results of operative treatment of prolapsethis condition is not common in multiparous women....

November 1953 BENTALL: The Results of Operative Treatment of Prolapse 545

but where abscesses or fistulae are present, theseare clear indications for preliminary ileocolostomywith exclusion. It this does not give relief,resection can be done more safely at a secondoperation.The danger of the ' blind loop ' blowing Gut

following an exclusion operation seems to be moreapparent than real, because the deflection of thefaecal stream away from the diseased area causesthe stricture to relent.Whatever the form of surgery employed, there

is no doubt that the recurrence rate is depressinglyhigh.

SummaryCrohn's disease is a non-specific granuloma of

the gut, commonest in the terminal ileum, some-times involving other parts.An acute form of the disease mimics appendi-

citis and is seldom recognized until the belly isopened. Nothing more should be done; appendi-cectomy is to be avoided as it may be followed bya fistula.

In its chronic stages the disease presents inmany ways, but its important features are chronicsmall intestine obstruction and the complicationsof subacute perforation. Operation may be neces-

sary, but whatever is done the chance of recurrenceis high.A follow-up study of 26 cases treated at one

hospital confirms these generalizations and empha-sizes the problem of the recurrent case.

In the chronic phase surgery should be lirnitedto those cases with clear evidence of obstruction,perforation, abscess or fistula formation, or severeintractibility.

I wish to thank Professor R. S. Pilcher for hisassistance in preparing this paper, and also theconsultant staff of University College Hospital forpermission to follow-up their patients.

BIBLIOGRAPHYARMITAGE, G., and WILSON, M. (1950-5i) Brit. Y. Surg.,

38, 183.BOCKUS, H. L. (I945), Y. Amer. med. Ass., 127, 449.CHESS, S., CHESS, D., OLANDER, G., BENNER, W, and

COLE, W. H. (I950), Surgery, 27, 221.COOMBE, C., and SAUNDERS, W. (I813), Med. Trans. Roy.

Coil. Phys. Lond., 4, I6.CROHN, B. B., GINZBURG, L., and OPPENHEIMER, G. D.

(1932), Y. Amer. med. Ass., 99, 1323.DALZIEL, T. K. (1913), Brit. med. 9'., 2, Io68.FELSEN, J. (1936), Amer. Y. Path., 12, 395.GARLOCK, J. H. (1946), Amer. 9'. Surg., 72, 875.HADFIELD, G. (I939), Lancet, ii, 773.HAWTHORNE, H. R., and FROBESE, A. S. (I949), Atnn. Surg.,

130, 233.HOMB, A. (1946), Acta. chir. scand., 94, 343.KANTOR, J. L. (I934), 9. Amer. med. Ass., 103, 20I6.PATEY, D. H. (I949), Proc. Roy. Soc. Med., 42, 769.

THE RESULTS OF OPERATIVE TREATMENTOF PROLAPSEA follow up of 340 cases

By A. P. BENTALL, M.A., M.D., M.R.C.O.G., D.C.H.Assistant Obstetrician and Gynaecologist, Norfolk and Norwich Hospital

IntroductionAt least twice a week the majority of gynaeco-

logists throughout the country come to the stagein their operating lists where, having taxed them-selves with the more exacting problems earlier on,they can sit down to deal with one or two cases ofprolapse before the hard part of the morning'swork is over. They are justified in expecting thatthe operation, though it may be tedious, especiallyto the assistant standing with bent back, will runsmoothly and according to the usual routinevaried but slightly to suit the particular nature ofthe case. Their experience teaches them to expecttheir patients to have some difficulty in passingwater for a day or two, to be unable to sit downin comfort for about ten days and to be anxious to

return home, usually with thanks for what hasbeen done, at the end of three weeks.We do not often see a recurrence and when we

do the original operation was often done elsewhereand we assume that it was done inefficiently. Wefeel justified in thinking that the great majority ofour own patients get on well and remain eternallygrateful, but in reality we know little of the endresults of the vast number of operations forprolapse which are done throughout the countryevery year.A study of the literature on the subject is not

very helpful. Publications on the results have beensurprisingly few in recent years and such as areavailable give a very varied picture of the successwhich may be expected, the picture usually

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depending on the thoroughness with which thecases were followed up.

