Cystocolpocele Complicating 
Pregnancy and Labor. 
BY 
SAMUEL C. BUSEY, M. I)., 
WASHINGTON CITY. 
BEPBINT FROM VOLUME XII 
4&nnecolo0ical Sransactfons. 
1887. CYSTOCOLPOCELE COMPLICATING PREG- 
NANCY AND LABOR. 
BY SAMUEL 0. BUSEY, M. D., 
Washington, D. C. 
Definition. - The word cystocolpocele1 is introduced 
here to express correctly the anatomical and pathological 
condition of prolapse of the bladder into the vaginal passage. 
It may be either partial or complete-partial when the fun- 
dus remains between the uterus and symphysis pubis, and 
the lower part of the posterior wall is felt in firm, small ru- 
gae behind the pubis, generally very tender, and the seat of 
extreme pain when the uterus is forced down into the pelvis; 
complete when the sac containing urine occupies the cavity 
of the pelvis, filling the hollow of the sacrum, pushing the 
os uteri beyond reach, and occluding the vaginal passage. 
1 My Dear Doctor : The term cystocele vaginalis has been in use thirty or 
forty years, but it is objectionable as bringing a Greek and Latin term together. 
Cystocele is, of course, Greek-kvotis, the bladder, and a tumor-but 
vaginalis is simply Latin. Nevertheless, it must be admitted that cystocele is a 
Latinized form-and so the offense is palliated. I think it would be better to 
substitute for vaginalis the accepted Greek equivalent kJattos, which is com- 
monly employed to signify the genital passage in the female-the term might 
be cystocolpocele or colpocystocele, the latter being more euphonious, but the 
first being more correct pathologically. 
It is very common to preserve the kappa in words compounded with kAk-kos, 
as kolporrhaphy, but I think if the Latinized form of c is used for Kvarts and 
it would be inconsistent to spell the newcomer with a k. 
Very truly yours, Robert Fletcher. 
Dr. S. C. Busey. 
P. S.-I have no doubt that a German writer would use the k, and write it 
(as would be quite allowable in view of the uncertainty of usage) kolpo-cys- 
tocele. 
December 21, 1886. 2 
CYSTOCOLPOCELE COMPLICATING PREGNANCY. 
Complete prolapse may also occur without distention, when 
the bladder will be felt disposed in rugae, extending from 
the symphysis pubis to the uterus, with the os high up and 
far back.1 The cystocele is usually located as a rounded or 
elongated elastic tumor, with or without vesical intumescence, 
above the pubes, in front of the uterus and presenting part 
of the fetus, either completely or partially filling the vaginal 
lumen, but in occasional instances it assumes a very different 
location and contour. Sometimes it is presented in the form 
of a painful and elastic swelling in the lateral wall of the 
vagina, either circumscribed or with its base diffused and 
extending along the side of the pelvis as far as the hollow of 
the sacrum. Sandiford reports a case in which it was located 
between the vaginal canal and rectum. In Madame La Cha- 
pelle's case, the tumor was attached by a thick pedicle to the 
middle of the anterior wall of the vagina. In the cases of 
Brennecke, Dick, and Charrier, the tumor presented in the 
form of hour-glass contraction, one part situated in the true 
pelvis, and the other either above or behind the symphysis 
pubis. The size of the vaginal tumor is in a measure de- 
pendent upon the quantity of urine contained in the bladder, 
but this is not the invariable rule. In the cases of hour-glass 
contraction, the prolapsed portion may be the lesser or larger 
part of the displaced bladder, and when the cystocele is con- 
nected by a stem-like communication with that organ it is 
described as about the size of an egg. In the case reported 
by Golinelli, the cystocele assumed a ring-like form which 
nearly occluded the vaginal lumen. 
Synonyms.-Vaginal vesicocele; anterior protrusion of 
bladder; lateral malposition of bladder with over-distention; 
hernia vesicae vaginalis; vaginal hernia; procidentia vesi- 
cae ; falling of the bladder; vesical hernia; prolapse of the 
bladder ; cestocele vaginale, Italian. 
History.-It has been long known that vesical distention 
was a hindrance to, and sometimes a dangerous complication 
of, labor. Neither the earlier nor the later obstetric writers 
1 Broadbent, Obst. Trans., London, vol. v, p. 44. SAMUEL C. PUSEY. 
3 
have omitted directions for the proper management of such 
cases. The gynecologist is familiar with the nature, causes, 
symptoms, treatment, and frequency of cystocele in child- 
bearing women. But cystocolpocele complicating pregnancy 
and labor has as yet commanded but little attention, though 
it is a condition far more serious than either vesical repletion 
or simple prolapse of the bladder, and demands, in the pres- 
ence of an unexpected emergency, readiness of diagnosis and 
treatment. It is one of those rare complications which sur- 
prises every observer, and more than once has, for a time, 
baffled the experienced obstetrician and diagnostician. Grave 
mistakes have been committed by inconsiderate and ignorant 
accoucheurs, and many women have been allowed to linger 
in anguish during many hours, by physicians and midwives, 
because of the failure to recognize the obstacle to labor and 
the cause of the intense suffering of the pregnant and partu- 
rient woman. 
The meager literature of the subject, excepting the brief 
references of late obstetric writers, is mainly comprised in 
the clinical reports of the cases which are reproduced in ab- 
stract in this paper. 
Nagele1 appends to a brief paragraph on the subject of 
cystocele vaginalis some references to well-known cases, and 
states that a previous collection of eight cases had been made 
by Puchelt.2 This statement is not verified by an examina- 
tion of the paper referred to. It contains references by title, 
without any description, to several cases of vesico-vaginal 
hernia, but the anatomical nature of the cases can not be as- 
certained. These citations, as well as the ordinary references 
in the works on obstetrics, relate only to the complication of 
labor. So far as is known to the writer a summary of the 
cases of cystocolpocele complicating pregnancy has not been 
1 Lehrbuch der Geburtshulfe von Grenser, p. 587, 1872. 
2 De tumoribus in Pelvi. Par turn impedientibus, 1839. It appears that this 
inaugural dissertation was enlarged and republished, with a preface, by F. C. 
Nagele, in 1840, at Heidelberg, which can not be obtained in this country. It 
is probable that the collection of cases to which Nagele refers may be found in 
this enlarged edition of Puchelt's monograph. 4 
CYSTOCOLPOCELE COMPLICATING PREGNANCY. 
made, nor has the subject been discussed by any writer on, 
obstetrics. 
After a very thorough examination of obstetrical litera- 
ture, I am able to find but six cases of cystocolpocele compli- 
cating pregnancy reported in detail. Birnbaum1 refers to a 
"peculiar distention of the bladder, not infrequently ob- 
served in the later months of pregnancy, dependent upon 
the position of the uterus. The bladder appears as a round 
swelling, often of the dimensions of a child's head, and filling 
the pelvic cavity, pushing the body of the uterus posteriorly, 
causing retroflexion, or elevating the uterus so that it can not 
be reached." He states that this condition is quite often found 
in cases of abortion, and during the early months of preg- 
nancy in those suffering from spasmodic retention of urine. 
He condenses briefly the history of two cases where " hys- 
terical cramps often attacked the uterus during the later 
months of pregnancy. One was thrown into violent convul- 
sions ; the other suffered from tetanic seizures, commencing 
generally with uterine colic. The lower segment of the ute- 
rus, being drawn high up, was very tense and painful." 
Sympathetic disturbances often occurred in both cases. 
To catheterize was sometimes difficult. The entire cavity of 
the pelvis was filled with the distended bladder, and the pre- 
senting part of the child was out of reach of the exploring 
finger. Nothing could be felt but the tense and painful 
swelling. 
If any delay to empty the bladder occurred, the distention 
continued, and the swelling could be felt in front of the ute- 
rus above the pubes. In one case the uterus was displaced 
upward, expansion and tension of the abdominal walls fol- 
lowed, attended with acute pain. 
Velpeau states that, in consequence of greater pressure 
upon the fundus of the bladder than below during the last 
two weeks of pregnancy, vaginal cystocele quite often occurs. 
Cazeaux has seen but two such cases. 
Many experienced and observant obstetricians will recall 
1 Med. Cor. Bl. rhein H. Westfal, Aerztc, Bonn, 1842, i, 333-336. SAMUEL C. BUSEY. 
5 
instances of pregnancy, presenting a chain of similar subject- 
ive symptoms, which were attributed to retention of urine 
and relieved by artificial evacuation of the bladder, no vagi- 
nal exploration being made to ascertain the anatomical rela- 
tions of the pelvic viscera. In those cases where the vesical 
intumescence is easily recognized above the pubes, mistakes 
are not likely to occur. But it is more than probable that 
very many cases of vesical prolapse, with a partially filled 
bladder and accompanied with the peculiar paroxysmal pains, 
so closely resembling labor pains, have been mistaken for 
threatened abortion or miscarriage, and relief has been 
sought through continuous medication, and obtained only 
after evacuation of the bladder under partial narcosis. Such 
mistakes are unfortunate for the physician, and the patient 
will continue to harbor the fear of a recurrence of impend- 
ing danger. 
In commenting upon the case of prolapse of the bladder 
during labor cited farther on, Hamilton refers to the obser- 
vation made by his father and himself, "that previous to 
labor the vesica urinaria is sometimes pushed down through 
the vagina in such manner as to resemble the membranous 
bag formed by the layers of the ovum and liquor amnii." 
He states also that " several cases of incurable incontinence 
of urine from this cause have fallen under his observation." 
He suggests that a mistaken diagnosis might result either in 
laceration or puncture of the bladder. 
The six cases of cystocolpocele complicating pregnancy 
are as follows. The first occurring in my own practice is re- 
ported in full, the others in abstract: 
Case I.-During the early morning of November 24, 1886, 
I received a note from a gentleman, informing me that his 
wife was in labor. I found the lady, who was expecting to 
be confined the latter part of December, in great suffering, 
the pains seeming to be continuous, with quickly recurring ex- 
acerbations. She insisted that they were labor pains. Pro- 
ceeding to make a vaginal examination, the finger passed the 
ostium vagina?, and with some force entered a tense resilient 6 
CYSTOCOLPOCELE COMPLICATING PREGNANCY. 
pouch, apparently lined with a smooth, moist mucous surface, 
the walls of which could be displaced by the movements of 
the finger to a limited extent laterally, upward and backward 
(the patient was lying upon hei' back), but always closing 
around the finger. I could not find the os, cervix, or a present- 
ing part. Neither could I feel a cicatrix, a line of adhesion, 
or a point of induration. My suspicion was that the vagina 
had been obliterated by inflammatory adhesion. It was not 
an amniotic sac because of its uniform tenseness, the absence 
of hemispherical or elongated shape, and the impossibility of 
defining its contour by forcing the finger' between it and the 
vaginal walls. After a careful and prolonged exploration, the 
patient all the time asserting that I was causing her increased 
pain, I desisted, completely baffled. I knew she had two 
years before given birth to a male child, and believed she was 
now far advanced in her second pregnacy. She had always 
enjoyed good health, and neither she nor her husband had 
ever called my attention to any pelvic trouble. Having elicited 
the information that she had, during the previous day, three 
loose movements from her bowels, but had not passed water' 
since the previous early afternoon, I resumed the examination 
by the introduction of the index and middle fingers. The 
blind pouch, formed by the pressure of the fingers against the 
cyst, remained persistent and inexplicable. Then turning the 
palmar surfaces of the examining fingers toward the bladder, 
and gently tapping with the unemployed hand the abdomen 
above the pubes, within the area of vesical distention, I felt 
distinctly the wave of fluctuation against the fingers below in 
the blind pouch, and was satisfied I was dealing with a dis- 
tended bladder prolapsed into and filling the pelvic cavity, 
obliterating the vaginal lumen, and interposing a column of 
fluid within its tense walls between the cervix uteri and os- 
tium vaginse. I immediately directed the nurse to assist the 
patient to the commode. She passed a very large quantity of 
urine. The pains ceased, and the blind pouch disappeared. The 
os and cervix could be easily reached. Labor had not begun. 
