CHAPTER II. PROLAPSE OF THE VAGINA. THIS condition presents itself under three forms, according as it affects the anterior or posterior wall, or the entire circumference of the canal. Each form involves displacements of the viscera connected with the vagina, and derives its importance from them. The yielding of the anterior parietes of the vagina drags down the bladder, and produces "Prolapsus Vesicæ," or "Vaginal Cystocele;" the giving way of the posterior wall induces "Rectocele;" whilst the descent of the entire circumference presents a true prolapse of the vagina, and almost necessarily involves more or less displacement of the connected pelvic viscera. This last will need no consideration distinct from that of Prolapse of the Uterus. I. Prolapse of the Anterior Wall of the Vagina.-Prolapsus Vesicæ, or Vaginal Cystocele. Cystocele. This not uncommon accident usually results from the stretching of the parts by repeated, or by difficult labours, and progressively becomes worse when left to itself. It may vary in degree from a slight bulging of the front wall of the vagina to the production of a tumour filling or stretching the canal, or even extending from it and hanging between the thighs. A ruptured perinæum, by removing the natural support of the pelvic viscera, may predispose to this, and, indeed, to either variety of prolapsed vagina. The relaxation of the vagina in front immediately causes an alteration in the position of the bladder and of its meatus, so as to impede the evacuation of its contents. This interference with the escape of urine again leads to imperfect emptying of the bladder, and to excessive accumulations, by the weight of which the vagina is stretched still further, and thrust downwards and forwards. Instead of the urethra rising upwards behind the pubes, it becomes curved backwards more and more, until eventually, in complete prolapse, its course is actually downwards and backwards, and its orifice external to the labia. See PLATE III. As might be presumed, the extruded bladder is liable to injury, and may become the seat of ulceration or of other morbid process. Symptoms. The patient complains of weight and bearing down, and sensations of dragging in the lower part of the abdomen; uneasiness and pain in walking, and more or less dysuria,— the bladder having, to a great degree, lost its power of contraction. Some patients are obliged to replace the bladder before they can evacuate the urine. On examination, a soft, elastic, fluctuating tumour is felt at the orifice of the vagina; it is of a red or bluish-red colour, and can be greatly diminished by catheterism: the finger can be passed into the vagina below the tumour, and the os uteri can be felt behind, nearly in its natural situation. The surface of the tumour, when distended, is smooth, moist, and shining; but, when the bladder is empty, it is thrown into transverse folds. There is always very considerable mucous discharge, which is exceedingly irritating to the labia and soft parts; and there is sometimes a very distressing irritability of the bladder, and the urine, when passed, is fœtid, and contains much ropy mucus. This arises from a small portion of the urine being always left in the bladder, and the consequent decomposition of that secretion. Cystocele may be easily distinguished from prolapsus of the uterus; it is soft and yielding to the touch, and, on introducing the catheter, the point will be felt through the walls of the tumour, towards the anus; and, on passing the finger upwards, the os uteri can be felt in its natural position. It can also be distinguished easily from prolapsus of the posterior wall of the |