In an attempt to ascertain the degree of successwhich is being achieved the results of 340 casesoperated upon in the years I948-5I have beenstudied; 240 of these cases have been treated inan outlying hospital where, in the absence ofa resident medical officer, the day-to-day care hasbeen undertaken by local practitioners. Thereamining IOO who, by reason of their age orsome medical complication, were in need ofcloser supervision, were treated in the main centre.

Certain conclusions have been reached fromthe experience gained in the treatment and followup of these cases and, in view of the paucity ofliterature on the subject of this everyday operation,they have been recorded.

SymptomsThe average age of the 340 patients was fifty-

one. Although multiparity is usually regarded asa predisposing factor in the production of pro-lapse, large families seem to be increasingly un-common even in a rural area such as Norfolk andthe average number of children works out at only3-25.The symptoms of which the patient complains

vary greatly and bear surprisingly little relation-ship to the degree of prolapse or anatomicalabnormality which is found on examination.Backache, a dragging sensation in the lowerabdomen or a feeling of ' something coming down'seem to be the most common presenting symptoms.The complaint of stress incontinence deserves

special consideration. It was confirmed, as wasemphasized during the discussion on the subjectat the 13th British Congress of Obstetrics andGynaecology (Jeffcoate, 1949), that the occurrenceof this symptom bears little relationship to thedegree of prolapse or cystocoele which is present.Stress incontinence was present to the extent ofcausing notable inconvenience to the patient in132 cases (39 per cent.). This means that in 207,or 6i per cent., of the cases, all of whom hadprolapse of sufficient degree to merit surgicaltreatment, there was no significant complaint ofstress incontinence. The symptom was severeenough to constitute one of the patients' principalcomplaints in 44 cases (II per cent.). Seventeenpatients, i.e. 5 per cent. of the total number andI2 per cent. of those with any complaint of stressincontinence, suffered from this complaint in asevere degree without any demonstrable uterineprolapse or cystocoele.

Complete procidentia, often with accompanyingulceration, was present in 41 cases (II per cent.).The age incidence and parity of these cases was

above the average, being sixty-three and 4.5 years,respectively.

Certain associated medical conditions wereencountered relatively frequently. Visceroptosisof sufficient degree to justify the wearing of aspecial belt was noted 27 times at the initialexamination. Functional uterine haemorrhage waspresent in 20 cases and fibroids in 6, althoughthis condition is not common in multiparouswomen. Prolapsed piles sufficiently severe tomerit surgical treatment were seen in I2 cases.Some degree of hypertension was common, butwas sufficiently severe to call for special con-sideration by the anaethetist on I2 occasions.Diabetes called for special supervision in 9 cases.Operation was contraindicated by cardiac failurein i case and by arthritis so severe as to preventadequate abduction and flexion of the hips fora surgical approach in another. I have onlyadvised against operation on 3 other occasions,and these were cases where the patients' age anddebility would have prevented their leading a lifeof any activity even if the prolapse were cured.

Certain other symptoms deserve considerationowing to the frequency with which they areencountered. Bleeding from chronic cervicitis,cervical polyp and, particularly, from ulcerationof the vaginal vault due to the prolonged use ofa ring not infrequently cause the general prac-titioner to refer the case as one of post-menopausalbleeding and possible malignant disease. Senileatrophy of the uterus predisposes to the conditionof prolapse and is often accompanied by senilevaginitis with an atrophic vaginal mucous mem-brane, calling for treatment with oestrogens priorto operation. One other symptom I have par-ticularly noticed to be misleading; the sorenessand swelling resulting from infection of the vaginawith trichomonas vaginalis has resulted in nota few patients being told that they require operativetreatment for prolapse when suitable local treat-ment will soon clear up their symptoms withoutany resort to surgery.

