus, combined with plastic operations, preservesthe possibility »f child-bearing, and for that reason alone is en-titled to favorable consideration in quite a large number of women.

Leaving out of consideration now those exceptional instancesin which total extirpation is called for in the treatment of com-

plete prolapsus of the uterus and vagina, I would strongly insist,in all cases ofcomplete prolapsus, in the operative treatment ofwhich the uterus is preserved, upon ventrofixation of the uterusas an essential adjunct to whatever plastic operations upon theuterus, vagina, and perineum may seem called for.

A properly performed ventrofixation of the uterus gives a betterguarantee of permanent cure of the prolapsus than any one ofthe additional plastic operations singly, or perhaps than any givencombination of these additional operations looking to the pre-servation of a vagina, can give. And this preservation of a va-gina is a very important matter to nearly every one ofour patients.

Consequently I would lay it down as an axiom that wheneverthe uterus is preserved in prolapsus operations it should be secure-ly ventrofixated. I say securely advisedly, because in the onlyone of my cases of uncomplicated complete prolapsus in which Idid ventrofixation, and in which I have known a recurrence ofthe prolapse to take place (Case 4), I have reason to believe thatthe uterus was not properly ventrofixated, the transperitonealhysterorrhaphy of Krug having been performed. By this I donot mean to assert that the failure was due to the method ofoperation. The fault may have been with the operator, whosefirst as well as last experience with the method it constituted.

I confess to a considerable degree of scepticism regarding theability to obtain a permanent cure of complete prolapsus of theuterus and vagina by the various methods of vaginal fixation ofthe uterus after Schiicking, Dlihrssen, Mackenrodt, and others,although a number of operators seem to be satisfied with theirresults thus obtained.

Whatever plastic operations, joined with ventrofixation of theuterus, are indicated by the conditions presented in a given caseof prolapsus of the uterus and vagina, I cannot too strongly insist.

EDEBOHES : the; operative; treatment of4

d£

Name.

<VbJO <

State.Children.|

Conditionbeforeoperation.

Dateof operation.

Operationsperformed.

Result.

iK.W.48

Married.2

Tubesandovaries

normal.Com-

pleteprolapsusofuterus

and

vagina.Laceration

andgreat

hypertrophyof

cervix.

February 19th,1890.

Amputationofcervix.

Shorteningof

roundli-

gaments,Perineorr-

haphy.

April19th,1893:

Uterusat

nor-

malheightinpelvisandin

nor-

malanteversionVaginaand

perineumnormal.Slight

cys-

tocele.Hasbeendoingthe

hardestofhousework,and

con-

sidersherself

perfectlywell.

3M.P.44

Married.8

Ovariesandtubesnormal.Com-

pleteprolapsusofuterusand

va

gina.Lacerationand

enormoushypertrophyof

cervix.Uterine

cavity11.5

centimetresdeep.

March5th,

1890

Amputationofcervix-

Shorteningof

roundli-

gaments.Perineorr-

haphy.

Resultperfectsixweeks

after

operation.Notraceofpa-

tientsince.

3K.S.54Widow.4

Ovariesandtubesnormalin

size.

Completeprolapsusofuterus

andvagina.Uterinecavity13

centimetresdeep.Corvixdeeply

laceratedand

enormouslyhy-

pertrophiedExtensive

ulcera-

tionsofvagina.

June2d,

1890-Amputationofcervix.

Anteriorcolporrha-

phy.

Oolpo-perineorr-haphy.

Resultgoodon

discharge,a

monthafter

operation,since

whenpatienthasnotbeen

seenorheardfrom.

4L.M.35

Married,2

Ovariesandtubesnormalinsize.

Completeprolapsusofuterus

andvagina

Uterinecavity9.5

centimetresdeep.

Cervixlacer-

atedanddeeply

excoriated.December 3d,

1890.Anteriorcolporrhaphy

(pursestring

opera-

tion).Hysteror

rhaphy

(transperitonealmeth-

odof

Krug).Colpo-

perineorrhaphy.Completefailure,the

prolapsus

recurringintwo

months-Pro-

lapseduterusimpregnated;

abortusproducedby

family

physicianatthird

month.Sec-

ondoperationtwoyearslater

(Case10).

5E.F.38

Widow.2

Extensivediastasisof

rectiabdo-

minis.Ovariesandtubes

nor-

malinsize.Completeprolapsus

ofuterus

andvagina.Cervix

laceratedandmoderatelythick-

ened.

April1st, 1891.

Curettageof

uterus.Amputationofcervix.

Anteriorcolporrhaphy

(pursestring

opera-

tion).Ventrofixation

ofuterus.

Perineorr-haphy.

Remainswell

althoughdoing

thehardworkofa

restaurantcook.Uteruswellup,

firmly

attachedto

anteriorabdomin-

alwall.

Perineumandpost-

eriorvaginalwall

normal.

Slightcystocele.

Lastseen

April19th,1893-

COMPLKTK PROLAPSUS UTERI kt vagina. 5

6M.M.35

Married.3

Ovariesandtubesnormalinsize

Completeprolapsusofuterus

andvagina

Deeplaceration

andhypertrophyofcervix.

September 11th,1891.

Amputationofcervix-

Anteriorcolporrha-

phy.Ventrofixationof

uterusColpo-perin-

eorrhaphy.On

discharge,a

monthlater,

uteruswellupin

pelvis,

firmlyattachedto

abdominalwall.Vaginaandperineum

normal-Patientlostsightof-

7M.M.36Married5

Ovariesandtubesnormalinsize.

Completeprolapsusofuterus

andvagina.

