338 MATERNAL DYSTOKIA. 



vaginal mucous membrane remaining intact ; or, which is more frequent, 

 the muscular and mucous tissues may be ruptured. In either case there 

 is found in the vagina a round, sm'ooth, and fluctuating tumor, attached 

 to the floor of the canal by a pedicle more or less wide, and beneath 

 which the meatus urinarius can be seen or felt. The most striking 

 pathognomonic feature of this kind of tumor is its rapid growth, in 

 consequence of the accumulation of urine in the interior of the displaced 

 bladder, the fundus of which is towards the vulva and the neck directed 

 forwards — its position being the reverse of normal ; the fundus, by 

 pressing on the urethra — which is doubled on itself — prevents the urine 

 from escaping, and we have in this way a rapidly increasing vaginal 

 tumor. In a case recorded by Violet {Recueii de Med. Veterifiaire de 

 Lyon, 1862, p. 371) the tumor had acquired, within eight hours, a diam- 

 eter of from eight to ten inches. Such a tumor must, therefore, con- 

 stitute a more or less serious obstacle to parturition. 



We have pointed out the necessity for a careful examination of the 

 tumor, in order to avoid making a mistake, as the cystocele resembles 

 other tumors, and especially the kysts we have already described, or 

 even the " water-bag," and an error in diagnosis may lead to grave 

 consequences. Such an error is recorded by Charcot {yournal Pratique 

 de Med, Veterinaire, 1826, p. 165), who, being called upon to attend a 

 Cow which had been attempting to calve for three days, found on sepa- 

 rating the labia of the vulva a whitish, tense, and fluctuating tumor. 

 Thinking that this was only the " water-bag," he punctured it ; when the 

 color and odor of the fluid which escaped quickly undeceived him. 

 When the bladder had collapsed, he then recognized the tear in the 

 vagina through which the viscus had passed. The Cow being in a dying 

 condition and the foetus still alive, Charcot had recourse to the Caesarean 

 section ; the calf was saved, but the mother died. 



As the diagnosis of this accident is of so much importance, we will 

 notice the symptoms in greater detail. 



Protruding through the opening of the vulva, or immediately within 

 the labia, will be discovered a tumor of a pyriform shape, and varying 

 in size and color, according to the duration of the accident. Sometimes 

 this tumor will be seen hanging from within the vagina by a kind of 

 peduncle, for at least eight or nine inches, and will contain two or three 

 pints of fluid. At times, the protruded part will be nothing more than a 

 thickening of the bladder, produced by strangulation and inflammation; 

 and it will be changed from its normal color to that of an inflamed 

 surface, or, if it has been hernied for some time, to a darker hue. 

 Sometimes it will become gangrenous and slough ; at other times its 

 surface appears rugged and plicated, and on occasions a large quantity 

 of blood has exuded from its surface. Should there exist any doubts as 

 to the nature of the tumor, the meatus urinarius must be looked for ; if 

 that cannot be discovered, then the greatest circumspection should be 

 exercised. The attachment and situation of the protrusion should be 

 noted, and also whether it is continuous with the vagina. The nipple- 

 shaped prominences which mark the openings of the' uterus into the 

 bladder should also be looked for, as their presence will at once denote 

 the case as inversion of this viscus, as will the escape of urine from 

 them. 



Treatment. 



The chief indication in vaginal cystocele is reduction, or reposition of 



