The symptoms of inversio vag. will consist of those of partial displace ments together with those of prolapsus uteri Tito diagnosis also needs no further elucidation. Only in rare cases is inversio to be observed in the stage in which the portio vag. does not occupy its lowest point. It then forms a prolapsed, ring-shaped vaginal tumor, in the middle of which is a funnel-shaped orifice which leads to the portio vag. (Fig. 26.) This is the transition form between a prolapsus ant. and post. beginning at the lower segment of the vagina, and a complete inversion.
Even in slight cases of circular protrusions of the vagina, treatment by rest in bed, and astringent injections and tampons, will usually not be sufficient; and in complete and old inversion, the tumor may be so large, and its walls so thick, that reposition itself may be very difficult. In these cases we must first remove the intra-abdominal tension by empty ing the bladder and placing the patient in the knee-elbow position. If its surface is dry and crusted, it should be covered with linen cloths soaked in water, oil, or glycerine. The tumor is best reduced in the knee-elbow position, pressure being made upon all sides of the mass, and the portio vag. first, then the posterior, and then the anterior wall pushed up. Oc casionally the reposition of the portio vag. alone will cause the reduction of the whole tumor. It is important to ascertain whether the uterus has prolapsed en masse, or whether only the elongated collum has come down. If the former is the case, it may hinder reposition by its mass and posi tion. It is best replaced by pushing it up somewhat obliquely, with one tubal angle in advance. It is generally easier to reduce the inversion in prolapsus colli uteri, since the elongated collum tends to go back as soon as the cystocele is replaced. Freund (I.c.) has observed a quite unusual obstacle in the shape of a colossal rectocele filled with freces; it took two weeks rest in bed, and c,areful emptying of bladder and rectum before Ile coUld replace the prolapse. Fehling's case (1.c.), in which a rude attempt on the patient's part to replace the mass caused rupture of its wall and prolapse of coils of intestine, will serve to warn us against the use of TiO lence in our attempts at reduction.
It is much more difficult to maintain the reposition, if we do not con tent ourselves with palliative treatment by pessaries and bandages.
The operative tre,atment of vaginal displacement is the only one which is reliable, and is to be recommended in all cases when the patient is not too decrepit to undergo it. Its purpose is, if possible, to remove the con ditions which caused the displacement, or, if that cannot be done, by keeping the protrusion in place, to prevent its growth. Thus the opera
tions are very largely the same as those in vogue for the cure of prolapsus uteri. They all depend upon the following points: 1. The removal of the pressure or tension which maintains tile protru sion.
2. The prevention of the relaxation and protrusion of the walls of the dilated vaginal tube, and the increase of its resistance to abdominal pres sure by narrowing its calibre.
3. The reproduction of the lost fixation points of the vaginal walls by the production of extensive and firm cicatricial masses in the peri-vaginal ccnnective tissue.
The accomplishment of these ends will in many cases entail several operations; but in some cases procedures directed to fulfill the first and second indications alone, will accomplish our purpose.
The reduction of the pressure of the anterior vaginal wall, when the protrusion is due to new growths in the septum ves. vag., may be attained by extirpation of the tumors. Cysts are especially to be considered, which we shall do later on. The pressure of a cystocele can only be averted by permanent retraction of the bladder, as might occur if a vesico-vaginal fistula were present. The production of such an abnormal orifice for this purpose has iu point been successfully accomplished in one case by J. Ely.' In spite of the greater certainty with which we operate upon fistulre to day, there is this objection to this method of treatment, that the elimina tion of vesical pressure, while the fistula is present, does not ensure us against a return of the cystocele when it is cured.
The pressure from Douglas's pouch upon the posterior vaginal wall may, when due to circumscribed collections of fluid, be removed for a time by vaginal puncture or incision. If cystomata, or dermoid cysts of the ovary, or fibromyomata of the uterus cause the protrusion, their removal by laparotomy may remedy it. If the uterus and the vaginal vault are depressed by hypertrophy of the cervix, amputation of the enlarged por tion will relieve the condition; and in cases where the supra-vaginal por tion is hypertrophically elongated, amputatio colli, especially by Hegar's method of funnel-shaped excision,' occasionally cures it by elevating the vaginal vault. I will refer the reader to the operation for prolapsus uteri, and will only say that I have once cured a case in this way. It is imma terial whether we consider the hypertrophic elongation as primary or sec ondary to explain it.