Bilaterallacera-

tionandthickeningofcervix.

March11th,

1892.

Curettageof

uterus.Amputationofcervix.

Anteriorcolporrha-

phy.

Perineorrhaphy. Ventrofixationofute-

rus.

Miscarriedatsecondmonth,in

October,1892-

SeenApril

17th,1893.

Uterus,vagina,

andperineum

remainas

they

wereimmediately

afteroper-

ation.Complete

cure-

80.L.51Married.6

Ovariesandtubesnormalinsize

Completeprolapsusuteriet

vaginaeof

twenty-sevenyears’

standing.Unsuccessful

opera-

tions,incompetenthands,three

yearsago.

April1st, 1892.

Curettageof

uterus.Anteriorcolporrha-

phy.

Oolpo-perineorrhaphy.

Ventrofixationofuterus.

Perfectresult,the

patientre-

mainingcuredwhenlast

seen,morethanayear

after

operation.

9M.K28

(Single.Ovariesandtubesnormal.Com-

pleteprolapsusuteriet

vaginae,

theresultofaseverestrainat

liftingthree

yearsago.

Uterus

hasneverbeen

replacedsince

May6th,

1892.

Curettageof

uterus.Amputationofcervix-

Lateralcolporrhaphy.

Perineorrhaphy

•

Ven-

trofixationof

uterus.Patient

remainsabsolutely

cured,ayearafter

operation,althoughhavingdonethe

hardestwork

eversince

10L.M.37

Married.2

Case4-

relapsed!the

samecondi-

tionspresenting

asrecordedin

CaseNo4.

October4th,

1892.

Curettageof

uterusLateral

colporrhaphy-Perineorrhaphy.Bila-

teralsalpingo-oopho-

rectomy.Ventrofixa-

tionofuterus.

Perfectresult,

lastingtodate,

May13th,1893-

11R.W.45Married.10

Ovariesandtubesnormalin

size.

Completeprolapsus,of

uterus

andvagina.

Lacerationof

cer-

vix.

December 20th,1892.

Curettageof

uterusAmputationofcervix-

Anteriorcolporrha-

phy-

Colpo-perineorr-haphy-

Ventrofixa-tionofuterus.

Perfectresult,

withexception

ofslightcystocele,whenlast

seen,April15th,1893.

12M.0.61

Married.1

Ovariesandtubesnormalinsize-

Completeprolapsusofuterus

andvagina;Completeinversion

ofcervixuteri

January27th,

1893.Vaginalhysterectomy,

bothtubesandovaries

beingremoved

with

theuterus.

Lateralcolporrhaphy.

Perin-Perfectresult,lastingtodate,

May,1893*

•

eorrhaphy.

6 EDEBOHES : THE OPERATIVE TREATMENT OP

upon the performance of all of them, including the ventrofixation,at one sitting. Not only is our patient at this day entitled toexpect this from the expert and to claim only one anesthesia, butthe result must be better when all operations are performed atone sitting, each separate operation forming one stone of the arch,the integrity of which is endangered by even the temporary ab-sence of one such stone.

The various combinations of operations I have practised ineach of my twelve cases, comprising my entire experience, ex-

clusive of two cases already published, with the operative treat-ment of complete prolapsus uteri, will be found recorded in thetable appended. The two cases already reported were completefailures. In one 1 the prolapsus was due to a tubercular ascites.In the other 2 ventrofixation of the uterus was not performed.

As I have, in the second of the papers just alluded to, fullydescribed my technique in the performance of the various oper-ations entering into combination in the treatment of completeprolapsus uteri, I will not enter anew upon the subject here.

I will merely reiterate that I have abandoned shortening ofthe round ligaments as a prolapsus operation, for the reasonthat, although a good and permanent result was obtained inCase i of the appended table, it has signally failed to realizeexpectations in a number of cases of incomplete prolapsus inwhich I have employed it in conjunction with plastic opera-tions.

A phenomenon of quite frequent occurrence, in cases otherwiseshowing perfect results, has been the recurrence of a slight cys-tocele, not annoying to the patient, but still indicating to theoperator a desideratum in the shape of improved technique witha view to its prevention.

In the three cases in which lateral colporrhaphy was performedinstead of an anterior and a posterior colporhaphy, no cystocelewas subsequently noted. The writer believes that this result isnot merely dependent upon chance, but is associated with thefact that in performing lateral colporrhaphy we secure a holdupon the fixed lateral walls of the pelvis, whereas in anterior andposterior colporrhaphy we attach the vagina to movable organs,

1 “Tubal and Peritonical Tuberculosis,” Transactions of the American Gynecological Society, 1891.

2 “Combined Gynecological Operations,” American Journal of the MedicalSciences, September, 1892.

COMPLETE PROEAPSUS UTERI ET VAGINA. 7

the bladder and rectum. Re-descent of the vagina, draggingwith it the bladder and establishing a cystocele, is thus favored.

Another great advantage of lateral colporrhaphy lies in themathematical precision with which we are enabled to give anydesired size to the resultant vagina. By leaving, for instance,a longitudinal strip, three centimetres in width, in connectionwith the bladder, and another of equal size attached to the rec-tum, removing the entire lateral walls of the vagina betweenthese strips and approximating the lateral margins of the stripsby sutures, a vagina six centimetres in circumference and abouttwo centimetres in diameter will be left.

All the operations recorded for each case of the accompanyingtable were invariably performed at one sitting. Primary unionwas obtained in every plastic operation, and in all the ventrofixa-tions except two. In these a small mural abscess for a shorttime delayed complete recovery.

198 SECOND AVENUE.