This was to me a unique observation. Such descent of 
the bladder during labor has been mistaken for a hematoma, SAMUEL C. BUSEY. 
7 
a hydrocephalic head, a persistent amniotic sac, and an 
ovarian cyst; and, in several instances, it has been either 
incised or punctured, thus establishing a vesico - vaginal 
fistula. 
It thus appears that in its diagnostic aspects I was deal- 
ing with a very grave complication. I supposed the patient 
to be in labor, and, if I had concluded the vesical prolapse 
to have been either of the conditions for which it has been 
mistaken, I might have committed a very grave mistake and 
seriously injured the patient. 
The case here reported differs from the cases of cysto- 
colpocele complicating labor in that it occurred a month 
previous to the labor and did not exhibit the usual subject- 
ive symptoms of that condition. It wTas characterized by 
pains not unlike labor pains, and therefore the more de- 
ceptive, and by absence of the usual sensation of fullness 
and dragging and constant painful desire with inability to 
pass water. Not only were tenesmus and dysuria absent, but 
there was not even an inclination to urinate, and the bladder 
was evacuated with facility and ease when the patient was 
assisted to the commode. The negative symptomatology 
■was calculated to entice one into the errors which have 
been committed in somewhat similar cases. 
Case II.'-"A woman, aged twenty-eight, in the latter 
months of her fourth pregnancy, was affected with violent cor- 
poreal agitation, attended with no foaming at the mouth, no 
insensibility, nor dilatation of the pupils, but with great pain 
in the head. These paroxysms continued for two days, and 
were succeeded by labor pains. The pains had the effect of 
pushing forward the vesica urinaria, at the fore part of the 
vagina, in the form of a membranous bag. The labor pains 
continued two days with considerable regularity and sever- 
ity, and finally the vesica was forced entirely without the 
parts during the pains. After venesection, the os dilated, and 
a premature child, weighing four pounds and four ounces, was 
speedily delivered." 
1 James Hamilton, Jr., Select Cases in Midwifery, p. 9. 8 
CYSTOCOLPOCELE COMPLICATING PREGNANCY. 
The patient had suffered in a similar manner during her 
third pregnancy. 
Case III.1-The patient was under the care of a young 
practitioner, and had been, apparently, in labor for a consider- 
able time, and was suffering intense pain. The pelvis was 
quite filled with a soft, fluctuating tumor. Neither the child's 
head nor the os uteri could be felt until the hand had been 
passed around the tumor. The head had not descended, nor 
was there the slightest dilatation of the os. A catheter was 
passed, and a very large quantity of urine drawn off. The 
pain was immediately relieved, and all the symptoms of labor 
disappeared. The subsequent history of the case was not re- 
ported. 
Case IV.2-Mrs. B. was taken in labor at the eighth month 
of her seventh pregnancy. Labor was induced by overwork. 
An examination revealed a pediculated tumor projecting be- 
tween the labia and out of the vulva. The anterior wall of 
the vagina could be traced from the meatus urinarius around 
the tumor to the anterior lip of the os uteri. The prolapsed 
bladder contained several ounces of urine, which could be 
passed back above the pubis, and disappeared after micturi- 
tion. After waiting several hours, one drachm of the fluid 
extract of ergot was administered. The pains became very 
strong, and when the head was passing the inferior strait a 
fold of the bladder was pushed between it and the symphysis 
pubis, causing intense suffering. 
The patient had for several months suffered from inconti- 
nence of urine. 
Case V.3-Dr. F. had seen a patient in labor with the os 
dilated, but the head had not descended into the cavity of the 
pelvis. A short time afterward he was surprised to feel what 
seemed to be the distended membranes protruding from the 
vagina. A more careful examination enabled him to pass the 
finger beyond this tumor and to reach the os, which had not 
changed. He passed a catheter, and found that it entered 
freely into the tumor, which was the prolapsed bladder. It 
1 Carson, Med. Times and Gazette, vol. xviii, old series 39, p. 171. 
2 Valin, Chicago Med. Jour, and Exam., vol. xli, 1880, p. 477. 
3 Fifield, Exir. Records Soc. Med. Improv., Boston, vol. v, p. 123. SAMUEL C. BUSEY. 
9 
was carefully held up by the finger until the head had passed, 
and labor was successfully terminated. The prolapse had come 
on during pregnancy, and was considered by the patient to be 
"falling of the womb." In order to urinate, she had been 
compelled to stand up and lean forward, the tumor being then 
replaced by the finger. 
Case VI.1-Mrs. T. had been suffering during the day with 
paroxysmal pains, in the abdomen and genitals, of a straining 
character. The bowels had been greatly disturbed by a dose 
of castor oil. The bladder was greatly distended and pro- 
lapsed, pressing through the vulva. It was emptied by means 
of a catheter, and then the os uteri could be reached. It was 
tilted upward and backward, pointing to near the top of the 
sacrum. Dilatation had not commenced. Fifteen days after- 
ward she was seized again with pains of the same character, 
felt exclusively in the abdomen and genitals. The bladder 
was not distended, but very tender and sufficiently filled to 
prevent the os uteri being reached. It was emptied by the 
catheter. Then the os could be reached only with great diffi- 
culty. It pointed to the upper part of the sacrum, and was 
but slightly dilated. The forward displacement of the uterus 
was rectified by a bandage tightly adjusted and the supine pos- 
ture. The pains assumed the character of true uterine contrac- 
tions, and labor terminated as usual. 
The history of retention of urine with tenesmus and 
dysuria, an abdominal tumor in the region of the bladder, 
and the detection of a fluctuating tumor in the vagina, either 
in front of the pregnant uterus or in the lateral walls-most 
frequently the left-of the vagina, and which can be evacu- 
ated through the urethra, constitute the essential signs for a 
correct diagnosis. With a knowledge of the possibility of 
such a displacement of the bladder, and method of diagnosis, 
no mistake would be excusable. But it may happen that an 
accumulation of urine may take place without any vesical in- 
tumescence above the pubes. In that event, the discovery of 
a soft, fluctuating, and elastic tumor projecting into the cavity 
1 W. H. Broadbent, Obst. Trans , London, vol. v, p. 54. 10 
of the pelvis, or situated in the lateral walls of the vagina, 
which can be evacuated through the urethra, must be relied 
upon for a diagnosis. In all cases of pregnancy attended with 
pain, either continuous or paroxysmal, located in the pelvis, 
and apparently due to uterine contractions, attended with 
vesical tenesmus and dysuria, the condition of the bladder 
should be speedily and definitely ascertained. A careful vag- 
inal exploration may obviate the employment of detrimental 
medication, and secure a more satisfactory and speedy relief. 
CYSTOCOLPOCELE COMPLICATING PREGNANCY. 
The cases of cystocolpocele complicating labor, though 
very rare, are far more numerous than those which have been 
considered. As a hindrance to and a cause of lingering and 
painful labor, it has received very general, if not adequate, 
attention from a few of the more recent obstetric writers. In 
its etiological and diagnostic aspects, it has commanded very 
little consideration. Since the publication of Puchelt's in- 
augural thesis, and, perhaps, the later and enlarged edition in 
1840, no summary of the cases has been made. Authors 
have usually simply enumerated it among the complications 
of labor and causes of dystocia, and dismissed the subject in 
a brief paragraph with a recital of the more obvious symp- 
toms. The writer, therefore, hopes to contribute something 
to the common stock of knowledge by a collection and an- 
alysis of all the cases, so far as the library of the Surgeon- 
General's Office will enable him. 
Most of the following cases are presented in brief ab- 
stract, setting forth only the salient points, others more fully 
because of their special interest, and a few in full to illus- 
trate the embarrassments which beset the reporter: 
Case VII.1-Mrs. B., September 8, 1848, 12 m. In labor 
since yesterday morning. Confinement expected August 15th. 
On that day had considerable show, which was repeated for 
many days, confining her to her chamber, which she has not 
CYSTOCOLPOCELE COMPLICATING LABOR. 
1 Meigs, Treatise on Obstetrics, p. 329. SAMUEL C. BUSEY. 
11 
left since. Her pains are now frequent, • and attended with 
violent tenesmus or bearing down. The os is very high, 
scarcely reached, thick, hard, and open to about the size of a 
ten-cent piece. The head presents ; membranes unruptured. 
He prescribed for the tenesmic distress, and left the patient 
until seven in the evening. The pains had recurred every few 
minutes, and were so violent that be supposed the child was 
pressing upon the perineum. She had passed urine scantily 
very often, and the bowels had been moved by an enema. He 
was surprised to find that the head had not advanced, and that 
the os uteri was not more than an inch in diameter. While 
carrying the exploring finger to the os uteri, it encountered a 
sort of cushion-like tumor occupying chiefly the right half of 
the pelvic excavation. He supposed it to be a pelvic entero- 
cele. He introduced a catheter, but when it had advanced about 
two inches it stopped, noi' did any urine escape. After a more 
careful examination, he concluded the tumor was a cystocele, 
consisting of the bladder of urine, which had been crushed un- 
der the womb, and obstructed so as to be unable to discharge 
the whole of its contents. Finding he could not cause the 
catheter to advance downward and backward without using 
imprudent violence, he desisted. The patient lay on the back 
with knees drawn up. He then introduced three fingers of the 
right hand far into the pelvis ; when the pain was off, he 
pressed the palps of the fingers upon the inferior surface of 
the mass, and lifted it upward toward the plane of the superior 
strait. Just as he had partially raised it there came a violent 
tenesmic effort, and the urine rushed from the orifice of the 
urethra in jets so violent as to surprise him. In the course of 
three or four such jets, the whole of the urine in the bladder 
was expelled ; the tumor disappeared ; and, within forty min- 
utes, the whole of the remaining dilatation of the cervix was 
completed and the child delivered. 
Case VIII.1-Madam X., aged thirty-two, eighth pregnancy. 
