Displacements of the posterior vaginal wall (descensus and prolapsus /tag. post.) more frequently occur without participation of the adjacent or gan than do those of the anterior wall, on account of the loose connective tissue union between vagina and rectum. Here also the descent may be partial, and affect the upper or the lower segment, or it may involve the entire extent of the wall.
Partial descent of the lower division of the posterior vaginal wall is an everyday occurrence in its lesser degrees, in women who have borne many children. It appears as a prominent tul)ercular fold of thickened mucous membrane, situated at or near the median line, corresponding to the lower end of the columna rug. post. Its occurrence is by no means limited to women who have perineal scars, but is always found in con junction with a wide vaginal entrance. When much developed it forms a prominent comb-like tumor extending an inch or more into the vaginal canal; it gets less in volume as it ascends, and bears some similarity to a rudimentary septum vag. It very rarely occurs during a first pregnancy, like the protrusions of the anterior wall, but is usually formed during labor and the puerperium. Pregnancy predisposes to it only from the hyperplastic development of the vaginal walls and the loosening of the peri-vaginal connective-tissue. The great stretching and tension upon this portion of the wall when the perineum is distended in labor, and the eicatricial traction caused by ruptures at the posterior vaginal entrance during healing, complete the process. Nevertheless, it is undeniable that in many cases of exquisite prolapse of this kind, there are no perineal cie,atrices. The partial protrusions of the upper segment of the posterior wall occur only exceptionally as lax transverse folds of the rr.ucosa, at the place of the normal posterior of the vaginal vault; more gener ally they are seen as extensive inverted depressions of the posterior vaginal vault. These are really secondary occurrences; since they are dependent upon descent of the uterus, or of Douglas's pouch, or upon excessive dilatation of the recto-vaginal septum from the side of the rectum. In the latter case they are large from the beginning, and involve the entire extent of the posterior wall above the perineum. When the rectum is full the sac is tense and does not fall; but when it is empty it immediately prolapses.
The participation of the anterior rectal wall in the protrusion, recto cele vag., occurs either to a small extent only or not at all. Only where there is a high degree of total prolapse does it occurto any extent. The tumor may then, as Freund ' has shown, reach an extreme size.
All the partial dislocations of the posterior wall are easily increased by the pressure exercised upon the tumors by the uterus and intestines, and by the abdominal pressure. They may then form extensive prolapses, their lower end usually appearing free just behind the posterior commis sure of the vulva. The retroflexed uterus always follows the tumor,
when it is not fixed in the pelvis by tumors or adhesions; and the perito neal excavatio retro-uterina is always drawn deeply down.
Secondary protrusions are formed when the retroverted and enlarged uterine body, or tumors of the uterus or its adnexa, or encapsulated col lections of fluid (hEematocele, pelvio-peritonitic abscess, hydrops saccatus) or an extra-uterine fcetal sac, lie in and depress Douglas's Free fluid may also, though more rarely, do the same thing, as when there is much ascites. We must agree with Iclegar and Kaltenbach in regarding hernia vag. post. or enterocele vag. as a rare cause of protuberance of the posterior wall without uterine prolapse being present. The reason is that the coils of small intestine which lie in Douglas's can be more easily displaced from it, and forced into the abdominal cavity, than could the elasticity of the walls of the be overe.orne, and the vaginal surface protruded. There must at all events be a relatively nar row entrance to Douglas's which may of course occur from an increased development of the sickle-shaped connecting band of the plicEe semilun. which Kohlrausch has figured, or from acquired pathological adhesions. In this case the tension of the hernial tumor may be great enough to c,ause a considerable displacement of the womb, and to hinder reposition. This we had occasion to see ourselves in the case shown in Figs. 22 and 23. Landau' relates an interesting case which belongs here. A woman forty-eight years old had bad nine children, and suffered from oh stinate constipation and meteorisrn. An enterocele vag. appeared, which protruded downwards and became tense during the pains. It formed an obstacle to delivery, resisted all attempts at reposition in the lateral posi. tion, and was only displaced when the patient was deeply antesthetized and the whole hand introduced into the rectum. The diagnosis of en terocele vag. is to be made in these cases by the soft elastic resistance of the tumor and the occasional rumbling during manipulation, and may be completed by percussion upon a long spool-shaped pleximeter. If repo sition is even partially successful, the diagnosis is simplified; in our case it could not be done, though repeated attempts were made to effect it in the knee-elbow position. But it occurred spontaneously after a lengthy course of mild laxatives. Although the symptoms were not troublesome, they were decidedly similar in character to those of an old hernia with large opening. The woman was a field hand, and the tumor pained her when she walked or stood for long periods of time, and caused difficulty in defecation. We know of no case in which symptoms of strangulation have been observed; but we cannot deny the possibility of the occurrence of the accident, especially when peritonitic adhesions of the intestinal coils are present.