November 1953 BENTALL: The Results of Operative Treatment of Prolapse 545 Postgrad Med J: first published as 10.1136/pgmj.29.337.545 on 1 November 1953. Downloaded from but where abscesses or fistulae are present, these sary, but whatever is done the chance of recurrence are clear indications for preliminary ileocolostomy is high. with exclusion. It this does not give relief, A follow-up study of 26 cases treated at one resection can be done more safely at a second hospital confirms these generalizations and empha- operation. sizes the problem of the recurrent case. The danger of the ' blind loop ' blowing Gut In the chronic phase surgery should be lirnited following an exclusion operation seems to be more to those cases with clear evidence of obstruction, apparent than real, because the deflection of the perforation, abscess or fistula formation, or severe faecal stream away from the diseased area causes intractibility. the stricture to relent. I wish to thank Professor R. S. Pilcher for his Whatever the form of surgery employed, there assistance in preparing this paper, and also the is no doubt that the recurrence rate is depressingly consultant staff of University College Hospital for high. permission to follow-up their patients. BIBLIOGRAPHY Summary ARMITAGE, G., and WILSON, M. (1950-5i) Brit. Y. Surg., Crohn's disease is a non-specific granuloma of 38, 183. BOCKUS, H. L. (I945), Y. Amer. med. Ass., 127, 449. the gut, commonest in the terminal ileum, some- CHESS, S., CHESS, D., OLANDER, G., BENNER, W, and times involving other parts. COLE, W. H. (I950), Surgery, 27, 221. COOMBE, C., and SAUNDERS, W. (I813), Med. Trans. Roy. An acute form of the disease mimics appendi- Coil. Phys. Lond., 4, I6. citis and is seldom recognized until the belly is CROHN, B. B., GINZBURG, L., and OPPENHEIMER, G. D. (1932), Y. Amer. med. Ass., 99, 1323. opened. Nothing more should be done; appendi- DALZIEL, T. K. (1913), Brit. med. 9'., 2, Io68. cectomy is to be avoided as it may be followed by FELSEN, J. (1936), Amer. Y. Path., 12, 395. a fistula. GARLOCK, J. H. (1946), Amer. 9'. Surg., 72, 875. HADFIELD, G. (I939), Lancet, ii, 773. In its chronic stages the disease presents in HAWTHORNE, H. R., and FROBESE, A. S. (I949), Atnn. Surg.,Protected by copyright. many ways, but its important features are chronic 130, 233. HOMB, A. (1946), Acta. chir. scand., 94, 343. small intestine obstruction and the complications KANTOR, J. L. (I934), 9. Amer. med. Ass., 103, 20I6. of subacute perforation. Operation may be neces- PATEY, D. H. (I949), Proc. Roy. Soc. Med., 42, 769. THE RESULTS OF OPERATIVE TREATMENT OF PROLAPSE A 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 http://pmj.bmj.com/ Introduction return home, usually with thanks for what has At least twice a week the majority of gynaeco- been done, at the end of three weeks. logists throughout the country come to the stage We do not often see a recurrence and when we in their operating lists where, having taxed them- do the original operation was often done elsewhere selves with the more exacting problems earlier on, and we assume that it was done inefficiently. We on September 29, 2021 by guest. they can sit down to deal with one or two cases of feel justified in thinking that the great majority of prolapse before the hard part of the morning's our own patients get on well and remain eternally work is over. They are justified in expecting that grateful, but in reality we know little of the end the operation, though it may be tedious, especially results of the vast number of operations for to the assistant standing with bent back, will run prolapse which are done throughout the country smoothly and according to the usual routine every year. varied but slightly to suit the particular nature of A study of the literature on the subject is not the case. Their experience teaches them to expect very helpful. Publications on the results have been their patients to have some difficulty in passing surprisingly few in recent years and such as are water for a day or two, to be unable to sit down available give a very varied picture of the success in comfort for about ten days and to be anxious to which may be expected, the picture usually DI Postgrad Med J: first published as 10.1136/pgmj.29.337.545 on 1 November 1953. Downloaded from 546 POSTGRADUATE MEDICAL JOURNAL November 1953 depending on the thoroughness with which the above the average, being sixty-three and 4.5 years, cases were followed up. respectively. In an attempt to ascertain the degree of success Certain associated medical conditions were which is being achieved the results of 340 cases encountered relatively frequently. Visceroptosis operated upon in the years I948-5I have been