4 suggesting the parametrial and paravaginal tissues (i.e., cardinal and uterosacral ligaments) were the primary support structures for the uterus [24]. However, Mackenrodt and Fothergill were not lone voices. In 1907, a gynecologist, Josef Halban, and anatomist, Julius Tandler, professors at the famed Vienna Medical School [25], published Anatomie und Atiologie der Genital- prolapse beim Weibe [26]. Their thesis on uterine support was quite contradictory to Mackenrodt and Fothergill’s. Halban and Tandler maintained that the pelvic fascia was like a spider’s web, able to bear the proper weight of the spider, but incapable of supporting a greater, abnormal burden [27]. Thus, it was the levator ani muscles that were essential to maintaining uterine support. Like Fothergill, they too turned to the comparative anatomic work of Peter Thompson but drew a diﬀerent conclusion. Consistent with a prime tenet of the Vienna School, form follows function [25], Halban and Tandler viewed the functional adaptation of the levator ani muscles from their tail wagging purpose to that of maintaining pelvic ﬂoor support as evidence they were not superﬂuous muscle bodies (otherwise they would have regressed with the tail), but signiﬁcant [28]. Others who were sympathetic to Halban and Tandler’s thesis would point to the observation of large prolapses in patients with mal- developed pelvic ﬂoor muscles from spina biﬁda, to the work of Goﬀ, who asserted that the “fascia” described in vaginal plastic procedures was the “loosely arranged areolar type,” as well as the work of Berglas and Rubin, who demonstrated the complete absence of ligamentous material in the endopelvic fascia [27, 29, 30]. In time, pelvic ﬂoor surgeons would recognize the importance of both structures [31] inﬂuencing new approaches to repair uterine prolapse. 6. Vaginal Hysterectomy and Vault Prolapse Vaginal hysterectomy was ﬁrst performed and developed in attempts to treat cervical and uterine malignancies [15]. The ﬁrst vaginal hysterectomy for uterine prolapse was reported by Choppin, of New Orleans, in 1861. The surgery was conducted under chloroform and the removal of the uterus, after it was dissected away from the bladder and rectum, was excised using “Chassaignac’s Ecraseur.” A little more than a month after the surgery, Choppin presented the patient to the class of the New Orleans School of Medicine, the patient holding the specimen in hand [32]. Choppin’s success was a rarity. However, as the new century arrived this fact would change. By 1915, Mayo would publish his technique for vaginal hysterectomy [33], as would Bissell, in 1918, coupling his technique of vaginal hysterectomy with an anterior and posterior colporrhaphy [34]. The rapid rise of surgery for the correction of uterine prolapse in the early twentieth century left one American gynecologist to write in 1923, “Gynecology has become so predominantly a surgical specialty. . . the young gynecologist of today frequently has no conception of what the pessary is meant to do and he is apt to be even irritated at the suggestion that such an implement should be accorded at least a modest position in his armamentarium” [35]. In the spring of 1937, at the sixty-second Annual Meeting of the American Gynecological Obstetrics and Gynecology International Society, Baer and his colleagues reported on the type of operations performed for uterine prolapse in 1928 compared to those performed in 1937. They noted that by the latter date vaginal hysterectomy had become the predominant operation, replacing interposition [36]. Modifying the sur- gical methods established by Mayo, and others, McCall, in 1957, published his technique of obliterating the cul-de- sac of Douglas to cure an enterocele and prevent subse- quent vault prolapse [37]. By the mid-twentieth century, vaginal vault prolapse had become a recognized sequela of hysterectomy. Thus, in 1965, Symmonds and Sheldon were able to report on the number of posthysterectomy vaginal vault prolapse cases they had observed at the Mayo Clinic [38]. Surgical attempts to correct posthysterectomy vault prolapse were made as early as the nineteen twenties. In 1927, Miller described a technique to reduce vault prolapse that amounted to a bilateral, transperitoneal iliococcygeus suspension (or, depending upon the actual depth of suture placement, a bilateral sacrospinous ﬁxation) [39]. Others would follow with modiﬁcations of established procedures such as ventroﬁxation [40], with or without the use of a biograft [41, 42]. However, it was Arthure and Savage from Charing Cross Hospital in London who would make the most lasting impact on the repair of apical defects. They recognized that vault prolapse could occur after abdominal or vaginal hysterectomy, total or subtotal: hysterectomy alone would not cure uterine prolapse. They analyzed the surgical techniques used at the time and noted the faults of each. In 1957, they published their surgical technique of sacral hysteropexy believing it to be a better anatomic repair that would prove to have superior durability and less risk of enterocele formation. The description they provided, save the use of a graft, is nearly identical to the abdominal sacrocolpopexy performed today (they even noted the importance of keeping the repair tension free while using the sacral promontory as a ﬁxation point) [43]. Long before the sacral promontory had been considered a ﬁxation point for correcting apical prolapse, Zweifel of Germany, in 1892, commented on his attempts to correct uterovaginal prolapse by using silkworm sutures to unilater- lly aﬃx the upper vagina to the sacrotuberous ligament [44]. The use of the sacrotuberous ligament to anchor vault prolapse was not attempted again until another Ger- man, J. Amreich, in the 1950s, reported on his experience using a transgluteal (Amreich I) and transvaginal (Amreich II) approach to a vaginal-sacrotuberal ﬁxation [44]. Two other German gynecologists, Sederl and Richter, avoided the diﬃcult-to-access sacrotuberous ligament in favor of the sacrospinous ligament, while attempting to repair vault prolapse transvaginally [45, 46]. Richter’s operative success popularized his technique across Europe and also stimu- lated the interest of two American gynecologists, Randall and Nichols. In 1971, Randall and Nichols reported the surgical outcomes of 18 patients who underwent transvaginal sacrospinous ﬁxation for vault prolapse performed over the previous four years. They found the operation restored the normal vaginal depth and felt it to be an eﬀective operation in women with vault prolapse and in those who were found