Operative TechniqueThe patients are usually admitted to the ward

in the afternoon or evening two days beforeoperation so that they have two nights and oneday to accustom themselves to their surroundings.Preparation, apart from routine procedures ofcleanliness, shaving, enema, etc., consists of apreliminary antiseptic douche, after which a swabsoaked in a i in a i,ooo solution of flavine is leftin the vagina. Only in cases where there has beensevere and obviously infected ulceration orgross oedema from procidentia has any longerpreparation been undertaken.The operative procedure adopted follows the



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principles of the Manchester type of operationsimplified to the utmost degree so that in themajority of cases the operation is not undulyprolonged and the duration of the anaesthetic andthe degree of shock, caused to the patient is cutdown to the minimum-a point of importancewhen it is remembered that the majority of thepatients are not ideal subjects for operation. Thepresence of three assistants, at least two of whomare trained in the procedure to be adopted, greatlyfacilitates the rapid performance of the operation.

Preliminary dilation of the cervix and curettageis carried out when there is any history of irregularbleeding or where the age and parity of the patientmake carcinoma of the body of the uterus apossibility, but not otherwise. A triangular areaof the anterior vaginalmucous membrane isremoved, the shape of this triangle varying withthe degree of prolapse and cystocoele present.The cervix is amputated and descending cervicalbranches of the uterine artery ligated on eitherside. The posterior lip of the cervix is recon-stituted and covered with mucous membrane bythree interrupted sutures, the centre one of whichdraws the mucous membrane into the entrance ofthe cervical canal. The remains of the cardinalligaments, previously marked by tissue forceps,and the mucous membrane, are brought togetherfrom either side to support and cover the anteriorlip of the cervix by two interrupted sutures; theanterior colporrhaphy is completed by a singlecontinuous catgut suture inserted with deep bitesso that a firm hold is obtained of the mucousmembrane and underlying musculo-fascial tissueon either side.The posterior colporrhaphy is carried out by

excision of a triangular area of mucous membranefrom the posterior vaginal wall, the base of thetriangle being at the perineum; the length of theincision at the base of the triangle depends on thedegree of deficiency of the perineum, while thedistance to which the apex of the triangle is takenup the posterior wall depends on the degree ofrectocoele and vault prolapse which is present.When this has been done the perineal muscles,particularly the levatores ani, are exposed andinterrupted sutures, usually three, are inserted tobring them together in the midline. The mucousmembrane of the posterior vaginal wall is thenbrought together by a single continuous suture,the underlying muscular stitches being tied as theirlevel is reached coming down the posterior vaginal'wall. The operation is completed by a few 'inter-rupted sutures of finer catgut to bring togetherthe mucles and skin of the perineal body. Finallya swab soaked in flavine and paraffin is insertedinto the vagina to prevent adhesions between theanterior and posterior suture line.

AK..

I

IxFIG. ia.-Amputation of the anterior lip of the cervix

only. After reflexion of the flap of anterior vaginalmucous membrane, the upper limit of the wedgeto be excised from the denuded anterior lip beingmarked with a guiding suture.

* K... ,

N

4*6.t3JI. .

FiG. ;ib.- After removal of the wedge from the anteriorlip of the.cervix.

This routine 'procedure is modified in threeways accord.ing to circ.umst'ances:



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548 POSTGRADUATE MEDICAL JOURNAL November I953

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FIG. Ic.-After repair of the cervix, ready to proceedwith the anterior colporrhaphy.

(i) In cases of marked vault prolapse orenterocoele it is often wise to open the pouchof Douglas; the depth of this pouch, whichunder these circumstances may be regarded asa hernial sac, may then be decreased by a pursestring suture placed as high as possible and thefloor supported by bringing the uterosacralligaments together in the midline as describedby Read (949). This type of prolapse isdifficult to cure and has been responsible forthe majority of my own failures. It is pointedout in the description quoted above that manycases of so-called ' recurrent ' enterocoele arenot ' recurrent ' but ' neglected ' cases ofenterocoele and a careful watch for such a con-dition and the adoption of the above procedurehas resulted in definitely improved results.