Her two last labors were difficult: one was terminated by the 
application of the forceps, required by complete inertia of the 
uterus, and the other by version. In her eighth pregnancy, 
about the fourth month, she had slight pains, frequent desire to 
1 Charrier, Gazette des Hopltam, 1866, p. 21. 12 
CYSTOCOLPOCELE COMPLICATING- PREGNANCY. 
urinate, and lost a little blood. The womb was lower than it 
usually is at this stage of gestation. There was great ampli- 
tude of the vagina, very great flaccidity of the anterior wall of 
the abdomen, complicated by considerable displacement of the 
linea alba. This condition was explained by the number of 
former pregnancies, and by the great quantity of amniotic 
fluid accompanying each gestation. I prescribed rest in bed, 
full baths, some enemata with laudanum, and the use of a gir- 
dle to support the walls of the abdomen. Madam X. kept her 
bed eight days, and all was restored to order. In the ninth 
month of her pregnancy, Madam X. sent for me on account of 
some premature uterine pains. I examined her, and, contrary 
to my expectations, found the presenting part pretty high. 
Auscultation gave a first position of the vertex-by a digital 
examination the position could not be well made out-the 
fetal part was pretty movable and above the superior strait. 
Three weeks after (March 14, 1865), I was called to Madame X. 
at five in the evening. I found her seated. She had frequent 
desire to urinate, which she gratified. I examined the urine 
but found no albumen. I made a digital examination. I 
reached the presenting part with even more difficulty than be- 
fore, and I could only make a certain diagnosis by introducing 
two fingers of the right hand, the index and the middle finger. 
I again observed the exaggerated amplitude of the vagina. 
All the walls of the vagina were flabby, wavy, and of an ex- 
treme softness. A little of the cervix still remained. I left 
the patient, advising her to remain in bed. I came back at 
eight in the evening. These are the changes which had taken 
place : the head was still high, but the cervix had entirely dis- 
appeared, and the dilatation of the os was equal to the circum- 
ference of a five-franc piece. The pains were dull, separated 
by distinct intervals, and terminated abruptly. They were 
ineffective ; sometimes half an hour passed without uterine 
contractions. It was a tiresome labor, the tedious labor of the 
English. I left the patient undisturbed till midnight, lying 
horizontally to avoid premature rupture of the membranes. 
Dilatation took place slowly. But about half an hour after 
midnight the pains became active, and the bag of water broke 
of its own accord. I made a digital examination, and now SAMUEL C. BUSEY. 
13 
commences the interesting part of the observation. I could 
not reach the opening of the uterus nor even feel the lower 
segment. The womb seemed to have gone up again. I intro- 
duced two fingers, but I felt absolutely nothing. All around 
there were only the vaginal walls, flabby behind and at the 
sides, resisting in front and under the symphysis pubis. I waited 
some moments. The patient was quiet during the interval of 
the pains ; the pulse beat 76 a minute ; the skin was moist; 
the abdomen painless ; but the uterine contractions were short- 
ened and under the influence of the efforts of the uterus. I 
had only the confused sensation of a hard body separated from 
the finger by a bag which resisted as if distended by a liquid. 
As far as my fingers could reach, I could not circumscribe this 
tumor. Great was then my astonishment 1 With what have 
I to deal ? What is the pathological case which offers itself 
to my observation ? I palpated the abdomen with the greatest 
care ; I percussed it; and I felt behind the pubis the head of 
the foetus, and a little above a resisting tumor which had the 
form of the bladder distended with urine. At first I put aside 
this idea, since at the commencement of labor Madame X. had 
urinated frequently and copiously (nearly 1,000 grammes). 
However, on re-examining the abdomen, and feeling the tumor 
above the pubis, I came back to my first idea ; but, then, what 
was the nature of the vaginal tumor ? Was it a cyst ? But it 
did not existat the beginning of labor! Was it a thrombus 
of the vulva and of the vagina ? But that is not the ordinary 
place for these venous ruptures. Ordinarily, a thrombus has 
its seat in the lateral or even in the posterior wall of the va- 
gina, or even in the thickness of the labia majora ; but, admit- 
ting the existence of a thrombus, what could then be the na- 
ture of the tumor above the pubis ? To clear up the diagnosis, 
I tried to introduce a female catheter into the urinary passage. 
It was impossible for me to penetrate it. I felt about ; I tried 
to pass the catheter from below up to penetrate the tumor 
above the pubis, or from above down, and almost horizontally, 
to penetrate the vaginal tumor. All these attempts were fruit- 
less. Then I decided to introduce my whole hand into the 
vagina, determined to go as high as possible, to terminate the 
labor, if there was room for it, or at least to try to find out 14 
CY8T0C0LP0CELE COMPLICATING PEEGNANCY. 
what to depend on, and make a certain diagnosis. So I intro- 
duced my whole hand gently, slowly, opened flat as for the 
application of forceps, up to the superior strait. In doing this 
it followed all the lower part of the vaginal tumor ; it went as 
far as the cul-de-sac of the vagina. Having got so far, I bent 
my fingers, and I was able to embrace the superior and poste- 
rior part of the tumor. Above, near its middle part, rested 
as on an air-pillow the uterine orifice, dilated by the head of 
the fetus. Evidently, this was the obstacle which must be 
overcome ; for, admitting that it was the bladder distended 
by urine, which seemed to me true, I had to fear a spontaneous 
rupture of that organ. Then I set myself to perform, so to 
speak, taxis of the tumor. I compressed it gently in the hope 
of making the liquid flow back into the tumor above the pu- 
bis, if, in fact, the two tumors communicated. I could not 
accomplish it. I was, I own, quite bewildered by this new 
failure. However, I let the patient, who was beginning to be 
uneasy, rest for a quarter of an hour, and during that time I 
set myself to reflect. Putting together the symptoms, the 
anatomical location, and the anatomical characters of the two 
tumors, I fixed on this idea, to wit: 1. That the bladder, enor- 
mously distended, was separated into two lobes, one supra- 
pubic, the other vaginal, by the head of the fetus. 2. That it 
was absolutely necessary to change the relations of this head 
to the urinary reservoir. 3. That if I succeeded by any means 
in making the head change its place, and consequently in stop- 
ping the pressure of the head upon the bladder, that reservoir 
would empty itself, or could be emptied, and then the labor 
would end without hindrance. Fortified by this idea, which 
seemed to me just and rational, I had the patient placed on 
her knees and elbows. I said, at the beginning of this obser- 
vation, that there was a displacement of the Jinea alba, a great 
flaccidity of the abdominal wall ; I hoped, therefore, that the 
head, not being supported, would descend a little toward the 
navel. This in fact happened. The, head of the fetus left the 
back of the symphysis pubis, and then, to my great joy, the 
patient let escape a considerable gush of urine-so abundant 
that it almost filled a chamber vessel. I then compressed the 
two tumors, with one hand pressing on the abdomen, while the SAMUEL C. BUSEY. 
15 
other introduced into the vagina was reducing the vaginal tu- 
mor. It was then four in the morning ; the pains grew stronger, 
became decidedly expulsive, and at half-past four our patient 
was delivered naturally of a living child. 
I had then been dealing with a bi-lobular, supra-pubic, and 
vaginal cystocele. Catheterization had been rendered impossi- 
ble by the pressure of the head, which had flattened out the 
canal of the urethra lengthwise. Should I have succeeded bet- 
ter if I had had at my disposal a flexible catheter ? I do not 
think so. I could not have unfolded the urethral canal which 
was bent on itself like a pair of eye-glasses. Still it might be 
tried if a similar case should present itself. What should have 
been done was to pass a catheter at the beginning of labor. 
But could I have done so ? Could I ever think of it ? Our 
patient had urinated spontaneously and repeatedly before me. 
One thing remained to be verified, it was the capacity of the 
urinary reservoir. This I was able to do about the fourth day. 
Madam X. urinated wTith difficulty. I took advantage of this 
circumstance, passed the catheter, and, after having evacuated 
the fluid, I injected with a Child's syringe about two litres and 
a half of tepid water. I only reproduced the vaginal cysto- 
cele. The distended bladder was indeed felt a little behind 
the pubis, but it did not project, which is intelligible since' 
there was now no fetal head to push forward this organ and 
prevent it from expanding backward in the abdominal cavity. 
I have, perhaps, been a little long, but I could hardly do 
otherwise. I know no similar observation in science. I have 
searched in special treatises, in periodicals, and have found noth- 
ing like it. So I was obliged to describe all the turns which 
I made, to tell my fears, all my uncertainties of diagnosis, for 
it has been my object in entering into such circumstantial de- 
tail to be useful to my brethren, if they should find themselves, 
which I do not wish for them, in a position as disagreeable and 
as painful as that of which I have just given the history. 
Case IX.1-July 11, 1821, there was admitted into the hos- 
pital a woman, about twenty-one years old, pregnant for the 
second time, and now at term. The labor had scarcely com- 
menced. The first thing that struck us on making an exam-' 
1 Mme. La Chapelle, Pratique des Accouchemens, Tome iii, p. 387. 16 
CY8T0C0LP0CELE COMPLICATING PREGNANCY. 
ination was a pediculated tumor the size of an egg, which 
presented a little from the vulva and was apparently attached 
midway of the upper part of the anterior and right wall of 
the vagina. The pedicle was about an inch and a half in thick- 
ness, and the tumor contained a liquid which could be pushed 
completely toward the pedicle ; there could be felt a canal 
with thick borders, seemingly communicating with the blad- 
der. According to the woman's statement, the tumor increased 
while she was in the erect posture. It often disappeared after 
micturition and always returned after a cold bath. The uter- 
ine pains increased the volume of this vesical hernia, and the 
head in descending pushed it farther out and stretched it con- 
siderably. I reduced it by emptying the bladder with a cathe- 
ter, and I advised the students to lift it with two fingers dur- 
ing each contraction of the womb. It was my intention to 
prevent rupture of the sac. The head passed without endan- 
gering the sac, and the hernia remained the same at the end of 
the labor, which was simple and natural. Some little flooding 
with uterine inertia, due, no doubt, to the length of the labor 
(eighteen hours) was, barring some syncope, the only accident 
which occurred after the delivery. 
During the whole time she remained in bed this woman 
scarcely felt the tumor, and it was not visible from the out- 
side. I advised her to wear in the vagina a bung-shaped 
sponge, in order to support the hernia and prevent its enlarge- 
ment. This vesical hernia had existed for two years. It 
made its appearance without straining or any other known 
cause nine weeks after the first confinement. At first very 
small, it had gradually acquired the size we have mentioned. 
The cases of Meigs, Charrier, and Madame La Chapelle 
are reproduced here in full because of the graphic descrip- 
tions of the difficulties and embarrassments which obstructed 
the diagnosis in each of these cases. If Madame La Chapelle 
in 1821, Meigs in 1848, and Charrier in 1866 were foiled in 
diagnosis by the anomalous situation and forms this compli- 
cation may assume, it is not surprising that obstetricians of 
less experience should have been completely baffled. In 
Meigs's case the displaced bladder occupied the right half of SAMUEL C. BUSEY. 
17 
the pelvic cavity, behind the vaginal wall. He failed, after 
persistent effort, to introduce the catheter, and only suc- 
ceeded in reaching a correct diagnosis by forcing out urine 
after elevating the mass by gentle pressure with the palps of 
three fingers of the right hand against its inferior surface. 
