It will be seen that very pronounced structural changes are present in old cases of prolapse of the uterus. The uterine ligaments and the pelvic attachments become so stretched and atrophied that they can never become functionally useful again. The normal shape and size of the uterus become very much changed from elongation of the supra-vaginal cervix and hypertrophy of the infra-vaginal cervix. The vaginal canal becomes patulous and stretched several times beyond its normal dimensions, and the delicate mucous membrane, from exposure, becomes tough and cutaneous in character. The large protruding mass of uterus and inverted vagina stretches the genital outlet far beyond its normal dimensions, and the muscular supports that may have remained after the original perineal injury undergo atrophy from pressure. [Illustration: FIG. 70.--Prolapse of the vagina and the vaginal cervix, with elongation of the supravaginal cervix. Extensive ulceration.] Accompanying the prolapse of the uterus is usually prolapse of the bladder and of the anterior wall of the rectum, producing a condition already described under Cystocele and Rectocele. Women who do hard manual labor are those who suffer with the most marked forms of uterine prolapse. The form of prolapse accompanied by elongation of the supra-vaginal cervix is usually characteristic of the hard-working woman. Such prolapse of the uterus is common among the Western Indian women, who return immediately after delivery to hard labor and horseback-riding. [Illustration: FIG. 70, _A_.--Elongation of supra-vaginal cervix (St. Bartholomew’s Hospital Museum).] Many cases of prolapse would be avoided, even though there might be serious perineal injury, if women remained in bed a sufficient time after delivery. By rising too early prolapse is favored, for a variety of reasons. The uterus is large and heavy; the uterine ligaments are elongated, and the abdominal walls are weak; consequently the retentive power of the abdomen is poor; the vagina is flabby and much larger than normal; the genital outlet has not contracted, and the muscular and fascial supports which may not have been torn are stretched and relaxed. The subjective =symptoms= of prolapse vary greatly and are not characteristic. A woman in whom the uterus has descended but slightly below the normal level may suffer so much with backache, weakness of the legs, and a feeling of pelvic weight, or “bearing down,” that her life will be rendered useless; while, on the other hand, a woman with complete prolapse of the uterus may suffer no inconvenience except from the presence of the protruding mass. In fact, the lesser degrees of prolapse seem to cause more suffering than the extreme degrees.