(2) In cases where cystocoele or laxity of theanterior vaginal wall is present without anymarked uterine prolapse, complete amputationof the cervix is technically difficult and oftenseems unnecessary, but an anterior colporrhaphy

alone elevates the bladder and anterior vaginalwall without corresponding elevation of thecervix; the uterus often remains in its originalvertical or retroverted position and is notanteverted as it should be when Fothergill'soperation has been well carried out. Indeed,when anterior colporrhaphy alone has beencompleted, the cervix often looks more pro-lapsed than it did before, owing to the elevationof the anterior vaginal wall.Under these circumstances a wedge-shaped

area is excised from the anterior lip of thecervix so that the remains of the cardinal liga-ments may be brought together in front of thecervix as they are when it has been whollyamputated. This results in a tidy repair of thecervix, which is so often lacerated and erodedalthough it is not markedly prolapsed, and it iselevated and restored to its natural relationshipwith the repaired anterior vaginal wall (Fig. ia,b and c).

(3) In cases of marked stress incontinenceunaccompanied by any very significant cysto-coele or prolapse, a more through dissection ismade exposing muscular tissue lateral to theurethra and bladder neck. These structures arethen elevated by two or three buried suturesbefore the anterior colporrhaphy is completed.

In this series of cases vaginal hysterectomy andrepair has only been carried out where there wassome associated abnormality of the uterus, makingits removal desirable. In cases where this seemedlikely to be technically difficult owing to littleuterine descent, I have had no hesitation inremoving the uterus per abdomen after the neces-sary repair had been carried out from below.This double operation does not seem to be follQwedby any undue shock provided the repair is carriedout simply and rapidly as described. (Sincereading of the operation of ' abdominal colpor-raphy,' as described by MacLeod (1952), thisdouble operation has been avoided on severaloccasions with results which at- present seemcompletely satisfactory. It is perhaps worthy ofnote that four cases of moderately severe stressincontinence, together with other uterine symp-toms, appear to have been completely cured bythis procedure.)Worry about the possibility of a further preg-

nancy not infrequently interferes with the com-plete restoration of physical and mental well-beingwhich might be anticipated after a successfuloperation for prolapse. In cases where the motheris already overburdened with the responsibility ofa large family or where there is some associatedmedical abnormality to contraindicate furtherpregnancies in addition to the contraindication of



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November I953 BENTALL: The Results of Operative Treatment of Prolapse 549

the risk of a recurrence of the prolapse after afurther pregnancy, sterilization may well beadvisable. (In this series a history of severe vari-cose veins, often accompanied by thrombo-phlebitis, was a common additional contra-indication to further pregnancy.) Where there ismarked descent of the uterus, it may be an easymatter to open the peritoneum at its reflectionfrom the bladder to the uterus and excise a portionof both fallopian tubes from below; where thereis not enough prolapse to make this an easy pro-cedure it takes very little longer, and causes muchless anxiety to the surgeon, to complete the repairin the usual way and then excise a portion of bothfallopian tubes per abdomen; adequate peri-tonealization of the ends of the tubes is muchmore easily achieved when this is done.Having seen the extreme discomfort caused by

prolapsed piles during convalescence after opera-tion for prolapse, I could not believe that it couldbe any worse if haemorrhoidectomy was carriedout at the same time; I now follow the repairoperation by haemorrhoidectomy in all caseswhere severe prolapsed piles are present; thediscomfort to the patient seems to be very littlegreater than after posterior colpo-perineorrhaphy.and the results encourage me to continue withthis practice.The relative frequency with which the various

procedures described have been employed isillustrated in Table i.