In La Chapelle's case the obstacle was presented in the form 
of an egg-size pediculated tumor " a little from the vulva, 
and apparently attached midway of the upper part of the 
anterior and right wall of the vagina. The pedicle was 
about an inch and a half in thickness." After the evacua- 
tion of the bladder, the fluid contents of the sac were par- 
tially pressed out along the pedicle. By this manipulation 
the diagnosis was determined. Charrier's case was even 
more perplexing. The enormously distended bladder was 
divided into two lobes by the pressure of the head of the 
child, one supra-pubic and the other vaginal. The urethral 
canal was bent on itself like a pair of eye-glasses. The diag- 
nosis was only made by the discharge of some urine during 
the knee-chest position of the patient. In each of these 
cases the labor was retarded, and the acute suffering of the 
patient greatly prolonged by the delay in determining the 
anatomical nature of the cause of the dystocia. 
The two following cases exhibit this complication in an 
equally perplexing, but different aspect : 
Case X.1-Mrs. T., age thirty years, robust, was, in the 
middle of April, at the end of her fourth pregnancy. The first 
three deliveries were normal, last birth four years ago. Patient 
since that time always well. 
Labor pains began forenoon of April 19th ; were not regu- 
lar or strong until premature rupture of the bag of waters 
during night of 20th. 
On the evening of April 20th, B. found the patient suffer- 
ing violent labor pains, following each other in quick succes- 
sion without intervals of rest. The abdomen was remarkably 
flat, and abdominal walls were tense and rich in fat. The 
2 Brennecke, Centrcdblai fur Gynaekologie, 1879, iii, p. 179. 18 
CYSTOCOLPOCELE COMPLICATING PREGNANCY. 
uterus was drawn to right of median line and child in first 
head position. 
By internal examination, a cystic tumor was discovered in 
true pelvis, the principal mass of which lay in the right pelvic 
half, extending by hour-glass contraction to the left, behind 
symphysis. The antero-lateral vaginal wall arched into the 
lumen of the pelvis. 
During the short, hardly perceptible intervals of pain, the 
soft and elastic tumor relaxes and becomes tense and prolapsed 
toward the pelvic brim during the pains. During the inter- 
vals, by pressure upon the principal mass, the contents of the 
tumor could be easily displaced from right to left. To ascer- 
tain the position of the.head and other' relations was difficult. 
The head, considerably swollen, was high up, with posterior 
displacement of cervix. Patient had not urinated for sixteen 
hours ; had never before suffered from urinary trouble. Ex- 
ternally, above symphysis, anterior to and beside uterus, no 
indication of a filled bladder could be seen or felt. The cathe- 
ter confirmed the diagnosis of a filled and displaced bladder. 
One third of a chamberful of urine was drawn off. The labor 
was protracted, and finally completed by the forceps. 
Case XI.1-Mrs. R., age twenty-two years. Third preg- 
nancy. The first two spontaneous ; both children now alive. 
Last child born July, 1876. 
Some time before her confinement she noticed a small, soft 
swelling at vaginal entrance, which gradually reached the size 
of an egg, and was constantly visible without disturbing mictu- 
rition. 
When D. was called by the midwife, he found the woman 
in full labor, with very severe pains. The os was fully dilated, 
the waters had escaped, and the umbilical cord was prolapsed. 
The abdomen was not much distended. In the ileo-cecal re- 
gion the filled bladder arched forward and was quite pain- 
ful to pressure. The pelvis was slightly but uniformly con- 
tracted. 
By internal exploration, the finger came in contact with a 
soft, fluctuating tumor situated in the right half of pelvis and 
painless upon pressure. It was about the size of an egg, and 
1 Dick, Centralblat fur Gynaekologie, 1879, iii, p. 154. SAMUEL C. EUSEY. 
19 
passed stem-like toward the right side, so that the part in the 
true pelvis measured ten centimetres in length. 
At commencement of uterine contraction, the swelling be- 
came hard and painful on pressure. The tumor filled by ex- 
ternal pressure upon the bladder. It was, therefore, evident 
that the swelling communicated through the contracted stem 
with the bladder. The easy introduction of the catheter pro- 
duced the disappearance of the tumor and also emptied the 
bladder in upper portion of superior strait. Labor was com- 
pleted with the forceps. 
The diagnosis in Cases X and XI was only determined 
by the introduction of the catheter and evacuation of the 
bladder. The hour-glass form of the cystocele was ascribed 
by Brennecke and Dick to a slight contraction of the pelvic 
brim and perverse position of the head. In Brennecke's 
case, " the head, considerably swmllen, was high up at the 
entrance of the pelvis " ; the " anterior fontanelle was to the 
right and against the promontory; the posterior fontanelle 
could not be reached. The conjugate diagonal measured 
eleven centimetres." In Dick's case the pelvis was slightly 
but uniformly contracted, and the head in " first frontal posi- 
tion wedged itself at superior strait and, thereby, by pressure 
against the pelvic parietes," produced the hour-glass form of 
displacement. In Brennecke's case the cystocele lay to the 
right, but extended anteriorly and to the left, and " caused 
by pressure from in front and from below an antero-lateral 
position of the head." In Dick's case, the cystocele and other 
part of the bladder lay to the right. In both cases the per- 
verse position of the head seems more likely to have been 
the cause of the hour-glass form of vesical prolapse than the 
slight contraction of the pelvis. 
Broadbent1 has invited attention to a form of partial pro- 
lapsus of the bladder, where the fundus remains between the 
uterus and symphysis pubis, of which Cases XII, XIII, XIV, 
XV,.and XVI are examples. In such cases, the bladder may 
be entirely empty, or contain but a very small quantity of* 
1 Obst. Trans., Loud., vol. v, p. 44. 20 
CY8T0C0LP0CELE COMPLICATING PREGNANCY. 
urine. This form of displacement is very likely to be over- 
looked. The symptoms are, however, mainly the same, and 
may be even more severe. " There is (Broadbent) almost 
constantly a frequent desire to pass water, and the urine 
never accumulates. The lower part of the posterior wall of 
the bladder is felt in firm, small rugae behind the pubis, gen- 
erally tender when touched, and the seat of extreme pain 
when the uterus is forced down into the pelvis. The cathe- 
ter, when introduced, may be felt to pass up between the cer- 
vix uteri and symphysis pubis, showing the prolapse is not 
complete. The pains have the spasmodic straining charac- 
ter; the uterine contractions affect the displaced bladder, 
causing pain and irritation; violent reflex action of the ab- 
dominal muscles is set up ; a kind of tenesmus which super- 
sedes the normal uterine action ; and thus not only is the 
first stage of labor rendered long and painful, but the patient 
is more exhausted than by a prolonged first state without 
this complication." 
Case XII.1-Mrs. F., in labor with seventh child, and had 
been suffering pains, for twenty-four hours, in the back, lower 
part of the abdomen, and right side. She stated that a month 
previous, during unusual exertion, she had lost a pailful of 
water, and since then there had been continual loss of fluid 
from the vagina, and a week before she had lost a large 
amount of blood. On examination, the os uteri was found 
high up in the pelvis, directed backward, and was reached 
with great difficulty. It was soft, dilatable, elliptical in form, 
and admitted three fingers. Under the arch of the pubis, ex- 
tending backward to the uterus, was the bladder, nearly empty, 
very tender, and thrown into rugae. The pains were frequent, 
occasioned much suffering, but ineffective. During the pains 
the uterus was forced down by the spasmodic action of the ab- 
dominal muscles, which seemed to be more frequent and ener- 
getic than the uterine contractions, like a series of straining, 
bearing-down efforts. The urine continued to dribble away 
involuntarily. This condition persisted for thirty hours with- 
1 W. H. Broadbent, Obst. Trans., Lond., vol. v, p. 57. SAMUEL C. EUSEY. 
21 
out any advance of the head, when chloroform was admin- 
istered and labor speedily completed. As the head was ex- 
pelled, the bladder was carried down before it, and brought 
completely out of the pelvis, under the pubic arch. The pla- 
centa was adherent. 
Case XIII.1-Mrs. S., 9.20 a. m., February 21, 1859. Sec- 
ond child. When first seen had been in labor all night; ex- 
treme pain in hypogastrium, and great involuntary straining. 
On examination, uterus found not to enter pelvis. Os reached 
with difficulty, high up, and far back, not at all dilated. An- 
terior half of lower part of uterus very tense. Bladder pro- 
lapsed. The woman was placed on her back, with directions 
to raise the fundus uteri with her hands during the pains. At 
10.20 the os uteri was fully dilated and a bag of membranes 
projecting. The prolapsed bladder contained urine, and the 
catheter was used. The labor progressed rapidly. 
Case XIV.2-Mrs. K., partial prolapse. Extremely rest- 
less ; unable to remain in any position ; wishful to walk about; 
assumed voluntarily the supine position, when lying down, as 
the easiest. There was frequent desire to pass water, and the 
pains were of the characteristic thrusting description, with 
much suffering from the bladder. The labor continuing with 
great severity, without satisfactory progress, chloroform was 
administered and labor completed. 
Case XV.3-Mrs. J., third child ; in labor for twenty 
hours. A fortnight before had thought she was in labor for 
some hours. Pains in back and hypogastrium ; can not retain 
water more than a few minutes. Bladder prolapsed and con- 
taining urine. When emptied, os uteri almost out of reach, 
soft, moist, with thick lips, no dilatation. After considerable 
delay the child was turned and labor completed. The pelvis 
was contracted at the brim. 
Case XVI.4-Mrs. C., multipara. Unable to retain water 
for a month ; now escaping with every pain. Pains incessant 
and straining, with much suffering in region of bladder ; con- 
stant moaning, tossing, restlessness, and tendency to hysterical 
symptoms. Bladder partially prolapsed. Os uteri high, near 
1 Broadbent, Obst. Trans., Lond., vol. v, p. 55. 2 Broadbent, ibid., p. 56. 
3 Broadbent, loc. cit., p. 56. 4 Broadbent, loc. cit., p. 58.  CYSTOCOLPOCELE COMPLICATING PREGNANCY. 
22 
sacrum, and somewhat dilated. Patient placed on back ; 
bladder emptied, and dilatation aided by drawing down cervix. 
Labor successfully completed. 
Mistakes and Injuries.-Merriman refers to a case de- 
tailed to him by Dr. Maurice, who saw the patient a fort- 
night after delivery, in which an inconsiderate practitioner 
punctured the prolapsed bladder in mistake for a dropsical 
head. James Hamilton relates an equally grave and rash 
error committed by an ignorant physician who supposed he 
was discharging the liquor amnii. Nelson reports the fol- 
lowing case in which the attending physician, after consid- 
erable toil, forced his finger through the bladder, making an 
opening the size of a silver quarter of a dollar. 
Case XVII?-In the latter part of December, 1856, Dr. 
