Unimportant as the prolapse may appear, it does give trouble to the patient, especially during pregnancy. It then becomes swollen from venous stasis; its surface is dry, and perhaps irritated or eroded, and there occur in consequence bearing-down pains and difficulty in walking and sitting. When the hypertrophied prolapse becomes long and comb shaped, and, by dragging upon the contiguous portions of mucous mem brane, displaces the sept. ves. vag., it becomes of even greater importance.
Very frequently there occurs in connection with the above-mentioned partial dislocation, a displacement involving the septum ves. vag. At first this only occurs when the bladder is distended or the abdominal pres sure exerted; later it is always seen when the patient is in the erect posi tion; and finally it is present even when the patient is lying down, as an egg-shaped or large prolapse. The soft tumor can always be readily re placed after the bladder has been emptied. When well marked, it obli terates the anterior fold of the vaginal vault, and is regularly accompanied by depression of the portio vag. uteri. The various layers of the sept.
yes vag. are so intimately united, that the bladder, as a rule, takes part in the protrusion, giving us a cystocele vaginalis (Malgaigne.') Most of these cases are of puerperal origin, and therefore we think that as a rule, the prolapse of the vaginal mucous membrane is the primary, and the sinking of the adjacent vesical wall the secondary phenomena. In newly delivered women we will often notice a slight degree of sinking of the vaginal wall. This is to be explained by the enormous dilatation of the vaginal sac, the gaping of the rima vulva, and the relaxation of the peri neum, sub partu. If the sinking of the anterior wall and of the bladder that is connected with it, is more marked than usual, as may be the case after difficult labors or speedy extractions, a valve-shaped bend of the urethra may occur, the anterior portion of that canal, being fixed by the lig. triang. remaining.
Thus there occurs that obstacle to urination to which Mattei and Ols hausen have drawn attention. It is not of very frequent occurrence, and can easily be remedied by giving a proper direction to the catheter.
A moderate protrusion may easily be increased to a prolapse, by getting up too early from childbed, physical exertion, or by retention of urine for too long periods of time. Venous stasis, swelling, and increase of weight then occur. Prolaps. vag. ant. with cystocele, exerts a double influence upon the puerperal uterus. On the one hand it tends to maintain the anteversion of the uterine body, the urinary bladder descending, and the womb following it; and on the other hand the tension exercised by the prolaps. vag. extends to the anterior lip of the os, and the anterior wall of the supra-vaginal portion of the organ. As a rule the uterus does not give way to this tA3nsion as a whole. The collum, relaxed and thinned sub partu, is distensible enough to stretch to a moderate extent. If the orif. ext. is so torn across that traction is not at once transferred from the anterior to the posterior lip, there occurs a unilateral elongation of the collum. The anterior wall is drawn out in gutter-shape, and the prolapsus vag. follows it; while the posterior lip remains stationary, or only sinks to a very small extent. This form of displacement is especially well marked when the uterine body is attached by adhesions or tumors to neighboring organs. SchrOder has described the condition as one of hypertrophy of what he calls the portio media, the median segment of the uterine neck.? I have observed it many times, and have invariably been able to prove its secondary origin.
The habitual retention of urine by women for long periods of time, has been by many authorities, and especially by Scanzoni,' regarded as the cause of the formation of cystocele, in contradistinction to the above de scribed primary origin of the prolapsus vag. ant. This is indubitably the case in a certain number of cases, but not in as many as axe of puerperal origin. Protrusions of the anterior vaginal wall by tumors (cysts, dense submucous new growths, htematokolpos, and the like) are to be consid ered under the heading of their special causes. And besides this, descent and prolapse of the anterior vaginal wall frequently occur as part of the total vaginal prolapse which follows descensus and prolapsus uteri.