TABLE INo. ofpatients

Routine procedure .. .. .. .. 252Routine procedure with amputation of anterior

lip of cervix only .. .. .. .. 36Anterior Colporrhaphy only (usually including

amputation of anterior lip of cervix) .. 7Posterior colpo-perineorrhaphy only (usuallycombined with repair of third-degree tear).. 4

Urethroplasty only .. .. .. .. I7Repair and subtotal hysterectomy .. .. 4Vaginal hysterectomy .. .. .. .. 20Repair accompanied by sterilisation:

Per abdomen . ... .. .. I8Per vaginam .. .. .. .. .. 12

Repair accompanied by haemorrhoidectomy .. I2D. & C. and repair followed by X-ray menopause 6

Post-Operative ComplicationsThe principles of the post-operative regime in

these cases are, irt the first place, to secure physicaland mental rest for the patient, which includes therelief of pain, until healing is complete; secondlyto encourage the re-establishment of normalfunction of the bladder and bowel and, thirdly,to encourage clean healing of the wound by suchmeans as hot baths and douches.The patients are encouraged to get up for a

short time on the third day and by the end of

a week they are helped into a bath; thereafterbed-pans can be dispensed with. Although thepatient is on her feet for short intervals from anearly stage, a full three weeks in hospital is con-sidered essential and, so far as possible, arrange-ments are made so that they do not have to returnto full household duties for two weeks after theirdischarge.The patient is encouraged to pass her water

naturally from the start, but if she is unable to doso, a catheter must be passed every eight hoursuntil one is satisfied that the bladder is beingproperly emptied. In spite of the utmost care,a urinary infection is very common and, for thisreason, prophyllactic treatment with a suitableform of sulphonamide is given as a routine forthe first five days. It is striking that, when thesecases are treated as a routine by a nursing staffaccustomed to dealing with cases of prolapse,natural micturition is established much soonerthan when only an occasional case is dealt with.Early rising is also a help in this respect.With such treatment, complications are unusual

and the convalescence may be expected to besmooth. An analysis of the complications en-countered in this series is given in Table 2. Therewas one death from pulmonary embolism.Moderately severe secondary haemorrhage requir-ing packing of the vagina was encountered on 7occasions. Further treatment for cystitis afterthe routine prophylactic treatment was completedwas required in I2 cases and a febrile reactionattributed to chest complications was encounteredi8 times, but in all cases was rapidly overcomewith treatment with penicillin; in only a smallproportion of these cases were the physical signssufficiently well defined to warrant a diagnosis ofbroncho-pneumonia. In only one case did thepatient's immediate post-operative condition giverise to grave anxiety; this may have been due toexcessive blood loss at the time of operation or tothe use of intravenous pethidene during theanaesthetic. Recovery was normal after bloodtransfusion.

TABLE 2. POST-OPERATIVE COMPLICATIONSDeath (pulmonary embolus) .. .. I (0.29%)Secondary haemorrhage . . 7 (2%)Persistent cystitis .. .. .. .. 2(3.5%)Chest complications .. .. .. I8 (5.3%)Superficial venous thrombosis .. .. 4Pelvic peritonitis (after vaginal hysterec-tomy in both cases) .. .. .. 2

Sepsis and superficial breakdown ofperineum .. .. .. .. 3

ResultsIn an attempt to assess the results of the treat-

ment described, a personal letter and question-naire was sent to each of the 340 patients, all of



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whom had their operation at least one year before.In the first question they were asked if theyregarded the operation as a complete success;the remaining questions related to any recurrenceof the sensation of something coming down and tomicturition symptoms. Every patient whoseanswer to the first question was other than ' yes'was sent an appointment to be seen again bymyself.

TABLE 3. RESULTS

Number traced: 3 I 8

Satisfactory result: 28o (88%)Patient regards operation as a complete

success .. .. .. .. .. 214Patient's complaint unrelated to prolapse

and result satisfactory on examination . . 66

Unsatisfactory result: 38 (I2%)Death (pulmonary embolus) .. ..Recurrence of cystocoele .. .. .. 3 )Recurrence of vault prolapse or high k 4%

rectocoele .. .. .. .. .. I I JTroublesome stress incoAtinence .. 8Dyspareunia .. .. .. 4Pyometra .. .. .. .. ..Patient did not regard operation as a com-