Nelson was requested to meet two physicians " in consultation 
on the wife of one of them who had been in labor three days 
and two nights." . . . " The labor had appeared to progress 
favorably, so far as the pains were concerned, but no advance 
had been made ; the head presented, but the presentation had 
not been made out. During the first night one of the phy- 
sicians had ruptured the membranes (!) and had helped the pa- 
tient since by constant manipulation. During the second day 
he had accidentally discovered some sort of a tumor or bag 
directly behind the symphysis pubis, which, becoming more 
tense and prominent during the pains, he concluded was the 
membranous bag of another child blocking up the vagina, and 
preventing the exit of the first one so long expected. He pro- 
ceeded to rupture this bag, and after one-half hour's toil he 
succeeded in penetrating it with his fingers ; a few ounces of 
water were discharged. He pronounced it the ' toughest and 
strongest bag of waters ' he had ever known. Nothing was 
gained by the procedure, and, in spite of bleeding, tartarized 
antimony, and repeated doses of secale cornutum, and McMunn's 
elixir of opium, the patient became more and more exhausted. 
Turning could not be accomplished. The forceps failed, and 
delivery was finally completed by craniotomy. After the ex- 
1 Nelson, British American Journal, vol. i, p. 885. SAMUEL C. EUSEY. 
23 
pulsion of the placenta, an opening, about the size of a silver 
quarter-dollar piece, was discovered at the anterior and inferior 
portion of the bladder, just posterior to its neck. The rupture 
was finally cured, and the patient was, eighteen months after- 
ward, safely delivered of a living child." 
McKee reports the succeeding case in which he, " failing 
to introduce a catheter, because of the want of a proper in- 
strument, tapped the bladder with a thumb lancet." 
Case XVIIL1-A colored woman, of robust and strong 
constitution, was taken in labor with her third child on Wed- 
nesday night. She was under the care of a midwife. On Sat- 
urday afternoon, when first seen by Dr. McKee, Cl her condition 
was as follows : Pulse 120, and feeble ; countenance anxious, 
and wore a peculiar expression, an aspect of anxiety mixed 
with distress, and complained of pain in the hypogastric re- 
gion, with a dragging sensation from the umbilicus, as if she 
would burst at each pain ; skin bathed in a cold and profuse 
perspiration ; tongue red and dry ; thirst great; pains strong 
and forcing ; external organs of generation swollen as thick 
as the wrist, hard, and at each pain blood exuded from the 
labia, they having become very sore, cracked, and dry from 
the repeated touching of the midwife. On examination, per 
vaginam, the finger came in contact with a large elastic tu- 
mor, filling up the vagina, so he found it impossible to reach 
the presenting part of the fetus. She had not passed water 
for twenty-four hours." Failing to introduce a catheter, be- 
cause of the want of a proper instrument, he tapped the blad- 
der with a thumb-lancet, guarded by the index finger intro- 
duced into the vagina. The relief was immediate, and in 
fifteen minutes a large-sized dead child was born. Her recov- 
ery was entirely satisfactory. 
The case of Elizabeth Lawrence, reported by Wilkinson,2 
has been occasionally referred to as one in which a prolapsed 
bladder was injured by an obstetric operation. A careful 
examination of this report does not justify this conclusion. 
1 William H. McKee, Medical Examiner., vol. viii, p. 634. 
2 Medical Memoirs, vol. iii, p. 480. 24 
CYSTOCOLPOCELE COMPLICATING PREGNANCY. 
It appears to have been a case of sloughing of the bladder 
due to impaction, and, perhaps, to injury inflicted during 
the performance of the operation of craniotomy. The 
operation was performed July, 1748, and the patient died 
in 1791. 
The abstracts of the following cases are presented with- 
out comment. They set forth the ordinary clinical history of 
this complication, and may be read with interest and profit 
by those who wish to study the forms in which it is present- 
ed, and the variations in its symptomatology: 
Case XIX.1-The lady, in her tenth labor, was found sit- 
ting on a chair, straining violently every two or three minutes. 
Her face was flushed, pulse rapid, and there was profuse per- 
spiration. She looked like a woman whose child was on the 
eve of passing into the world. She had suffered daily for two 
hours during the past week the same kind of pains. They had 
come on the previous evening, but, instead of leaving, had con- 
tinued with gradually increasing intensity. She was, however, 
quite satisfied they were not labor pains. She was removed to 
bed, and an examination discovered the bladder prolapsed, fill- 
ing the fore part and left side of the pelvis, drawing down 
with it the anterior face of the vagina. The tumor was soft 
and fluctuating, no increased distress was produced by press- 
ure upon it, and it occupied so much of the pelvis as to render 
the passage of the finger up to the os uteri somewhat difficult. 
The os was dilated to the size of a crown piece, soft and flac- 
cid ; membranes whole. The uterus was acting occasionally ; 
but the cause of the violent pressure experienced was spasmod- 
ic contractions of the abdominal muscles, which, when the 
hand was placed upon the abdomen, gave a deceptive sensation 
as though the uterus was acting. No vesical tumor could be 
felt above the pubes. Eight ounces of urine were drawn off. 
The fluctuating tumor entirely disappeared, the violent forcing- 
pains ceased, and the uterus acted moderately at intervals of 
ten or fifteen minutes. The membranes were ruptured, a very 
large quantity of fluid was discharged, and labor was speedily- 
completed by natural efforts. 
1 Ramsbotham, Med. Times and Gazette, vol. xxxix, p. 4, 1881. SAMUEL C. BUSEY. 
25 
This patient had eight years before suffered from proci- 
dentia of the uterus, which had been relieved by local treat- 
ment and rest. 
Case XX.1-To this patient Dr. R. was called while under 
the care of a young practitioner. He found her lying on her 
left side on the bed, grasping a towel, and bearing down 
strongly, in the belief that the child was about to pass imme- 
diately. She had been in this position and suffering the same 
pain for more than twelve hours. The bladder was prolapsed 
before the head. Relief immediately followed evacuation of 
the bladder, and the labor terminated satisfactorily. 
Case XXI.2-M. P., aged forty, began to experience labor 
pains, in her tenth labor, Saturday morning, but continued to 
discharge her domestic duties until Monday morning, when the 
membranes ruptured and the midwife was called. The pains 
continued strong ; the os was fully dilated ; but the head re- 
mained resting upon the pelvis. Dr. Christian was summoned. 
He discovered a "fullness on one side of the pelvis, which be- 
came more prominent during the presence of the pains, and, 
from its tense, elastic feel had no doubt but that it was occa- 
sioned by a fluid." Upon feeling for the bladder above the 
pubes externally nothing but a solid body could be discovered. 
The patient had not passed any water since the preceding 
night, but she was constantly wet. A pint and a half of urine 
was drawn off, and the instrument was distinctly felt along the 
side of the vagina, extending to the os sacrum. The head 
descended into the pelvis during the next pain, and labor was 
soon completed. The next morning Dr. C. was again sum- 
moned. On examination he found a second fetus, and the 
same distention of the bladder as before, which was in like 
manner evacuated, with the same immediate effect. 
Case XXII.3-A forty-year-old woman, large, strongly 
built, heavy-boned, but very haggard from pale appearance, 
distressed and exhausted, was delivered surprisingly easy five 
1 Ramsbotham, Med. Times and Gazette, vol. xxxix, p. 4. 
2 Christian, Edinburgh Med. and Surg. Jour., vol. ix, p. 285, 1813. 
3 Birnbaum, Med. Cor. Bl. rhein, H. Westfal, Herzte, Bonn, 1842, r, 
333-336. 26 
CYSTOCOLPOCELE COMPLICATING PREGNANCY. 
times. Up to sixth pregnancy she was well, excepting vari- 
cosities of thigh and pudenda. On the 22d day of December, 
1839, after breaking of bag of waters, slowly increasing pains 
began, which became so severe at 6 p. m. that a midwife had to 
be called. She found labor pains replaced by a pain commenc- 
ing on left side, passing through abdomen to right side ; a 
quick, easy labor was expected. As the pains increased and 
little progress being made, B. was called at 10:30 p. m. 
The patient complained of very severe and continued pains 
in pubic and left inguinal regions ; uterus protuberant; fundus 
at umbilicus was well and regularly formed. The vaginal 
canal was filled by a tense, painful tumor, pushing back lower 
segment of uterus. Os could hardly be reached, being pushed 
high up. At sacro-iliac synchondrosis presenting part was 
reached. Midwife assured B. that head presented and that 
patient, shortly after her arrival, passed a considerable amount 
of urine. B. emptied bladder with catheter, drawing off one 
and a half pint of cloudy, flaky, yellow, and very warm urine. 
Immediately thereafter the uterus descended and labor was 
speedily completed. 
Case XXIII.1-A woman, aged twenty-nine, has had two 
children, was admitted to the institution April 25, 1861. The 
waters had broken fifteen hours before her admission. Through 
the dilated os the head was plainly felt. Later, upon examina- 
tion, pelvic cavity was filled to a large extent with a fluctua- 
ting tumor. Head could now be felt only with difficulty. The 
os was also pushed posteriorly by the swelling. Upon pressing 
the swelling urine passed from the urethra. The woman com- 
plained of suffering from retention of urine. As soon as the 
diagnosis was made a male silver catheter was introduced and 
a large quantity of urine was drawn off. Notwithstanding the 
removal of the obstacle, the labor continued for nine and a half 
hours longer, but ended without interference. The bladder 
formed a tumor which filled the pelvis on one side, extendino- 
as far back as the vertebral column, and occupied one third of 
the transverse diameter of the pelvis. 
Case XXIV.2-Mrs. C., twelfth confinement, forty-six years 
1 Hecker, Klinik der Geburtskunde, ii, p. 135. 
2 Dodge, Peoria Med. Monthly, vol. v, p. 207, 1884-'85. SAMUEL C. BUSEY. 
27 
of age, large, strong, and swarthy. Had had fits in hei' last 
three labors. The labia were much swollen, and the vulva was 
large, hot and dry. At the orifice was a globular body, which 
was mistaken for the unruptured membranes, but wThich reced- 
ed upon pressure. The head could not be felt. The globular 
mass being firmly pressed back, there followed a discharge of 
scalding urine ; after which the dilated os and protruding bag 
of waters could be recognized. For an hour there wTere no 
pains and no advance of the head. Chloroform was adminis- 
tered. The distended bladder was emptied, the membranes 
ruptured, and the prolapsed bladder pushed up and held in 
position. The pains soon became very strong and expulsive. 
Labor was speedily terminated. The bladder had been pro- 
lapsed from the time of her eighth labor, wThen she had the 
first convulsion. Since that time it had been hanging in the 
vagina, at times protruding externally, so that she had to push 
it back to evacuate it. 
Case XXV.1-Mrs. J., aged thirty ; third child. Had been 
in labor for three days. On examination, the vagina was found 
filled with a tumor formed by the bladder, which was pro- 
lapsed and distended with urine. The child's head presented 
at the brim, with the vertex, but could not enter on account of 
the state of the bladder. The bladder was emptied and pushed 
above the brim of the pelvis. Delivery was accomplished by 
turning. The woman suffered for some time with slight pro- 
lapse of the anterior wall of the vagina, which -was treated 
with astringent injections, rest in bed, and tincture of the mu- 
riate of iron. 
