892 JUNE x8, I921g OPERATIVE TREATMENT OF GENITAL PROLAPSE. tKurnc"^TOLJOUUWAI
women free from active malaria until the confinement.Then as the vital powers of resisting disease are muchlowered by the excessive fatigue of child-bearing, it isnecessary to give 10 grains (in very small doses) a day forfive or six days, as very often, if not given, a revere attackof malaria will delay recovery with these doses.
I have never found quinine cause abortion. On theother hand, I have treated cases of abortion in nativewomen (who do not take quinine), in which the frequentabortions were undoubtedly caused by chronic malaria, forwhen given the above prophylactic doses they were able togo to term and give birth to healthy living children.With regard to the effect of quinine on the non-pregnant
uterus, undoubtedly in a small percentage of cases it causesexcessive and too frequent periods. Years ago I found thatwhen 5-grain doses of quinine caused deafness or noises inthe ears it was a sign that a smaller dose (3 grains) wassufficient as a prophylactic, and the majority of womenunder 120 lb. weight will, I think, find this smaller dosewill keep them free from active malarial manifestations.Recently I have treated this menorrhagia also as a sign
that only smaller doses of quinine need be taken, and ifthe 5-grain prophylactic dose is necessary it should betaken in 21-grain doses twice a day; the few cases treated,however, are not sufficient to lead me to any definite con-clusions, and I would value greatly the experience of othersin treating this very trying complaint.
WALTER FISHER, M.R.C.S., L.R.C.P.Kalene Hill, Northern Rhodesia.
*tptrts of iociettes.THE END-RESULTS OF PLASTIC VAGINALOPERATIONS FOR GENITAL PROLAPSE.
THE first British Congress of Obstetrics and Gynaecologywas held at Birmingham on June 3rd and 4th, when thefollowing societies were represented: the Obstetrical andGynaecological Section, Royal Society of Medicine; theEdinburgh Obstetrical Society; the North of EnglandObstetrical and Gynaecological Society; the GlasgowObstetrical Society; and the Midland Obstetrical andGynaecological Society.The opening session in the morning of June 3rd was
presided over by Professor H. BRIGGS, President of theObstetrical and Gynaecological Section of the Royal Societyof Medicine. Mr. CHRISTOPHER MARTIN, chairman -of theMidland Obstetrical and Gynaecological Society, welcomedthe Congress to Birminglham, and expressed the hope,wllich was echoed by various speakers throughout theday, that this Congress would now become an annualaffair, and the chief and authoritative mouthpiece ofBritish gynaecology.The morning session was devoted to a discussion upon
the operative treatment of genital prolapse, opened byDr. W. E. FOTHERGILL and Dr. F. H. LACEY, of Manclhester.The title of their paper was " The End-Results of PlasticVaginal Operations for Genital Prolapse."
Dr. W. E. FOTHERGILL said that the discussion hadoriginated at a meeting of the Nortlh of England Societyheld at Liverpool in December, 1918. Professor H. Briggshad described the treatment of a case of procidentia, ina patient aged 18, by a vaginal operation combined withventrofixation, but advocated a modification of Gilliam'soperation. Dr. W. F. Shaw deprecated abdominal opera-tions for prolapse, preferring the vaginal methods used inManchester. Other members urged that the end-resultsof these measures should be ascertained and publishedand a collective investigation by the society was suggested.At subsequent meetings this project was developed andthe scope of the inquiry came in question. It was pro-posed to exclude all except cases of complete prolapse, butthis was not thought feasible. The term "genital pro-lapse " had a fairly definite connotation all over tlle worldand medical men constantly used the word " prolapse" asincluding both so-called vagino-uterine prolapse and so-called utero-vaginal prolapse. In view of these considera-tions, it was decided at a Council meeting of the North ofEngland Society in December, 1919, that the inquiryshlould include "cases of (1) cystocele, (2) rectocele, (3)prolapsus uteri, and (4) elongated cervix protruding from
the vulva "-namely, in two words, eases of "genitalprolapse." At an ordinary meeting of the society inLiverpool in October, 1920, Dr. F. H. Lacey gave a pre-liminary report on traced cases operated on at St. Mary'sHospital, Manchester, during the years 1914-15-16. Sub-sequently it was arranged to defer the further considera-tion of the subject to this meeting.