plete success and did not attend forfurther examination o.. .. .. I

The results of this enquiry are summarized inTable 3. Twenty-two patients could not betraced (three of these are known to have diedsubsequently from an unrelated cause). Thesepatients were omitted from the survey. Twohundred and fourteen patients regarded theoperation as a complete success (many of theseadded a touching word of gratitude, including onewho hoped that the surgeon would have a longlife and be spared to carry out this operation formany yeats to come !). Sixty-six of the patientswho did not regard the operation as a successwere seen again; a small proportion of these had-to be classed as failures,; the great majority hadcomplaints which were unrelated to prolapse;carcinophobia, functional uterine haemorrhage orjust a desire to be reassured that everything wasgoing on all right accounted for the greatestnumber. A complaint of persistent backache,often due to visceroptosis and relieved by asurgical belt, was not classified as an unsatis-factory result unless it was thought to be due torecurrent prolapse or retroversion after examina-tion. Ten patients who did not regard the opera-tion as a success but failed to. attend for furtherexamination were included in the number ofunsatisfactory results. An unsatisfactory resultwas found in 38 cases (i2 per cent.). In analyzingthese unsatisfactory results a localized recurrenceof cystocoele .was found on three occasions.

These were possibly attributable to the use of asingle continuous suture for the anterior colpor-rhaphy; the incidence is small (less than i percent.) and all three cases have been cured by afurther relatively minor operation. The risk fromthe use of a single continuous suture thereforeseems to be slight and is more than outweighedby the low incidence of post-operative complica-tions which must be partly due to the ease andrapidity of operation, especially in elderlypatients.A recurrence of some degree of vault prolapse

or high rectocoele in iI cases (3.4 per cent.) isdisappointing. In two cases the patient wasquite unconscious of the recurrence. No treat-ment is considered necessary at the present time,but they are being kept under observation in casethe condition gets worse. Five patients, all ofwhom had a complete procidentia of many years'standing say that they have been completely freefrom symptoms since they were fitted with asmall ring when the recurrence was recognized.Two cases have undergone further operation withresults which at present appear satisfactory andtwo are still waiting for this to be done. Over halfof these recurrences were in patients of over sixtywho had a complete procidentia prior to operation.This point is considered further in the discussionof the results of procidentia (vide infra).The total number of recurrences, cystocoele,

rectocoele or vault prolapse, is therefore 14 (4.3per cent.). It is of interest that, with one excep-tion, all these recurrences occurred within sixmonths of operation.One patient complained of attacks of abdominal

pain and intermittent dark brown discharge.Examination revealed a pyometra from stenosisof the cervical canal. Total hysterectomy wasundertaken, owing to the difficulty of excludingcarcinoma of the body of the uterus, and thepatient is in good health.The figure of only four cases of dyspareunia is

probably inaccurate. Enquiry regarding thispoint was not included in the original question-naire because, knowing some of thepatients inthis area, I felt sure that it would prevent a certainnumber from replying at all. All the patientswho were seen again were questioned about thispoint and difficulties were only encountered infour. In a small proportion of more elderlypatients with marked vault prolapse, the vaginalvault was deliberately overnarrowed; these patientswere told that complete intercourse might beimpossible after operation and so might notcomplain of it afterwards. Although the incidenceof this difficulty is almost certainly higher thanappears from these figures, I have formed theopinion that it is a relatively rare complication



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when the posterior repair has been carried outwith due care.

Further information can be gained from theseresults if they are analyzed with reference tocertain of the presenting symptoms:

Stress incontinence was present in I32 patients(39 per cent.) when they were first seen. Thiscondition was cured in 68 per cent. and greatlyimproved in a further 26 per cent. The resultsare summarized in Table 4.