Case XXVI.3-Davis was consulted in a case of protracted 
labor, of which the progress had been suspended at an early 
period by the mechanical interference of an over-distended 
bladder. The distended bladder occupied the greater part of 
the brim of the pelvis, and might have been mistaken for the 
membranes of the ovum. Beyond this tumor he found the 
orifice of the uterus considerably dilated. After emptying 
the bladder, which contained some pints of urine, the fetal 
head speedily descended into the pelvis, and the patient 
1 Charles James Egan, Med. Times and Gazette, vol. ii, p. 225, 1872. 
2 Davis, Obstetric Practice, vol. ii, p. 986. 28 
CYSTOCOLPOCELE COMPLICATING PREGNANCY. 
was delivered without further difficulty in one and a half 
hours. 
Case XXVII.1-A woman, in labor of her fourth child, re- 
ported to have been ill for three days previously. " On ex- 
amination, a large tumor was found in the vagina, which was 
discovered to be the distended bladder pushed down before 
the head of the child. The catheter was passed and the urine 
removed, after which the tumor nearly disappeared. A purga- 
tive was then administered, followed by an injection ; the 
uterus continued to act with considerable force at intervals 
from her admission, for six hours, yet the labor made no prog- 
ress. The head was lessened and delivery effected by the 
crotchet." 
Case XXVIII.2-In a case of labor to which the elder 
Hodge was called, during the second stage, he found a large, 
fluctuating, soft tumor pressing down toward the vulva, while 
the finger could, with difficulty, be passed under it to reach 
the os uteri, which last was found nearly dilated. The patient 
had suffered exceedingly from this complication, especially as 
the bearing-down efforts were strong. 
Case XXIX.3-E. C., aged thirty-five, a strong, muscular 
woman, in her ninth labor. Her previous labors had been 
tedious, but this was more so. She had been purged with 
castor-oil, and subsequently by an enema. After labor had 
continued quite actively for two days, during which time she 
had been under the care of a midwife, Dr. D. discovered, high 
up, as far as he could reach with his finger, " an elongated, 
puffy body, resembling an elastic sac, like the membranes, or 
more like the placenta to the touch, extensively protruding 
and occupying the lower and anterior part of the pelvis." A 
pint of high-colored urine was drawn off. An enema was 
given, and six hours afterward the urine was again drawn off. 
After waiting twelve hours, without any advance whatever in 
the labor, it was discovered that the sac was the bladder dis- 
tended with urine. A pint of high-colored urine was drawn 
off, and at once the sac disappeared and the obstruction to 
1 Collins, Practical Treatise on Midwifery, London, p. 463. 
2 System of Obstetrics, p. 512. 
3 Doyle, Dublin Med. Press, 1840, vol. iv, p. 2'74. SAMUEL C. BUSEY. 
29 
labor was removed. In about two hours afterward the patient 
was delivered of a large, living child. Previous to last dis- 
charge of urine, the head of the child had been pushed up, 
thus removing the pressure which had, apparently, divided the 
bladder into two chambers. 
Case XXX.1-The doctor was called to see a woman, aged 
thirty, in her sixth confinement, who had been under the care 
of a midwife for three days. On examination the os was dry 
and slightly dilated. She was much exhausted. Tully pow- 
ders were given. During digital dilation of the os, good pains 
came on. During the progress of the pains, a tumor was dis- 
covered just under the arch of the pubes, which was found to 
be the bladder, presenting in front of the head. Delivery was 
completed with the forceps. 
In the discussion of the case, Dr. Quackenbush stated that 
he had heard of several similar cases occurring in the city of 
Albany. 
Martemucci2 reports three cases (XXXI, XXXII, and 
XXXIII) of vaginal cystocele occurring during delivery, 
but omits any detailed description of them. In each case the 
vertex presented, one in " right occipito-sacral " and two in 
" left occipito-cotyloid " position. One case occurred during 
the third and two during the fourth confinement. The au- 
thor attributes the prolapse of the bladder to spasmodic con- 
traction of the muscular fibres of the body of the bladder. 
Case XXXIV.3-Mrs. B., multipara, in labor for thirty hours 
with her eleventh child. Dr. O. found prolapse of the blad- 
der, with extreme relaxation of the vagina, head above the 
brim, and gradually increasing inertia. An attempt to deliver 
with the long forceps having failed, turning was tried with 
no better success. Dr. More found the entire vaginal passage 
filled by the somewhat loose, prolapsed bladder ; the os was 
high up and widely dilated. A pint of turbid urine was drawn 
1 Sabin, Trans. Med. Soc. County of Albany, M. Y., vol. ii, p. 414. 
2 Del Cistocele vaginate durante it par to Osservaton, Torino, 1873, ix, pp. 
129-133. 
3 More, Obst. Jour. G. B. and I., vol. vii, p. 630. 30 
CYSTOCOLPOCELE COMPLICATING PREGNANCY. 
off, but no change in the position of the presenting part fol- 
lowed. The forceps were again tried, and failed. Craniotomy 
was performed, but delivery could not be accomplished. Turn- 
ing was finally effected, and, with the blunt hook inserted in 
the mouth of the child, delivery was completed. The patient 
made an uninterrupted recovery. 
Case XXXV?-D. M., second pregnancy, was admitted 
to hospital May 17th, under the care of the midwife on duty. 
The labia majora were slightly edematous, painful, and sepa- 
rated four lines by a bluish-red, tense, fluctuating tumor. Its 
outer coat was formed by the superior and right vaginal walls, 
and the urethral orifice with anterior vaginal wall, was drawn 
down to the external genitalia. The swelling, the size of a fist, 
filled one third of the distended vagina. A finger introduced 
on the left side and below the swelling came in contact with 
the head, which, when forced down by the contractions of the 
womb, forced the tumor partially external to the genitals. 
During the hard and quick pain the patient suffered acutely. 
She had not urinated for four and a half hours. One pound 
of urine was drawn off, the swelling disappeared, and the walls 
of the vagina resumed their normal position. The head was 
born five minutes after the evacuation of the bladder. No 
trouble followed. 
Case XXXVI.2-On February 2, 1868, I was called to a 
woman, aged forty-five, in the beginning of labor. The pa- 
tient is of slight build, though of sound constitution. She 
had previously passed through nine labors without accident, 
and had reached the end of her tenth gestation with no unto- 
ward symptoms, when, at about five o'clock, while still in bed, 
the bag of waters suddenly ruptured without the occurrence of 
labor pains. A half hour later she had fully entered upon her 
labor, and had sent for her midwife. 
The vaginal examination failed to give any information as 
to the presentation and position of the child, but the midwife 
found nothing worthy of note ; the form and volume of the 
womb indicated that the child lay in a longitudinal position. 
1 Balandin, St. Petersb. Medicin. Zeitschr., 1861, i, p. 324. 
2 Golinelli, Bollittino delle Scienze Mediche, Bologna, 1868, series v, vol. v, 
pp. 378, et seq. SAMUEL C. BUSEY. 
31 
The woman was made comfortable. One hour later, the pains 
becoming stronger and more regular, the midwife attempted 
another examination, and was surprised at the difficulty ex- 
perienced in carrying her finger across the vaginal canal, and 
found it impossible to determine the nature of the presenta- 
tion. The os was slightly dilated, and she was able to touch 
the child's head over a very small area. After repeated ex- 
plorations, with no better success, and experiencing the same 
difficulty in introducing her fingers into the vagina, she be- 
came anxious and sent for me. 
Seven hours had elapsed, and the patient was suffering ex- 
treme pains. During my first visit I found it difficult to intro- 
duce the finger into the vagina, and next to impossible to 
determine the position of the child ; but, after palpation and 
auscultation of the hypogastric region, I determined that the 
child's heart lay in the middle of a line drawn from the um- 
bilicus to the right anterior and superior spine of the ilium ; it 
was, therefore, certain that the head was the part presenting, 
and that the position was, in all probability, the right occipito- 
cotyloid (cervico-iliac of some authors). The mouth of the 
womb, situated very high up, presented an opening of about 
two centimetres in diameter, and that at about the middle of 
the vaginal canal there was a ring-like narrowing of the va- 
gina, which nearly occluded it, with the exception of its rectal 
portion. This narrowing or constriction was due to a tumor 
whose surface was soft and fluctuating, and which might have 
been mistaken for the uterus itself, as the latter was uncom- 
monly soft. During the uterine contractions it was well-nigh 
impossible to introduce two exploring fingers into the vagina, 
on account of the tension of this tumor, which separated it into 
two parts. The child's head was undoubtedly hindered in its 
descent by the presence of this tumor, which, during the uter- 
ine contractions, gave the fingers the sensation of being a cyst 
filled with liquid, whose tension was greater at the time of the 
contractions, and resumed its soft, flaccid condition between 
them. 
The mouth of the womb was now sufficiently well dilated, 
the child's position and presentation favorable ; its heart could 
be distinctly heard on auscultation ; there was no malforma- 32 
CYRTOCOLPOCELE COMPLICATING PREGNANCY. 
tion of the pelvis, so that I was justified in assuring the patient 
that she would be safely delivered. At 3 o'clock p. m. I found 
her in about the same condition, and the vaginal examination 
gave nothing new. She was more restless, and beginning to 
fear that my assertion that she would soon be delivered was 
not well grounded. At 8 o'clock p. m. I again visited her; she 
was red in the face, had an obstinate desire to vomit, and was 
bathed in perspiration. Her pulse was weak and frequent, the 
uterine pains more frequent; in the intervals the patient com- 
plained of great suffering. The fundus uteri was still at the 
same level, and the abdomen painful on pressure. Another 
vaginal examination was made, in an interval of uterine rest, 
when I found the mouth of the womb was equally dilated, 
and the head of the child in the same position. The fluctua- 
tion of the tumor was more noticeable, which proved that the 
tumor was filled with liquid. I suspected that the liquid was 
an accumulation of serum deposited in the anterior sac of the 
peritoneum. But she assured me that she had never had dis- 
ease of any kind, and never had any difficulty in urinating. 
By a careful examination of the hypogastric region I found, 
above the pubis, a slight elevation, as wide as my finger and 
parallel with the superior border of the pubis, which I took to 
be the fundus of the bladder. I at once catheterized the pa- 
tient and brought away a full litre of urine. The obstacle dis- 
appeared at once, the vaginal canal resumed its normal size and 
form, the head of the child appeared, and the birth appeared 
without accident. 
This case presents a form of vesical prolapse entirely 
unique. It was in the form of a horse-shoe, with the heels 
resting upon the posterior vaginal wall, and during the 
uterine contractions was divided by the impingement of the 
head into two lateral lobes, thus assuming very different con- 
ditions according to the presence or absence of uterine con- 
traction. 