Dr. Fothergill briefly indicated the steps by which ho-was led to his present technique, starting with his wvork inEdinburgh under Sir A. R. Simpson and David BerryHart, who used at that time anterior and posterior colpor-rhaphies of moderate size, amputation of the cervix, andrepair of the perineum. These were done as separateoperations, and in some cases all four were used for onepatient. Chromic catgut was the suture material, and theimmediate results were good. On coming to Manchesterin 1895 he found that, owing to the initiative of ProfessorA. Donald, surgical treatment of genital prolapse wasalready highly efficient; anterior colporrhaphy incisionswere larger than those done in Edinburgh, and the wholethickness of the vaginal wall was removed. Donald hadalso combined the operation of posterior colporrhaphywith perineorrhaphy in a single operation done from abovedownwards.
Dr. Fothergill was gradually convinced by clinical experi.ence that the uterus, vagina, and bladder were mainly keptin position by the lateral combinations of unstriped muscleand connective tissue known as the parametrium and theparacolpos, and this was demonstrated by him to theRoyal Society of Medicine in 1907. The practical applica-tion was that anterior colporrhaphy could be improvedby carrying the incision well up and out on either sideof thle cervix, fully exposing the paracolpos, so thatclosure of the wound must bring together in front of thecervix structures formerly at its sides. This he demon-strated to the Edinburgh Obstetrical Society in 1908.Subsequently he found that by carrying the incisionround behind the cervix instead of in front of it, anteriorcolporrha'phy and amputation of the cervix could be con-veniently combined in one single operation. When thewound was closed the cervical stump passed upwards andbackwards so far that the uterus was left in a position ofanteversion, thus dispensing with the need of excessivenarrowing of the vagina. An improved technique andmodifications were afterwards described in tlle BRITISHMEDICAL JOURNAL (Apiil 12tb, 1913) ; the AmericanJournal of Surgery (May, 1915); and in the Journal ofOb8tetrics and Gynaecology of the British Empire (Marchand May, 1915). Dr. Lacey had traced as far as pos-sible the after-histories of tlle cases treated by Dr.Fothergill at St. Mary's in 1914-15-16, so that sincethese operations were done periods varying from fourand a half to seven and a half years had elapsed; nocases treated by mere perineal repair were included.One hundred and fifty - six patients replied to Dr.Lacey's letter of inquirv; of these, 150 stated withoutqualification that they were cured, while 6 did not. Ofthese 6, No. 1 had had three children since the operation,and the womb has gone down again; No. 2 said the" womb was not as it sliould be," but on examination noprolapse nor other abnormality was found; No. 3 hladchronic bronchitis and asthma, and the operation wastherefore a failure from the start; in No. 4 the uterus wasin good position, but there was some vaginal prolapse;No. 5, a case of rectocele only, lhad an instrumental labourand was torn badly, and there was a slight recurrence ofrectocele ; and in No. 6 nothing was found on examination,but she said she still lhad pain at .times. This gave97?1-per cent. of cures. As to the ages of the patients,about one-third had passed tlle menopause.In 124 cases combined amputation of the cervix with
anterior colporrlhaphy was done, while in the remainder thecervix was retained. Thirty-two were examples of elong-ated cervix witlh inversion of the vaginal walls from abovedownwards. It would be unreasonable to expect that thenew pelvic floor should always stand the test of labour;the original pelvic floor did not always do so. Frolm thispoint of view it was of interest to note tllat 21 of tllewomen under 40 and 3 of those over 40 lhad since bornechlildren, and 2 othlers were now p)regnant; and, of the.se26, 23 head had the cervix removed by thle combined opera:tion. To thle 24 patients 30 chlildrenl had been horn;23 labours were natural and 7 instrumental, but in no
OPERATIVE TREATMENT OF GENITAL PROLAPSE; 89f3aZIALJUS
case was labour obstructed. Four patients hiad hiad twolabours eaclh with no recurrence of prolapse; 17 onelabour eaclh, with no recurrence, and one was badly tornwith a slialgt recurrence of rectocele. Another had onelabour and said that the womb fell slightly when she wastired. Another had three labours, and in this case therewas recurrence, requiring another operation. Thus pro-lapse sufficient to cause inconvenience had only returned inone out of 24 cases. The speaker wvas therefore of opinionlhat the addition to these vaginal operations of anyabdominal intervention was unnecessary and undesirable,increasing the risk and discomfort to which the patient wasexposed. He especially deprecated the use of abdominalmeasures not in addition to but instead of vaginal surgery.
Dr. F. H. LACEY said tllat the patients were mostlyworking women wlho had to return to work in cotton millsand other laborious work very soon after operation. Helhad written to 750 patients and received 521 replies, and455 (87 per cent.) replied to tlle question,"'Did tlle wombkeep up well now?" with the answer "Yes." Of thosewlho said "No" he had examined 29: 17 of these hadsome