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Vol. XIV. No. I.

I

Clinical LectuitaSIBRARY A Olapse of the posterior we would find the

January, 1893:"} THE COLLE IN2804INICAL RECORD.

isca prolapse of its anterior wall; if it were AS

prolapse

finger pass in front of it. In this case you COMPLETE LACERATION OF THE

would probably say that there was prolapse PERINEUM AND ITS TREATMENT.

of the vagina, but upon examination of the * Clinical Lecture Delivered at the Jefferson Medical College patient I find the uterus is somewhat deHospital, November 8, 1892.

pressed, yet the protruding mass is not the BY E. E. MONTGOMERY, M.D.,

uterus but the anterior wall of the vagina.

The diagnosis is readily made in these cases Professor of Gynecology, Jefferson Medical College.

by making pressure against the mass. If the GENTLEMEN :-During the last two lectures uterus were situated in it we would find prothe subject of consideration has been lesions jecting from its summit the cervix with the of the pelvic floor, more particularly those in external os. Patients, in a condition of this in which there was not so much loss of the kind, you will find, suffer more and more the perineum as there was of rupture of its sup- longer the duration of the trouble. As the porting muscle, the levator ani, resulting, con prolapsed portion projects over the vagina it sequently, in prolapse of the posterior wall of decreases the ability of the patient to evacuate the vagina. Prolapse of this wall through the the urine, and we have her consequently sufvulvar orifice is known as a rectocele. The fering from distress as a result. That portion protrusion of the anterior wall is called cysto- of the bladder which is situated below the cele. I hope, however, none of you, when level of the internal os is not completely asked “What is a cystocele ?” will be guilty emptied, consequently it gives rise to decomof giving an answer such as I received from a position of urine and cystitis, the presence of graduate of another school, who was apply. an ammoniacal odor and finally deposits of ing for an indorsement of his diploma. He calcareous material and formation of calculi, said it was “A cyst containing fluid.” In these calculi sometimes attaining to large the anterior wall of the vagina the intimate size. relation of the bladder leads to prolapse of a Cystocele usually results from injury during portion of this viscus; in the posterior wall, parturition. It may be of the posterior seghowever, the rectum is much less intimately ment of the vagina, causing increased strain connected, so that it is not always prolapsed upon the anterior segment, which, no longer with the protrusion of the vaginal mucous supported, is finally crowded down by the membrane. In this patient you notice the intra-abdominal pressure. Most frequently, vulva stands open. There is a protrusion however, direct injury has occurred to it durfrom it. As I ask this patient to bear down, ing parturition. The bladder has been paryou notice that the protrusion is considerably tially filled, has been pushed before the head increased. It is increased by the mere effort of the descending child until the fascia is torn of abdominal pressure. Mere inspection in off from one or both sides. As the anterior such a case discloses the condition. The fact wall of the vagina sags down it drags upon that the mass is more prominent from the an- the cervix, producing in normal conditions a terior backward is an indication that it arises displacement downward of the cervix, until here from the anterior wall and not the pos- finally the body of the uterus falls backward, terior. The protrusion is continued upon becomes nearer to the axis of the vagina, and the anterior surface, which shows very the subsequent intra-abdominal pressure proreadily that we have not a rectocele. The motes the descent. This may result in comprojecting mass in no way involves the plete prolapsus or what is known as prociposterior wall of the vagina. My finger dentia. In those cases in which the uterus is readily passes into the vagina behind this pretty well fixed, either by healtlıy and normal mass, which shows without question that it tone of its ligaments, or by inflammatory

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