TABLE 4. RESULTS-STRESS INCONTINENCENumber of patients with an initial complaint

of stress incontinence .. .. .. I32 (39%)Number traced .. .. .. .. 123

Cured according to their own statement 84 (68%)Still slight stress incontinence . . . . 31I (26%)Still severe stress incontinence ... .. 8 (6%)

Number of patients with severe stressincontinence unassociated with prolapse I7Cured according to their own statementand no stress incontinence demon-strated on examination .. .. (65%)

Still slight stress incontinence after plasticoperation from below (urethroplasty). . 3 ('7%)

Still severe stress incontinence *.. 3 (I7%)

Complete procidentia was encountered in 41cases. This was treated by the Manchester typeof operation on 39 occasions, which includedopening and decreasing the depth of the pouch ofDouglas and securing the uterosacral ligaments onfive occasions. Examination of the results showsthat some degree of persistent enterocoele waspresent in four cases (io per cent.). Two othercases were unsatisfactory, one being one of thethree cases of recurrent cystocoele previouslymentioned, and one developing a pyometra. Twocases were treated by vaginal hysterectomy withsatisfactory results. These results are disappoint-ing and indicate the importance of looking forthe associated enterocoele and dealing with itadequately. To my mind the results do notindicate the routine employment of vaginalhysterectomy except in those cases where thisprocedure is necessary to obtain adequate exposure-and support for the floor of the pouch of Douglas.

TABLE 5. RESULTS-COMPLETE PROCIDENTIA

Satisflactory UnsatisfactoryNumber of cases .. 41 35 (85-36%) 6 (14.66%)Routine operation 34 30 4Routine operationplus opening pouchof Douglas, etc. . . 5 3 2

Vaginal hysterec-tomy . .. 2 2 0

Examination of the age incidence shows thatoperation was undertaken at the age of seventy orover in I3 cases. Six of these suffered from long-standing complete procidentia and were only

driven to seek advice because they could nolonger get about or because of bleeding fromulceration of the prolapsed mucosa. In none ofthese cases was there any serious post-operativecomplication; in ii the results were completelysatisfactory; in two there was a slight persistententerocoele (already included in the unsatisfactoryresults of operation for complete procidentia).Both of the latter were rendered completely freeof symptoms by fitting a small ring.

TABLE 6. RESULTS-AGE INCIDENCE OF OVER 70Number of cases .. .. .. .. I3Results:

Completely satisfactory .. .. IIMarked improvement .. .. 2

DiscussionThe fact that 88 per cent. of the patients were

satisfactorily cured of their prolapse is gratifying,but consideration of the remaining I2 per cent.shows that there is room for improvement.

Fletcher Shaw (I934) advocating the employ-ment of an operation, the principles of whichare very similar to those here described, for alltypes of prolapse, reports 98.36 per cent. of 664cases ' completely cured.' On the other hand,Stallworthy (I940), in a very careful study of 268cases operated upon by different surgeons, reportsa recurrence rate of I3 per cent. (a; quarter ofthese being after a further pregnancy). Inaddition to this, io per cent. suffered fromsevere stress incontinence and io per cent. fromdyspareunia.

It is in cases of complete procidentia and entero-coele that opinions differ most, and examinationof the results in the present series shows therewas a recurrent of some degree of enterocoele inI0 per cent. Currie (1952) reports on the resultof 62 cases of ' massive prolapse ' treated by theManchester type of operation with a definiterecurrence in 4.8 per cent. and some bulging ofthe vault in a further 8 per cent.An alternative method, of treatment for this

type of case is vaginal hysterectomy and repair.It is questionable whether this gives any betterresults unless special precautions are taken todiminish the depth of the pouch of Douglas andsupport the pelvic floor. Gniou (1950) reports,a recurrence rate of 6 per cent. in $5 cases treatedby vaginal hysterectomy, which is no great'improvement on the figures given here.The importance of enterocoele and herniation

of the floor of the pouch of Douglas is clearlyrecognized by Veenbeer and Kooistra (1947), whodescribe a procedure which gives additional sup-port to this area by utilization of the utero-sacralligaments after vaginal hysterectomy. Theyreport only two failures in I04 cases.



