Vol. XIV. No. 1. THE COLLEGE AN4804INICAL RECORD. Clinical Lectur</BRARY A prolapse of the posterior we would find the isa prolapse of its anterior wall; if it were COMPLETE LACERATION OF THE BY E. E. MONTGOMERY, M.D., GENTLEMEN:-During the last two lectures the subject of consideration has been lesions of the pelvic floor, more particularly those in in which there was not so much loss of the perineum as there was of rupture of its supporting muscle, the levator ani, resulting, consequently, in prolapse of the posterior wall of the vagina. Prolapse of this wall through the vulvar orifice is known as a rectocele. The protrusion of the anterior wall is called cystocele. I hope, however, none of you, when asked “What is a cystocele?" will be guilty of giving an answer such as I received from a graduate of another school, who was applying for an indorsement of his diploma. He said it was "A cyst containing fluid." In the anterior wall of the vagina the intimate relation of the bladder leads to prolapse of a portion of this viscus; in the posterior wall, however, the rectum is much less intimately connected, so that it is not always prolapsed with the protrusion of the vaginal mucous membrane. In this patient you notice the vulva stands open. There is a protrusion from it. As I ask this patient to bear down, you notice that the protrusion is considerably increased. It is increased by the mere effort of abdominal pressure. Mere inspection in such a case discloses the condition. The fact that the mass is more prominent from the anterior backward is an indication that it arises here from the anterior wall and not the posterior. The protrusion is continued upon the anterior surface, which shows very readily that we have not a rectocele. The projecting mass in no way involves the posterior wall of the vagina. My finger readily passes into the vagina behind this mass, which shows without question that it I finger pass in front of it. In this case you would probably say that there was prolapse of the vagina, but upon examination of the patient I find the uterus is somewhat depressed, yet the protruding mass is not the uterus but the anterior wall of the vagina. The diagnosis is readily made in these cases by making pressure against the mass. If the uterus were situated in it we would find projecting from its summit the cervix with the external os. Patients, in a condition of this kind, you will find, suffer more and more the longer the duration of the trouble. As the prolapsed portion projects over the vagina it decreases the ability of the patient to evacuate the urine, and we have her consequently suffering from distress as a result. That portion of the bladder which is situated below the level of the internal os is not completely emptied, consequently it gives rise to decomposition of urine and cystitis, the presence of an ammoniacal odor and finally deposits of calcareous material and formation of calculi, these calculi sometimes attaining to large size. Cystocele usually results from injury during parturition. It may be of the posterior segment of the vagina, causing increased strain upon the anterior segment, which, no longer supported, is finally crowded down by the intra-abdominal pressure. Most frequently, however, direct injury has occurred to it during parturition. The bladder has been partially filled, has been pushed before the head of the descending child until the fascia is torn off from one or both sides. As the anterior wall of the vagina sags down it drags upon the cervix, producing in normal conditions a displacement downward of the cervix, until finally the body of the uterus falls backward, becomes nearer to the axis of the vagina, and the subsequent intra-abdominal pressure promotes the descent. This may result in complete prolapsus or what is known as procidentia. In those cases in which the uterus is pretty well fixed, either by healthy and normal tone of its ligaments, or by inflammatory |