of sufficient degree to justify the wearing of a studied; 240 of these cases have been treated in special belt was noted 27 times at the initial an outlying hospital where, in the absence of examination. Functional uterine haemorrhage was a resident medical officer, the day-to-day care has present in 20 cases and fibroids in 6, although been undertaken by local practitioners. The this condition is not common in multiparous reamining IOO who, by reason of their age or women. Prolapsed piles sufficiently severe to some medical complication, were in need of merit surgical treatment were seen in I2 cases. closer supervision, were treated in the main centre. Some degree of hypertension was common, but Certain conclusions have been reached from was sufficiently severe to call for special con- the experience gained in the treatment and follow sideration by the anaethetist on I2 occasions. up of these cases and, in view of the paucity of Diabetes called for special supervision in 9 cases. literature on the subject of this everyday operation, Operation was contraindicated by cardiac failure they have been recorded. in i case and by arthritis so severe as to prevent adequate abduction and flexion of the hips for Symptoms a surgical approach in another. I have only The average age of the 340 patients was fifty- advised against operation on 3 other occasions, one. Although multiparity is usually regarded as and these were cases where the patients' age and a predisposing factor in the production of pro- debility would have prevented their leading a life lapse, large families seem to be increasingly un- of any activity even if the prolapse were cured. common even in a rural area such as Norfolk and Certain other symptoms deserve considerationProtected by copyright. the average number of children works out at only owing to the frequency with which they are 3-25. encountered. Bleeding from chronic cervicitis, The symptoms of which the patient complains cervical polyp and, particularly, from ulceration vary greatly and bear surprisingly little relation- of the vaginal vault due to the prolonged use of ship to the degree of prolapse or anatomical a ring not infrequently cause the general prac- abnormality which is found on examination. titioner to refer the case as one of post-menopausal Backache, a dragging sensation in the lower bleeding and possible malignant disease. Senile abdomen or a feeling of ' something coming down' atrophy of the uterus predisposes to the condition seem of prolapse and is often accompanied by senile to be the most common presenting symptoms. vaginitis with an atrophic vaginal mucous mem- The complaint of stress incontinence deserves brane, calling for treatment with oestrogens prior special consideration. It was confirmed, as was to operation. One other symptom I have par- emphasized during the discussion on the subject ticularly noticed to be misleading; the soreness at the 13th British Congress of Obstetrics and and swelling resulting from infection of the vagina Gynaecology (Jeffcoate, 1949), that the occurrence with trichomonas vaginalis has resulted in not http://pmj.bmj.com/ of this symptom bears little relationship to the a few patients being told that they require operative degree of prolapse or cystocoele which is present. treatment for prolapse when suitable local treat- Stress incontinence was present to the extent of ment will soon clear up their symptoms without causing notable inconvenience to the patient in any resort to surgery. 132 cases (39 per cent.). This means that in 207, or 6i per cent., of the cases, all of whom had Operative Technique prolapse of sufficient degree to merit surgical The patients are usually admitted to the ward treatment, there was no significant complaint of in the afternoon or evening two days before on September 29, 2021 by guest. stress incontinence. The symptom was severe operation so that they have two nights and one enough to constitute one of the patients' principal day to accustom themselves to their surroundings. complaints in 44 cases (II per cent.). Seventeen Preparation, apart from routine procedures of patients, i.e. 5 per cent. of the total number and cleanliness, shaving, enema, etc., consists of a I2 per cent. of those with any complaint of stress preliminary antiseptic douche, after which a swab incontinence, suffered from this complaint in a soaked in a i in a i,ooo solution of flavine is left severe degree without any demonstrable uterine in the vagina. Only in cases where there has been prolapse or cystocoele. severe and obviously infected ulceration or Complete procidentia, often with accompanying gross oedema from procidentia has any longer ulceration, was present in 41 cases (II per cent.).