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The observations of Read on this point havealready been mentioned (Read, I949). In a seriesof 139 cases, all of whom were operated uponspecifically for enterocoele (many of them afterprevious repair procedures), there was a recur-rence in only one, and 9I per cent. of the patientstraced were cured and symptom-free. Vaginalhysterectomy was employed in a very smallper centage of these cases. It would seem thatrecognition and adequate treatment of the entero-coele is the secret of success whether the uterusis removed or not.A second alternative in the treatment of these

cssv^% of severe prolapse with associated prolapseof the vaginal vault is the employment of LeFort's operation. In view of the very satisfactorymortality and morbidity figures which can beachieved by the Manchester type of operation (orvaginal hysterectomy), the argument that LeFort's operation is a less serious procedure for anelderly patient carries little weight. The oblitera-tion of the vagina which this procedure entailscould only be justified if the results were definitelysuperior; in fact, this does not seem to be thecase. Kiihnel (1952), in an analysis of 58 casestreated in this way, reports a recurrence in 5.4per cent. and a mortality of over 3 per cent. Thedifficulty of investigating and treating any sub-sequent uterine haemorrhage is also emphasizedby Mazer and Israel (I948).

ConclusionsA repair procedure based on the principles of

the Manchester type of operation may be reliedupon to produce a satisfactory result in approxi-mately go per cent. of cases of prolapse.The operation is not accompanied by any grave

disturbance to the patient and post-operativecomplications are rare. The number of patientswhose age or general condition contraindicatesoperation is small and very few should be con-

demned to the permanent use of a ring or cupand stem pessary or any similar contrivance.

Stress incontinence is cured in over 6o percent. of cases and greatly improved in a further 25per cent. There remains a small but very definiteproportion in whom some more extensive pro-cedure is necessary to relieve this complaint.

Cases of complete procidentia can be satis-factorily cured by the Manchester type of opera-tion, provided that any associated enterocoele isexposed and dealt with. It is not essential toemploy vaginal hysterectomy in such cases unlessadequate exposure cannot be obtained without orthere is some associated uterine disease.The purpose of this investigation has been to

examine and endeavour to improve upon my ownresults. No new principles have been describedor new arguments put forward. If it shouldstimulate others to look into their own resultswith a critical eye, its purpose will have beendoubly achieved.My thanks are due to Mr. Aubrey Goodwin,

Mr. Charles Read and Miss Hetty Player (latetheatre sister at Chelsea Hospital for Women),who gave me the instruction and courage whichwas necessary in the beginning; to the theatreand ward staff at the Norfolk and NorwichHospital and the Wayland Hospital, Attleborough,whose co-operation has made the work a pleasure;and to my patients for the gratification of satis-factory results and the stimulation to improvementwhere the results have been otherwise.

BIBLIOGRAPHYCURRIE, D. W. (I952), Y. Obstet. Gyn. Brit. Emp., 59, 96.GNIOU, N. M. (I950), Canad. Med. Ass. J., 63, 147.JEFFCOATE, T. N. A. (I949), J. Obstet. Gyn. Brit. Emp., 59, 685.KUHNEL, P. (1952), Acta. Obstet. Gyn. Scand., 31, 151.MAcLEOD, D. (I952), -7. Obstet. Gyn. Brit. Emp., 38, 583.MAZER, C., and ISRAEL, S. L. (1948), Amer. -7. Obst. Gyn., s6,

944-READ, C. D. (I949), 'Trans. XITth Brit. Cong. Obst. Gyn.,' p. I89.SHAW, W. F. (1934), Y. Obstet. Gyn. Brit. Emp., 4I, 853.STALLWORTHY, J. A. (1940), Ibid., 47, 391.

RUTHIN CASTLE,NORTH WALESA Clinic for the diagnosis and treatment of Internal Diseases (except Mental or Infectious Diseases). The

Clinic is provided with a staff of doctors, technicians and nurses.The surroundings are beautiful. The climate is mild. There is central heating throughout. The annual

rainfall is 30.5 inches, that is, less than the average for England.The Fees are inclusive and vary according to the room occupied.

For particulars apply to THE SECRETARY. Ruthin Castle, North Wales.Telegrams: Castle, Ruthin. Telephone: Ruthin 66



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results of operative treatment of prolapsethis condition is not common in multiparous women....

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