In a few rare cases the bladder remains in its normal place with prolap sus vag. ant., the peritoneal pocket of the excavatio vesico-uterina on the other hand being abnormally depressed and drawn forward into the prolapsus. This occurrence has been supposed to be a special form of dislocation of the anterior vaginal wall, due to the sinking of this cavity, and has been called hernia vaginalis anterior.' But the loosening of the bladder and urethra from the uterus and vagina, with depression of the anterior peritoneal pocket, as has been represented in some of the draw ings, does not appear to exist at all; rather the septum urethro-vaginale under all circumstances forms the boundary up to which the anterior vaginal wall may be separated from the bladder.' Hiiffel's excellent drawing of a section of the pelvis with prolapsus ut. incompl., without any change of position of the urinary bladder, shows us how the separa tion of the prolapsed anterior vaginal wall from the bladder is limited anatomically by its intimate connection with the layers of the urethro vaginal septum. It shows also a relatively firm vesical attachment, the peritoneal covering of the organ lying above the upper edge of the sym physis, and the ligamenta vesicalia being tense. On the other hand the connective-tissue union between the portio supra-vaginalis colli uteri, the upper part of the anterior vaginal wall, and the bladder, appears to be unusually loose and to be stretched into a thin stratum. Had the blad der been depicted empty, all the conditions necessary to originate a hernia vaginalis anterior, might have been demonstrated in this drawing.
Since a congenital depression of the excav. ves. ut. has not been noticed, and since in the few cases of the affection which have been recorded, there has always been the complication of prolapsus ut,eri totalis or partialis present, we must regard hernia vaginalis anterior as an acquired disloca tion. For its development the urinary bladder must be firmly attached to the anterior abdominal wall, and there must be an unusually loose connective-tissue layer between the supra-vaginal portion of the collum uteri and the bladder, and between the anterior vaginal wall and the blad der; and finally the excav. vesico-uterina must be abnormally broad from reclination of the body of the womb, and must also be drawn down by the prolapsus colli uteri. When these conditions are present, the intra abdominal pressure upon the excav. ante-uterina on the one hand, and the tension of the prolapsus upon the other, may be able to cause disloca tion and separation of the layers of the septum vesico-vaginale in a degree such as E. Martin has described. The anatomical disposition in question is most intimately connected with the etiology of prolapsus uteri; and we can only look upon hernia vag. ant. as one of its consequences. We can not recognize its primary occurrence from the cases thus far described.
The diagnosis of prolapsus vag. ant. needs but littleconsideration after what has been said. It may, however, be necessary to distinguish it from protrusions caused by new growths in the septum ves. vag., or from con genital anomalies with unilateral closure of the vag. septa and retention of fluid. The dilatation and separation of the layers must be especially considered. This is to be done by examining the vesical dilatation with the catheter, and by finding out the exact position of the utenis. If cystocele is present, the catheter will go downwards a short distance behind the orif. uretline, and its point can be felt through the protruded wall. If the bladder does not participate in the protrusion of the wall, it can easily be proven with the catheter that the viscus has not sunken, and thus we can ascertain whether we have to deal with a hypertrophic prolapse of the mucous membrane, an interstitial neoplasm, or the lateral half of an atresiad vagina distended with fluid. In the latter ease the uterus will be situated at its normal height.
The symptoms resemble in general those of descensus or prolapsus uteri. They consist of impediments in walking, standing, or any hard work. which causes increase in the size of the tumor, in irritation of the
prolapsed mucous membrane from dessication and friction, and finally, in frequent desire to urinate. Only when the prolapse is very marked can urinary retention occur from bending of the urethra, or more rarely from pressure or tension upon the ureters. Some observations seem to show that cystocele vaginalis may form a mechanical hindrance to child birth; ' but it was in cases where, from an abnormal position of the head, or from absence of the proper relation between it and the pelvis, an unu sual amount of compression of the full bladder against the anterior pelvic wall occurred. In this way the viscus was forced into an hour-glass shape; and the tense pelvic portion formed an obstacle to delivery which sometimes, as in Moor's case, could not be removed by the catheter.
Much may be hoped from treatment, even when it is restricted to rest in bed, frequent emptying of the bladder, looseness of the bowels, astrin gent and cooling injections, and the introduction of tampons of absorbent cotton of not too large size, to be changed night and morning. But fre quently this treatment alone is not enough, and in old cases it is useless to attempt to accomplish anything with it. Thus operative narrowing of the vagina, kolporrhaphy, or palliative treatment with pessaries and bandages, need only be considered. The operative treatment of prol. vag. ant. must not, to be successful, be confined to the anterior wall. All the various methods of anterior kolporraphy do not ensure us against a return of the cystocele; under the influence of the abdominal pressure the scar gives way, and the vaginal wall comes down. Kolpoperineor rhaphy must be done, or a septum-like connection between the anterior and posterior walls, after the methods of Neugebauer and Lefort, be made, to prevent the inversion and prolapse of the vaginal wall. I cured a case of very marked cystocele vaginalis in an elderly woman, in whom all pal liative measures for the retention of the prolapse were useless, by Neuge bauer's operation; and I came to the conclusion that in just such cases, where the cystocele was the most important part of the malady, it prom ised better results than in cases of total utero-vaginal prolapse, since there was less pressure upon the cicatrix. It has been attempted to improve the patient's condition, by sustaining the organ in various ways. We will only mention a few here, the object of which is to lift up the ante rior vaginal wall. Such are pessaries designed to raise the anteverted uterus, point those of Greily Hewitt and Thomas. When these instru ments find a sufficient point d'appui in the vagina. so that they may be worn without causing too much tension, they act by sustaining the re. placed septum ves. vag. upon their horn-shaped convexity. Occasionally the instruments which Vuillet and Kehrer have recommended for the retention of uterine prolapsus will be found applicable. More efficient, but much more irritating from the fact that their fixation point lies with out the pelvis, are the stem pessaries which are fastened to a pelvic band, and which elevate the ant,erior vaginal wall either alone or together with the uterus. Roser's hysterophor is the best known of these arrange ments, and has been modified by many surgeons, especially by Scanzoni and Lazarewitch. But they have all fallen into desuetude from their uncomfortable nature, and from the irritation they caused; and in non operative cases, where the above-mentioned pessaries are not supported, voluminous instruments designed to sustain the uterus aro employed, now one form and now another being recommended. Most of them are, however, open to the objection, that they only prevent vaginal prolapse by great dilatation of the channel above the introitus; they exercise con siderable pressure, cause the rime vulvre to gape, and set up an intense catarrh of the vaginal mucous membrane. If the necessary conditions are present for the retention of the egg pessaries, to be mentioned later on, they will render the most efficient service in these cases.