Examination with the sound gave the following measurements: Especially remarkable was the relaxation and thinness of the perineum and the muscular floor of the pelvis. When the child cried they were bal looned out. The child nursed well; spontaneous movements of the lower limbs were normal, though the reflex motions were slow.
Unfortunately Professor Epstein's efforts to obtain perm.ssion for a post-mortem examination in the probable event of the child's dying were fruitless.
Under these circumstances we can say but little as to the anatomical conditions present which had led to the prolapse of all the organs that lie along the floor of the pelvis. I can only surmise that an imperfect de velopment, and perhaps an abnormal position of the muscular structures of the pelvic floor, may have caused its relaxation, and the dilatation of the places of exit of uretlint, vagina, and rectum. The presence of fissure of the symphysis and of spina bifida would favor this view.
There are no other anatomical investigations concerning the condition of the muscular and aponeurotic pelvic floor in these cases. Not only is this so with rare congenital anomalies such as we have been considering, but it is also the cage with the very frequent acquired descensus and prolapsus. From a clinical point of view Schatz ' and Emmet 9 have called attention to the importance of the ruptures and contusions of the mus cular structures of the pelvic floor incidental to childbirth; and Hegar ' has insisted upon its efficacy as the etiological agent in displacements of the pelvic organs.
Billroth has recorded a case of prolapsus uteri with vesical ectopia in a girl eighteen years old, and has added a handsome drawing to it.' The sketch shows us that the pelvis was fissured and the perineum imperfectly developed.
Among the more recent literature a case of Prochownik's ° deserves men tion here. The girl was a virgin, twenty years old, and had prolapsns septus with congenital deficiency of the perineum. Prochownik believes that the earlier occurrence of the prolapse in this case was prevented by the tension of the lateral attachments of the uterus, although a deficient development of the muscular structures of the pelvic floor could be recog nized. I think also that the shape and breadth of the womb, in relation to the lumen of the vagina, had something to do with it. After the patient had had to do very hard work upon very poor food for seven months, a prolapse occurred. It was well retained by a Schatz pessary.
Undoubtedly dilatation and relaxation of the introit. vagime can usually he proven to be among the efficient causes of vaginal dislocation. Yet the influence of rupture of the perineum as a predisposing moment, has been much overestimated, since without doubt the larger number of vagi nal prolapses occur without its being present.
The loosening of the attachments which we have described explains the occurrence of a displacement in layers of the septum vesica3 and recto vaginale in those cases in which the bladder or the rectum does not fol low the dislocation. Only in exceptional instances are we unable to prove the anatomical reasons for predisposition of the vaginal attachments to be loosened; and in these the amount of pressure or of traction must have been enough to overcome the resistance of the normal means of fixation.
As to the participation of neighboring organs, uterus, bladder, and rec tum, in vaginal displacements, we must distinguish between primary and secondary projections. In the first ease the vaginal walls sink on account of their loosened attachments, not being able to withstand the normal amount of pressure which bears upon them; and the organs attached to the vagina follow it. In the second case the vagina is permanently dis placed by the constant pressure and tension exercised upon it by the neighboring organs. In advanced cases these causal relations cannot always be distinguished.
The protrusion of the anterior wall (descensus or prolapsus vagin. anterior) may be partial, and originates now from the lower and now from the upper kgment of the vagina; or it may be complete. In both the latter cases it is regularly accompanied by sinking of the collum uteri.
Partial descent of the lower segment of the wall, sometimes prolapsing to a moderate extent through the vulva, is dependent upon the projection forwards of the lower extremity of the columna rugarum ant., (the tuber culum vag. of Lusaka, and the carina vag. of Kohlrausch), just below the urethral orifice. It occurs from swelling of the mucosa and the submu cosa, and is frequently seen in gravidity from the combination of venous stasis with the hyperplasia of pregnancy. Its dark livid color, and suc culence, as well as the fact that it occurs in prirniparre only during the last three months, and in multiparw, together with phlebectasias of vulva and vagina, show how much venous stasis is concerned in it,s development. Nor does it always retrogress during the puerperium; and we find it in women who have borne children as a dense tumor of the normal color of the mucous membrane, and composed of the hypertrophied mucosa and submucosa. If the prolapse is more extensive, the covering mucous membrane becomes skin-like. The direction of the urethra is not much changed, though its orif. ext. is usually gaping and displaced somewhat forwards; occasionally it is covered by the prolapsed folds which lie be hind it.