Etiology.-Multi parity is an essential and constant fac- 
tor of causation. Every case reported occurred in a multi- 
parous woman. In a few instances it was present during 
the second or third labor, but mostly in later labors, from SAMUEL C. BUSEY 
33 
the fourth to the twelfth. Multiparity cannot, however, 
without a coefficient, be regarded as a cause. The changed 
relation of the pelvic viscera resulting from child-bearing 
invites and facilitates the operation of other coincident 
and more active agencies. Numerical frequency, together 
with quickly-recurring pregnancies, in women compelled to 
perform laborious work in the erect posture, seem ostensi- 
bly to have been the most common cause. Yet the infre- 
quency of vesical prolapse in that class of child-bearing 
women excludes these conditions as very potential factors, 
and clearly involves the co-existence of some supervening or 
superadded etiological condition of actual but rare occur- 
rence. In most cases the patients were strong, robust, mus- 
cular women, accustomed to physical hardships and possess- 
ing more than ordinary endurance, so that the circumstances 
of life which necessitate work and effort are far more im- 
portant and effective agencies than constitutional or acquired 
defects of physical condition, strength, and vigor. To the 
condition in life must also be added the ignorance, inexperi- 
ence, and, perhaps, neglect of the attendant, for, strange as it 
may appear, it is nevertheless true that far the larger num- 
ber of cases have occurred in the practice of midwives, and 
a lesser number in the service of young and inexperienced 
physicians, to which the reporters have been called to dis- 
cover the cause of a lingering and unusually painful labor. 
In the category of predisposing influences must also be 
enumerated a pendulous abdomen,, which favors anterior 
deflection of the gravid womb; relaxation of the anterior 
vaginal wall, which promotes descent of the bladder; and 
increased amplitude of the vaginal canal. These conditions, 
most often consequent upon numerous and quickly-recurring 
pregnancies, may exist either as separate or co-operating 
causal elements. Dilatation of the bladder due to habitual 
retention of urine also claims mention. Schroeder's state- 
ment that the " dilated bladder only forms a large tumor in 
the vagina interpartum, if a cystocele pre-existed," can not 
be accepted. A pre-existing cystocele commands but little 34 
CYSTOCOLPOCELE COMPLICATING PREGNANCY. 
attention as a cause, not being present more often than pro- 
lapse of the uterus, and neither can be regarded more than 
an incidental circumstance in the history of the afflicted 
women, or else the cases of cystocolpocele complicating labor 
would be far more common. Again, the fact that the cases, 
with two or three exceptions, have recovered, without any 
history of the existence of a cystocele subsequently, or its 
recurrence during subsequent pregnancies, must prove con- 
clusively that the prolapse of the bladder is a complication 
incident to some combination of conditions present during 
that particular labor and not antepartum or persistent. In 
the few exceptional cases cystocele existed previous to labor, 
in one for several years, and was due to the ordinary causes 
of vesica] prolapse. 
Ramsbotham asserts that in a majority of the cases there 
is present a slightly diminished pelvis, in the conjugate, at 
the brim. Birnbaum, Brennecke, Dick, and Broadbent 
have observed a similar malformation of the pelvis, and in 
one case, a minor, but uniform contraction was present. It is 
claimed that the descent of the head is arrested and a per- 
verse position established, thus causing pressure of the head 
upon the fundus or middle portion of the bladder at a time 
when it is partially distended with urine. Yet in several 
cases the bladder had been completely evacuated at the be- 
ginning of labor, and in a large number of the cases there 
is no evidence that any contraction or other malformation of 
the pelvis existed. Christian suggests the presence of some 
peculiar conformation or certain morbid changes in the parts 
connected with the bladder. Martemucci ascribes it to con- 
traction of the muscularis of that organ. Others assert be- 
lief in the primary and immediate influence of sympathetic 
and spasmodic contraction of the abdominal muscles. 
In fact, there is no single or known combination of cir- 
cumstances or conditions to which this complication can be 
attributed. Multiparity, laborious life, head presentation, 
slight diminution of the conjugate at the brim, and the at- 
tendance of a midwife constitute the curious array of the SAMUEL C. BUSEY. 
35 
most common and concurrent predisposing events in the 
causation of cystocolpocele in the reported cases. 
Symptomatology.-Lingering labor is the constant and 
most prominent subjective symptom. It is characterized by 
acute and ineffective pains, closely resembling in paroxysmal 
character labor pains, though, in most cases, sufficiently dif- 
ferent to impress the patient with their distinctive peculiari- 
ties. Their frequency and sharpness, with the distressing 
sensation of fulness and distention in the lower part of the 
vagina, indicate rapid progress and speedy termination ; yet, 
in fact, they are usually unaccompanied with any advance of 
labor. The intervals are shorter than in true labor pains. 
The patient refers the pain to the " bottom of the stomach," 
and is more inclined than in natural labor to seek relief by 
leaning (Broadbent) on the back of a chair, or by sitting down, 
bending forward with the hands or elbows on the .knees. 
One peculiarity is described by Meigs as a " tenesmic dis- 
tress," which in some cases entirely obscures the lesser pain 
of uterine contraction, and in others seems to acutely in- 
tensify the ordinary suffering of the early period of labor, 
and is usually associated with straining and bearing down re- 
sembling, but more prolonged and agonizing than, the expul- 
sive efforts of natural labor. Broadbent asserts that the 
manner of the patient is different. " There is more frown- 
ing, more active contortion of the features, biting of the lips, 
and, what is very characteristic, violent straining or forcing; 
not three or four prolonged efforts, as in the expulsive stage 
of labor, but in a series of spasmodic jerks, almost involun- 
tary, attended with great pain and expressions of impatience 
and suffering." Christian says the cry is also distinctive. 
He describes it as a shrill shriek instead of the moaning and 
holding of breath during the paroxysm. In some cases there 
is complete retention of urine, with frequent desire to pass 
water, or inability to do so, or both; but more often, frequent 
scanty discharges take place accompanied with the suffering 
of aggravated vesical tenesmus. This chain of symptoms 
may be present when the bladder is entirely empty, which 36 
CYSTOCOLPOCELE COMPLICATING PREGNANCY. 
Broadbent ascribed to the pressure of the descending head 
upon the prolapsed and tender organ. When there exists 
retention of urine, with considerable accumulation, a vesical 
tumor may be found above the pubes, in front of the womb; 
but in some instances there is entire absence of vesical in- 
tumescence above the pubes, with large collection of urine in 
the bladder, which has been forced down and imprisoned in 
the pelvic cavity. In several cases the patient and attending 
midwife insisted that it had been freely and spontaneously 
evacuated before the onset of the peculiarly distressing symp- 
toms ; yet large quantities of urine were discharged by cath- 
eterization. In other cases dribbling had been going on for 
a week or a month before labor began ; in others, the accumu- 
lation had taken place, to a greater or less extent, during the 
progress of labor; and, again, the cystocele, with accumula- 
tion and consequent dysuria and tenesmus, had manifestly 
induced premature labor. The uterine contractions are not 
always synchronous with the characteristic tenesmic parox- 
ysms. More frequently the normal action of the uterus is 
suspended, for dilatation of the os uteri is either arrested or 
does not begin, or progresses very slowly; but when the ob- 
stacle is removed by evacuation of the prolapsed bladder it 
proceeds with remarkable rapidity. When the uterine con- 
tractions are present and synchronous with the forcing and 
straining efforts of the incarcerated bladder, the suffering of 
the patient is greatly aggravated. 
The pain is described by the patient as something unlike 
any experienced during previous labors; is located within 
the vulva, or behind and above the pubes; is forcing, strain- 
ing, bearing down, and attended with a sensation of fullness 
and distention of the vagina, and dragging at the umbilicus. 
In some cases the uterine contraction is followed by a painful 
spasm of the abdominal muscles. In a single instance the 
pain and swelling were located in the ileo-cecal region. In 
this case the cystocele existed in the form of hour-glass 
contraction, with the intra-pelvic lobe extending toward the 
right. SAMUEL C. BUSEY. 
37 
The objective symptoms are, however, the most impor- 
tant and distinctive. These can only be discovered by a 
careful and intelligent vaginal exploration, and, it would 
seem from the clinical reports, only by those whose knowl- 
edge and skilled experience are enlarged, refined, and aided 
by the tactus eruditus. 
When the prolapse is partial, and the organ empty, the 
ordinary subjective symptoms will, to a greater or jess de- 
gree, be present; but a physical exploration will only dis- 
cover the posterior wall of the bladder as a firm, hard mass, 
marked by rugae, exquisitely tender, and the seat of acute 
pain during every contraction of the uterus. 
When the bladder, wholly or partially filled with urine, 
is completely prolapsed and imprisoned in the pelvis, there 
will be entire absence of vesical intumescence above the 
pubes. In such cases the displacement may be lateral, in 
either wall of the pelvis, or anterior, that is, lying in front 
of the cervix and presenting part of the child. When an- 
terior it may wholly or partially fill the pelvic cavity, and is 
presented as a soft, resilient, fluctuating and tender tumor, 
which increases in tenseness with every uterine contraction, 
and relaxes during the intervals, and partially or completely 
occludes the vaginal canal. The exploring finger can be 
swept around its lateral and posterior circumference, but be- 
hind the pubes the attachments of the organ limit, on either 
side, the exploration. The examining finger can sometimes, 
with difficulty, be forced beyond the obstructing tumor, and 
the os uteri, pushed upward and backward, may be reached. 
The extent of the dilatation, if any, is usually much less than 
the intensity and duration of the suffering would indicate. 
Dilatation of the os is slowed or arrested, the womb is ele- 
vated or pushed backward, labor is retarded and sometimes 
suspended. In anterior protrusion labor cannot be com- 
pleted until the mechanical hindrance, which diminishes and, 
perhaps, occludes the vaginal lumen, is removed. 
In lateral displacements the exploring fingers will enter 
the vaginal canal without difficulty. On either side may be 38 
CYSTOCOLPOCELE COMPLICATING- PREGNANCY. 
discovered the characteristic tumor, narrow in front, but dif- 
fused along its base, extending backward toward the prom- 
ontory of the sacrum, and filling, to a greater or less extent, 
the lateral half of the pelvic cavity. This tumor, not 
rounded, spherical, or regularly elongated as in anterior mal- 
positions, will be somewhat irregular in contour, but will re- 
tain the usual characteristics of a vesical tumor. The evi- 
dences $f a sac containing fluid may, perhaps, not with equal 
facility, be made manifest by a careful examination. The 
same condition of dilatation of the os and position of the 
cervix, and progress of labor obtain as in anterior displace- 
ments. In rare cases pelvic malformations and perverse 
positions of the head have been recognized. In every case 
of cystocolpocele complicating pregnancy or labor the head 
has presented. 
In the cases where the cystocele assumed the form of hour- 
glass contraction or egg shape, with stem-like attachments to 
the base of the bladder, the physical examination was em- 
barrassed by difficulties which were overcome only by the 
most painstaking and patient efforts to establish a communi- 
cation between the pelvic obstacle and the cavity of the 
bladder. The cases of Madame La Chapelle, Brennecke, 
Dick, Charrier, Meigs, and Christian are referred to for 
special information in regard to the symptomatology of this 
class of cases. 
