DISPLACEMENTS OF THE VAGINA.
Hence vaginal displacements uo not possess the importance which atta,ches to dislocations of other organs. We would refer the reader to the introductory chapter for an anatomical description of these attach ments.
Pathological dislocations of the vagina depend upon a change in the normal fixation of the organ, and form, as Klob ' has rightly insisted upon, projections of the vaginal walls into its lumen. They may affect the anterior or the posterior wall, or the whole circumference. In conse quence of the intra-abdominal pressure and the lesser resistance anteriorly, they will always lead either to descensus or prolapse, in accordance with whether the projection remains within the vulva or protrudes from it.
The conditions which influence vaginal dislocation are more or less connected with those that cause prolapsus uteri. They consist on the one hand of a loosening of the anatomical fixation bands, which are the predisposing conditions, and on the other hand of a force which acts either as a pressure from above or a traction from below. Pregnancy and childbirth especially cause loosening of the vaginal supports. The increase in vascularization and in mass of the vagina, the disappearance of fat from the peri-vaginal connective tissue, the venous stasis of the last month of gravidity, all these concur to affect an anatomical predis position, which is immensely increased by the process of birth, with its acute tissue-loosening and immense vaginal dilatation. And when the child's head passes through the lowest portion of the vagina and the labia, the least mobile portion of the vagina is stretched and torn, and the relaxation of the periueal vaginal support is pushed to its utmost extent.
In a somewhat similar way voluminous uterine polypoid fibromyomata may fill the vagina and cause such a loosening of the attachments of that organ that descent and prolapse may be very marked after •the growth has been extirpated. Other influences also, such as frequent tension and distension by coitus, persistent pressure by bladder, rectum, uterus, tumors of the true pelvis, or fluid accumulations, etc., may bring about the same result.
In extreme old age and in marantic conditions the loosening of at tachments may occur from the disappearance of the fat in the pelvic con nective tissue and the atrophy of the muscular structures of the floor of the pelvis.
Prolapse of vagina and uterus are extremely rare in undeveloped girls. Examples have, however, been seen in very early life, as the following two cases, which I have seen myself, will show.
In one, which I saw at the Prague Foundling Asylum, a girl a few weeks old had a ring-shaped vaginal prolapse, which was easily replacea ble with the finger through the exceptionally large introitus vaginre. As soon as the child cried it reappeared. A more minute examination was not at that time possible.
But I possess more complete notes of a second case, which Prof. Ep stein was good enough to send to me for examination. I have also a schematic sketch of the condition. It appears to me to be interesting enough to be reproduced. On February 28, 1881, Therese Roth, 39 years old, from Tiskow, near Prague, who had three weeks previously had her fourth labor easily and quickly, brought me her infant for examina tion. She had had twins the first, and triplets the third time. Immedi ately after birth the child had a rectal prolapse, and a tumor situated at the small of the back was noticed. On the fifth day a tumor appeared at the genitals, and it has remained there ever since. The child was badly nourished, but at full term; over the sacrum was a spina bifida sacralis with meningocele. The pelvis was fissured, though there was no exter nal cleft; a yielding spot replaced the symphysis pubis, the arch being formed at most by a ligamentous band. Clitoris and labia majora and minors were normal; the hymen formed a thin, gaping, ring-shaped border, especially low upon the left side. The urethral orifice was con siderably dilated, and the smaller vesical mucous membrane projected out of it as a small tumor. Out of the introitus protruded the portio vag. uteri, and there was a pronounced ectropian of the os. For the vaginal portion of the collum was greatly lengthened; a complete eversio vaginw was not present, but the organ was short and prolapsed. Bi manual palpation was practised with the little finger in the rectum after replacing the prolapse, and with the other band applied to the abdominal wall. By its aid, as also with the sound, I could satisfactorily decide that the uterine body stood at its usual height. The rectum formed the largest prolapse. The succeeding sketch shows the condition.