patients when they notice a tumor appear at their external genitals soon consult a physician for the greatly feared " falling of the womb." Recognition of their trouble is usually easy. In 74 cases of prolapsus vaginEe Malgaigne found cystocele vaginalis 39 times. The patient is placed in the lithotomy position, is told to press down, and when the tumor attains its greatest size it is to be grasped with the left hand, and fluctuation will be detected. Then a vaginal examination is made to find how far the cervix has fallen. A metallic male catheter is now introduced into the tumor, with its concavity directed downwards; if you succeed, the instrument can easily be felt in the tumor, and the diagnosis is certain. Finally the urine drawn off must be examined for pus, albumen, and casts. After drawing the urine the tumor seems smaller and its vaginal walls are wrinkled. After carefully considering the causes of the malppsition, an attempt at replacement is to be made, to ascertain the mobility of the organ.
lf, with Jobert, we very c,arefully diagnosticate cystocele during life, and fail to find it post inortem, it does not prove that our diagnosis was at fault. Prolonged rest in the horizontal position tends to cause the tumor to dimppear, and if it has not been of long standing there may bo no demonstrable anatomical changes after death.
The prognosis is in most cases good, since the malady causes but little trouble, and may be held in check by palliative measures. If neglected it tends continuously to increase and become more and more annoying. In old individuals especially, from the relaxation and thinness of their organs, it is difficult to devise suitable methods of retention. A radical cure of cystocele can, however, only be obtained in most cases by opera tion. Though Scanzoni, in 18:i9, declared that he had never seen a per manent result from the operative treatment of cystocele vaginalis, nowa days the reverse may be maintained, and unsuccessful operations are among the rare exceptions.
Therapy.—Reposition and retention are the only indications for treat ment. The first one is usually simple to fulfill; but the second often ex ceedingly difficult Reposition may be effected with the hand when the patient is in the dorsal position; it is hardly ever necessary to use the catheter for anything else than to completely empty the viscus. That accomplished, retention may be effected palliatively by pessaries and tampons, or radically by means of various operations. In the beginning and with the slighter grades of the affection, tampons with astringent salves may do good.
But in later stages this mode of treatment will not accomplish much, though when a patient will not consent to an operation, and has acquired catarrh from a pessary, we may be compelled t,o have recourse to it.
Since most patients will not submit at once to a bloody operation, we must as a geneml thing use at first at least the mechanical means of re tention. Of the long list of these apparatuses we will mention those only that are especially applicable to cystocele. Among these we reckon stem, external, simple and winged pessaries. C. Mayer's simple round rings of rubber do good service in the slighter cases. But they are too yielding, and are at once squeezed out in more pronounced cases, and we may then use hard rings of round rubber well shellaced. These round pessaries are pushed over the levator ani and pelvic fascia, and by dilating the vaginal vault tend to ke,ep the prolapsed vaginal wall in place. But even the largest of them will be expressed when the vulva is dilated and the pressure considerable, and then the Martin stem-pessary may be used. Besides these a few cases may require the Zwanck-Schilling hystero phore. 'For I have found cases in which all other instruments could not be retained, but this one could. Its thin edges, however, may do harm by pressure, and may cause a vesico-vaginal fistula.
Some patients may be improved by the use of stem pessaries fastened to an external belly-band, such as those of Roser and Scanzoni. I for merly permitted patients to carry these for long periods of time, but do so no longer. Poor patients cannot well afford to get them, and all soon begin to complain of pain and burning, since the arm may easily cause ulceration in the urethral region. And if the pressure is great, the knob at once glides out, the arm falls, or the vaginal wall slides down beside or behind it.
The Scotch hysterophores which Breslau ' has especially recommended are better, but can only be used for the less severe cases. They dilate the vagina both antero-posteriorly and transversely; but they often cause irritation and may readily set up catarrhal trouble in unclean individuals.
For some patients a lightly-applied T-bandage is sufficient, and this, with the tamponade should at all events be tried in the less severe cases.
For a radical cure of inversion and cystocelo an operation is needed; an operation so simple and effective that, if the measures already described do not quickly succeed, it should be proposed to the patient.