After all, the only positive and absolutely certain symp- 
tom is the discharge of urine through the urethra, and the 
lessening or entire subsidence of the swelling. This dis- 
charge may occur in dribbling or scanty jets, accompanied 
by a severe paroxysm of straining, or be induced by manipu- 
lation of the swelling, either by pressure directed from below 
upward, or from its base along its course or stem-like con- 
nection with the bladder, or by elevation of the protrusion. 
More frequently, however, it is only accomplished by the 
employment of the catheter. The introduction of the catheter 
has not always evacuated the bladder completely because of 
its division into two separate compartments, by the form and SAMUEL C. EUSEY. 
39 
location of the complication, or the pressure of the head com- 
pressing its walls against the bony frame, and forcing a portion 
of the organ, tilled to its utmost tension, into the pelvic cavity. 
Sometimes the catheter cannot be introduced because of the 
tortuous condition of the urethra; and again, when intro- 
duced, it may fail to evacuate the sac because the beak is 
turned in the wrong direction. When successfully inserted 
and the bladder is emptied, complete subsidence of the pelvic 
protrusion follows, and the course of the instrument can be 
distinctly traced along the connection of the cystocele with 
the organ. 
In a few instances the cystocele has refilled before labor 
was completed. In one case of twins it re-formed and pre- 
sented as formidable an obstacle to the delivery of the second 
as of the first child. 
Lateral mal-position does not offer as great obstacles to 
delivery, and does not, usually, so completely interrupt the 
progress of the first stage of labor as anterior protrusion, so 
that it is probably overlooked in many cases, and the tardi- 
ness of labor is ascribed to other undetermined causes. 
Differential Diagnosis.-The symptoms and diagnosis 
of this complication have been sufficiently set forth, and it 
only remains to call attention to the normal and pathological 
conditions with which it may be confounded, and to indicate 
their distinctive features. 
The anatomical attachments of the bladder, thickness 
of its walls, discharge of urine, and manner of replacing the 
viscus are valuable diagnostic signs. 
The presentation of the head seems to possess a peculiar 
value in the differential diagnosis of this obstacle to labor. 
The clinical reports do not supply a single example of any 
other presentation. The position of the head varies, the 
perverse positions being generally regarded as effects rather 
than causes of the obstruction. It would seem, then, that 
the determination of the position of the child in utero, which 
can be ascertained by abdominal palpation, must be an es- 
sential preliminary expedient, and of special value in those 40 
CYSTOCOLPOCELE COMPLICATING PREGNANCY. 
cases where the presenting part can not be reached per va- 
ginam. A cystocolpocele would be excluded by the discovery 
of a breech or transverse presentation. 
The tumor is characterized by softness, elasticity, and 
fluctuation; increases in tension during pain, and slackens 
but does not disappear or collapse during the intervals. It 
may, therefore, be and has been mistaken for the amniotic 
sac. Its location in the lateral walls of the pelvis would 
exclude such an error. In anterior protrusion the differen- 
tiation is not so easily made. The bladder is situated at 
the anterior part or wall of the vagina directly contiguous to 
the symphysis pubis, while the membranous bag occupies 
the center of the upper and posterior part of the vaginal 
canal, or may be near the sacrum, and is encircled by a firm, 
resisting and defined ring-the os uteri. The circumference 
of a prolapsed bladder may be distinctly outlined, imparts 
the sensation of softness, firmness, and thickness, is dimin- 
ished or partially effaced under direct pressure, and there is 
constant painful desire to pass water, with inability to do so. 
It is tender to pressure and painful when scratched. The 
membranous bag is much less firm and resisting, and during 
the intermission of uterine contraction the presenting part 
may be felt through it. No pain is induced by pressure 
upon or by scratching it. 
A hydrocephalic head is much less likely to be mistaken 
for cystocolpocele. By a careful combination of abdominal 
palpation and a digital examination, the latter ought to be 
easily excluded. The fontanelles, bony margins, with inter- 
vening membranous partitions, and surrounding dilated os 
uteri, should establish the intra-uterine nature of the obstruc- 
tion. These, together with the absence of the peculiar sub- 
jective and physical symptoms of cystocele, should remove 
all doubt in regard to its existence. 
In one or more instances labor has been complicated with 
a1 hydro- and a pyo-colpocele. A hydrocolpocele is found in 
association with ascites, and is produced by the descent of 
1 Winckel, Diseases of Women, Parvin. SAMUEL C. BUSEY. 
41 
the posterior vaginal wall, and may present itself as a cyst, 
as large as the fist, in communication with the abdominal 
cavity, and located behind the cervix. A pyocolpocele exists 
in connection with a grave inflammatory condition of the ab- 
domen. In each the tumor is " irreducible and the inverted 
vaginal wall will be reddened, swollen, and edematous, while 
the general symptoms will be grave." 
Winckel asserts that about one third of the cases of vagi- 
nal cysts " are as large as a pear or the fist " ; and Peters re- 
ports a case where the cyst was as large as a child's head, and 
interfered with labor. Brednow describes a cyst as large as 
an orange, situated in the lower portion of the anterior wall, 
in a woman of nineteen years, and in her first pregnancy. 
The diagnosis of these cysts is generally made without diffi- 
culty, but Winckel states that they have been mistaken for 
cystocele, rectocele, hydrocolpocele, prolapse of the uterus, 
and ovarian cysts. They are bluish or reddish-brown in 
color, irreducible, attached to the vaginal wall, tense, elastic, 
and persistent in size and consistency. Ovarian cysts must 
be differentiated by the characteristic symptoms of that class 
of tumors.1 
The term vaginal hernia has been so frequently employed 
to express the morbid complication now recognized as cysto- 
colpocele that one is forced to the conclusion that many such 
cases have been mistaken for vaginal enterocele.2 In entero- 
cele the tumor may assume a variety of shapes, sizes, and lo- 
cations. It is soft (Winckel), elastic, may be flattened out 
and lessened in size, the gases in it may be recognized by 
the tympanitic sound, and often the contents may be moved 
about. In the knee-elbow posture the tumor may diminish, 
but, upon coughing or bearing down, it again descends. Im- 
pulse upon coughing may usually be detected. Constipation 
is usually present. 
It is barely possible that a metrocolpocele could be mis- 
1 "Case of Labor obstructed by an Hydatid Cyst in the Vagina," Austral. 
M. J., 1880, N. S., ii, p. 42. 
2 More properly, enterocolpocele. 42 
CYSTOCOLPOCELE COMPLICATING PREGNANCY. 
taken for a cystocolpocele, because of the great improbability 
and location of the former, yet the case of Sandiford is re- 
ferred to as one in which the prolapsed bladder was impris- 
oned behind the cervix uteri, and Monro, Jr., makes the 
statement that the "bladder of urine sometimes forms a 
prominent tumor at the lateral or posterior part of the va- 
gina in virgins, and still more frequently in married women, 
when that canal has been reduced to a state of - relaxation 
from repeated pregnancies at short intervals. In some cases 
the projecting bladder of urine within the mouth of the va- 
gina has been said to have proven an obstacle to delivery." 1 
Ovariocele may be either primary or secondary. When 
the inversion (Winckel) of the posterior wall is produced by 
the pressure and weight of a displaced and enlarged ovary, 
the diagnosis can only be made by exclusion, and a careful 
consideration of all the symptoms of ovarian tumors. When 
the ovariocele is secondary, resulting from the displacement 
of an ovary into the sac of the inverted posterior wall of the 
vagina, it may be recognized by the size, form, surface, and 
sensibility of the mass within the pouch of the inverted wall. 
An ovariocele, when complicating pregnancy, may be re- 
duced. If not reducible, it may be diminished by puncture 
of the fluctuating part. If obstructing labor, Caesarean sec- 
tion may be necessary. 
Inversion of the anterior wall of the vagina may occur, 
unassociated with a displacement of the walls of tile bladder. 
In such case there would be found an oedematous tumorous 
mass of indefinite size, with limited mobility, and irreducible. 
From a cystocele it could be differentiated by the evacuation 
of the bladder. Such inversion of the vaginal wall, simula- 
ting a cystocele, may interfere with the progress of labor, 
and it might become necessary to reduce it either by punct- 
ure or scarification. The essential point is to determine the 
nature of the mass before interference. 
Treatment.-Speedy and complete evacuation of the 
bladder not only removes the obstacle to delivery, but re- 
1 Morbid Anatomy of the Human Gullet, Stomach, and Intestines. SAMUEL C. BUSEY. 
43 
stores the natural course, and usually promotes rapid progress 
of labor. This must be accomplished either by the introduc- 
tion of the catheter, or by some skillful manipulation of the 
cystocele, or by both combined. The difficulties and failures 
which some observers have encountered in the use of the 
catheter seem to have been due to the employment of a me- 
tallic instrument. In such cases as that of Madame La Cha- 
pelle, where the protruding pouch was connected with the 
base of the bladder by a thick but pervious stem-like pedicle, 
the cases of hour-glass contraction, and the bi-lobular form 
of displacement, as was present in Charrier's case, might 
have been successfully evacuated by a soft and flexible in- 
strument. Some observers have found it necessary to ele- 
vate and hold in position the prolapsed part. This has been 
done with the fingers, or as recommended by Leishman and 
Cazeaux, by a dexterous use of the catheter. In some cases 
the failure to empty the bladder, or the prolapsed part or 
pouch, has been due to the improper direction of the instru- 
ment. The beak should be turned downward or in the direc- 
tion of the stretched and curved urethra, instead of along 
the natural course of that channel. Meigs failed to intro- 
duce a catheter, but succeeded in emptying the lateral cysto- 
cele by elevating and pressing upon it from backward toward 
the urethral orifice. Broadbent, in several cases, drew down 
the cervix uteri, placed the patient in the supine posture, and 
applied a bandage to retain the uterus in position. In every 
case where the diagnosis was made, with a single exception, 
the cystocele was finally evacuated either by some digital 
manipulation, by catheterization, or by some postural pro- 
cedure, as in the cases of Broadbent and Charri er. In the 
single exception the prolapsed bladder was punctured with a 
thumb-lancet-an expedient, entirely unjustifiable and rep- 
rehensible. It does not appear from the clinical reports that 
any special treatment was needed during the puerperal period. 
In those cases where the cystocele existed previous to the la- 
bor and persisted, the ordinary methods of treatment would 
be required.  CY8T0C0LP0CELE COMPLICATING PREGNANCY. 
44 
In conclusion I must acknowledge my obligation to Drs. 
S. S. Adams, T. E. McArdle, and Andrew F. Hofer for the 
valuable assistance rendered by them in the preparation of 
this paper. 
Note.-In consequence of the incomplete removal of the library of the Sur-' 
geon-General's office to the new building, it has been impossible to examine the 
reports of the following cases in time to make abstracts for this paper. I there- 
fore append the references to them : " Labor, prolapse vagina and bladder," 
Nashville J. M. and N., 1880, N. S., vol. xxvi, p. 152. " Cistocele vaginal, como 
causa de distocia," Gac. dent, de Venezuela, Caracas, 1881, 1882, vol. iv, p. 35. 
" Case of cystocele, induction of premature labor, operation, recovery," Brit. 
M. J., London, 1882, vol. ii, p. 1246. These will be presented in a supplemental 
contribution.