LONDON-F. J. REBMAN, MANAGER, 40 BERNERS STREET, OXFORD STREET, W. VIENNA-JOSEF SAFAR, VIII SCHLOSSELGASSE, 24. PROLAPSUS OF THE VAGINA- By E. E. MONTGOMERY, M.D., No. 1. its most marked constriction at the external opening, where we have the vulva, with its vagina. The orifice of the vagina and its poslongest diameter at right angles to that of the terior segment are re-inforced by the muscles which form the perineum; these in their nor Professor of Gynecology in Medico-Chirurgical College; Ob- mal muscular tonicity aid in the support of the stetrician to Philadelphia Hospital; ex-President American G ENTLEMEN: A few weeks ago I brought before you a woman suffering from a protrusion of the vaginal walls. This protrusion affected more particularly the anterior surface, which presented a globular, rounded mass, and was greatly increased in coughing or straining. This protrusion is known as a cystocele. Before entering upon its further discussion, however, it is well that we say something of the anatomy of the vagina and the forces that retain it in its normal position. ment. You will see the vagina, in the ordinary anatomical text-books, represented as a widely distended canal, closed by the uterus above, as a cork in a bottle. This is not a correct representation, and gives false ideas as to the arrangeThe vagina is the passage which leads from the vulva to the uterus, and is a closed canal, standing at an angle of sixty degrees with the horizon when the patient is in the erect position. In making the transverse section, you will see that the vagina is simply a slit in the pelvic floor, and that any protrusion of its walls, or of the uterus through it, is as much a hernia as would be the protrusion of the viscera through the other natural canals of the abdomen. The widest portion of the vagina is that into which the uterus projects, and it narrows down as we approach the vulvar orifice, presenting vagina and the viscera above. Its position is still further maintained by its relation to the levator ani muscles, which pass on either side of the vagina, and to which its walls are partially attached. The vagina is a musculo-membranous canal, having three walls, from without inward,—the areolar fascia, the muscular wall, and the mucous membrane. The latter is lined with pavement epithelium, and does not differ greatly from the skin when subjected to similar conditions. The vagina is 21⁄2 inches in length on the anterior wall and some 4 inches on the posterior. This difference in length is due to the vagina, which is at the expense of the the manner in which the cervix projects into anterior wall. with the bladder, and the urethra forms a cordAnteriorly, the vagina is closely connected like projection into its wall. The association with the bladder is so intimate as to render it exceedingly difficult to completely separate these viscera. Posteriorly, the peritoneum extends over the whole of the posterior surface of the uterus down upon the surface of the vagina to the extent of from 2 to 1 inch, that, introducing the finger into the vagina behind the uterus, but 1 inch of tissue intervenes between the finger and the peritoneal cavity. The mucous membrane of the vagina is thrown into folds or rugæ, and consequently presents a roughened sensation to the finger. Under SO |