Obstetrics and Gynecology International twenty-three diﬀerent kinds of pessaries, embracing every variety, from a simple plug to a patent threshing machine, which can only be worn with the largest hoops. They look like the drawings of turbine water-wheels, or a leaf from a work on entomology. Pessaries, I suppose, are sometimes useful, but there are more than there is any necessity for. I do think that this ﬁlling the vagina with such traps, making a Chinese toy-shop of it, is outrageous” [14]. Despite this sentiment, pessaries would remain popular throughout the eighteen hundreds. However, with the discoveries in asepsis by Lister and anesthesia by Morton, paired with advances in suture materials and surgical instruments, surgery would soon replace the pessary as the predominant method of treating uterine prolapse. 4. The Rise of Surgery The surgical management of uterine prolapse has been recorded as far back as the second century C.E. Soranus advised, “cutting oﬀ the black part,” when the prolapsed uterus became gangrenous [4]. Similarly, Berengario claimed he witnessed his father, a surgeon, remove a prolapsed uterus by scalpel asserting that not only had the patient survived, but also she was able to resume coitus. He later claimed to have achieved the same outcome using strong twine as an ecraseur [3]. Later, the prominent seventeenth century Dutch gynecologist Hendrik van Roonhuyse reported a case in which he extirpated a prolapsed uterus after multiple attempts by other caregivers had failed to adequately restore the organ (previously placed pessaries made of cork and wax had led to ulcerations, pain, foul discharge, putrefaction, and fever). The patient was reported to have survived, but van Roonhuyse provided no details of his surgical technique or of an anesthetic used, if any [3]. In these early reports it remains unclear whether “hysterectomy” meant removal of the cervix, the cervix and a portion of the uterus, or the uterus in total. During the mid to late 19th century, opening the peri- toneum for any indication remained a risky endeavor and was largely reserved for cases of presumed gynecologic malignancy [15]. Consequently, surgical attempts to treat uterine prolapse consisted of eﬀorts such as narrowing the vaginal vault (by colporrhaphy or the application of cautery or astringents), performing a perineorrhaphy or inﬁbulation, or oﬀering cervical amputation [10]. However, as the 19th century progressed, notable advances would take place. In 1877, the Frenchman LeFort—inﬂuenced by the works of German gynecologists such as Hegar, Simon, and Spiegelberg, who had the idea of occluding the vaginal introitus to restrain uterine prolapse—described the principle of partial colpocleisis, the operation that has borne his name since [16]. In 1886, Olshausen reported performing a laparotomy solely for the purpose of uterine ventroﬁxation [17]. In 1899, Watkins and Wertheim separately reported on the use of uterine interposition to treat uterine prolapse [12]. Although, by the end of the nineteenth century there were several treatments for uterine prolapse, the ability to achieve durable repairs remained elusive due to a limited understanding of female pelvic ﬂoor anatomy. 3 5. Mechanisms of Uterine Support In 1895, while practicing in Berlin, Alwin Mackenrodt published his comprehensive, and accurate, description of the female pelvic ﬂoor connective tissue. In regard to what have become known as the Cardinal or Mackenrodt ligaments he remarked: “This whole ligamentous apparatus appears so excellent and extensive that it is quite sur- prising that it has not been recognized previously” [12]. Shortly thereafter, Fothergill, building upon the work of his senior colleague, the prominent Manchester obstetrician gynecologist Archibald Donald, recognized the importance of the Cardinal ligaments to uterine support and perfected what became known as the Manchester-Fothergill surgery. Fothergill’s procedure involved dissecting the bladder oﬀ the lower uterine segment followed by plication of the parametrial and paravaginal tissue at the anterior aspect of the cervix, thus eﬀectively shortening the uterine supports. He would combine the aforementioned steps with an anterior and posterior colporrhaphy and perineoplasty to keep recurrence in check [12, 18] and later would advocate cervical truncation as part of the surgery [19]. Fothergill would become a vociferous proponent of the belief that the parametrial (and paravaginal) fascia was the key structure to maintaining uterine support [20]. Referring to Peter Thompson’s research on the comparative morphology of the levator ani muscles in tailed apes and man [21], he considered the levator ani muscles withered muscle bodies no longer required to carry out their original function (tail movement) and therefore deemed them inadequate supports for the uterine body. He remarked, “Injuries to the perineum and levator ani doubtless straighten and widen the road from the pelvic cavity to the exterior. But if the organs remain ﬁrmly attached above, no mere enlargement of the opening below will make them come down.” To bolster his thesis, Fothergill was fond of noting, “The true supports of the uterus can be seen at vaginal hysterectomy. . . Let him incise. . . round the cervix, and. . . freely divide the posterior attachments...Next let the operator deliver the fundus. . . this aﬀords another proof that the broad and round ligaments have no value as suspenders. . . the uterus still remains ﬁxed by the tissue known as the parametrium, and by this alone. Until this is divided. . . the organ is. . . as completely supported as before an incision was made” [20]. In 1934, Bonney published, “The Principles that Should Underlie All Operations for Prolapse.” Using basic analogies such as an in-turned ﬁnger of a rubber glove and the securing of stove piping in a metal box, Bonney was able to convey the manner in which the pelvic viscera are supported [22]. These concepts would later be reﬁned by DeLancey and described as levels of fascial supports: level I: proximal suspension; level II: lateral attachments; level III: distal fusion [23]. In 1936, Mengert, inspired by 1858 cadaveric data from Legendre and Bastien, published a simple but inﬂuential study in which cadaveric uteri were subjected to traction with a 1 kg weight while structures attached to the uterus were severed in various sequences. The uterine descent observed after incising the parametrial tissues reinforced Mackenrodt’s anatomic research and Fothergill’s clinical observation,