It is much more common to see loops of intestine descend into Douglas's pouch, when that fold is drawn down in prolapsus ut,eri and inversio vagi, me. But even here the intestine rarely reaches to the lower limit of the tumor. As a rule, we find tympanitic resonance only at the upper parts of such prolapsus, though Rokitansky and Fehling ' have described re markable cases in which rupture of the posterior wall of the prolapse and descent of coils of intestine through the tear occurred.
As to treatment, we can only relieve secondary invaginations of the fornix and the upper portion of the vagina when we succeed in removing their causes. If the descent and prolapse of the lower division of the posterior vaginal wall is great, but little is to be hoped from the measures recommended for the relief of cystocele, even in recent cases. Retention by means of pessaries is only useful in those exceptional cases in which the vulva is not much dilated. We must here rely upon surgical proced ure; and it is only because in uncomplicated cases, where there is no pro lapsus uteri, the troubles caused by the condition are not great, that operations are so seldom done.
Descent of the vagina in its whole circumference, inversio vaginre, so common in marked cases of uterine prolapse, may be dne to an even dis placement of the vaginal vault which drags the surrounding walls of the canal down with it, or to a protrusion and approximation of the anterior and posterior segments of the vaginal tube. (Fig. 24.) In the first case direct pressure is the cause of the displacement. The vaginal vault may be pressed upon by the uterus or the abdominal muscles, or, more rarely, by tumors. Relaxation of the pelvic connective tissue, and of the vagina and the uterine ligaments, predispose to the affection. Hence its frequency in the puerperium, and in old age, and hence also the great preponderance of cases among the working classes. An origi nally low position of the uterus with a short vagina, as well as flexions of the womb, predispose to inversion; but I do not think that small inclina tion and great width of the pelvis exercises by any means that influence which many authorities, and especially Biwisch, have ascribed to it. Under these circumstances there usually first occur primary descent of the uterus and depression of the vaginal vault, from abdominal pressure, the womb itself being normal, or, if senile involution has set in, even sub normal as regards weight. But, of course, the enlarged uterus might pull down the vaginal vault by its weight, if its volume is not too great and it is not fixed by adhesions. Only in rare cases do we find vaginal
de4cent in consequence of hypertrophy of the collum. Where we do see it, the hypertrophy affects the vaginal portion of the neck, and gradually drugs the entire uterus and the fundus downwards.
When the inversio vag. has occurred in this way, and has led to a pro lapse of the whole inverted vagina, the tumor always includes the entire uterus. But if on the other hand the inversio rag. proceeds from pro lapsus vag. ant. and post., the uterine descent is secondary, and often Involves only the elongated collum; the corpus uteri itself taking little or no part in the displacement' From what we have said in regard to the etiology of prolapsus vag. ant. and post, it will be seen that the puerperal state furnishes the chief con dition necessary for the origination of inversion with prolapsus colli uteri.
But whether vaginal inversion be primary or secondary, it always in creases in size, and finally forms a prolapse of the total inverted vagina. At its lower portion will be seen the orif. ext. ut,eri, situated to one or other side in accordance with the relative protrusion of the anterior and posterior portions of the tumor. Its shape depends partly upon its con tents, and partly upon the amount of thickening of mucosa and submu cosa. It is usually either cylindrical or pear-shaped. The walls of the prolapse at first are thin; but in time the hypertrophy of the dry, der moid-like mucous membrane and of the submucosa, may become so grea,t that the walls of the tumor nearest the portio vag. may measure from ill to 1 inch in thickness, and the whole mass be compared, as has been done by Klebs, to an elephantiasis. The surface will then be smooth, rugosities being absent; the epithelium is thickened; and not infrequently erosions and fissures leal to losses of substance very like varicose ulcers. This is favored by the intense venous congestion of the hypertrophic tis sue. In old inversions which have not been replaced for years, the thick ness and rigidity of the walls is often so marked that it forms a great though, in our experience, a not impassible hindrance to reposition. The portio vag. uteri is blended in with the walls of the tumor. This is due t,o the hypertrophy above-mentioned, and also, if the os is ruptured to any great extent, to the ectropion-like eversion of its lips. These, to gether with the other changes occurring in the mucous membrane of the portio vag. and the cervix, will be considered in connection with prolapsus uteri.