CYCLOP/EDl A 
OF 
OBSTETRICS AND GYNECOLOGY 
VOLUME TEN 
DISEASES 
OF THE 
Female Urethra and Bladder 
BY 
F. WINCKEL, M.D. 
PROFESSOR OF OBSTETRICS AND GYNECOLOGY AT THE ROYAL UNIVERSITY, MUNICH. 
AND 
DISEASES OF THE VAGINA 
BY 
A. BREISKY, M.D. 
PROFESSOR OF OBSTETRICS AND GYNECOLOGY AT THE ROYAL UNIVERSITY, VIENNA. 
WITH NINETY-NINE FINE WOOD ENGRAVINGS. 
EDITED BY 
EGBERT H. GRANDIN, M.D. 
OBSTETRIC SURGEON TO THE NEW YORK MATERNITY HOSPITAL; INSTRUCTOR IN GYNECOLOGY 
AT THE NEW YORK POLYCLINIC I FELLOW OF THE OBSTETRICAL SOCIETY, ETC. 
NEW YORK 
WILLIAM WOOD & COMPANY 
1887 Copyright, 1887, 
WILLIAM WOOD & COMPANY. 
The Publishers' Printing Company 
157 and 159 William Street 
New York CONTENTS- 
DISEASES OF THE FEMALE URETHRA AND 
BLADDER. 
PAGE 
CHAPTER I. 
Historical Retrospect 1 
CHAPTER II. 
Preliminary Remarks upon the Anatomical and Physiological Peculiarities 
• of the Female Urethra and Bladder 6 
CHAPTER HI. 
The Examination of the Female Urethra and Bladder 13 
CHAPTER IV. 
Statistical Inquiry into the Frequency of Occurrence of the Various Diseases 
of the Female Urethra and Bladder * 24 
PART I. 
MALFORMATIONS AND DISEASES OF THE FEMALE 
URETHRA. 
CHAPTER V. 
The Congenital Malformations of the Female Urethra 27 
CHAPTER VI. 
Abnormal Shape and Position of the Female Urethra 34 
CHAPTER VII. 
Disturbances of Nutrition of the Female Urethra 43 
CHAPTER VIII. 
The New Growths of the Female Urethra 49 
CHAPTER IX. 
Neuralgias of the Female Urethra 62 
CHAPTER X. 
Foreign Bodies in the Female Urethra 64 IV 
CONTENTS. 
PART II. 
DEFORMITIES AND DISEASES OF THE FEMALE BLADDER. 
PAGE 
CHAPTER XI. . 
Developmental Deformities of the Bladder 66 
CHAPTER XII. 
Malpositions and Malformations of the Female Bladder 81 
CHAPTER XIII. 
Injuries to the Female Bladder 94 
CHAPTER XIV. 
Nutritive Disturbances of the Female Bladder 174 
CHAPTER XV. 
Foreign Bodies in the Female Bladder 189 
CHAPTER XVI. 
Neuroses of the Female Bladder 201 
THE DISEASES OE THE VAGINA. 
CHAPTER I.: 
Anatomico-Physiological Introduction 211 
CHAPTER II. 
Congenital Malformations of the Vagina '. 224 
CHAPTER HI. 
Acquired Atresias and Stenoses 263 
CHAPTER IV. 
Displacements of the Vagina 268 
CHAPTER V. 
Ruptures of the Vagina 292 
CHAPTER VI. 
Haematoma of the Vagina 302 
CHAPTER VII. 
The Inflammatory Affections of the Vagina 305 
CHAPTER VIII. 
New Growths of the Vagina 341 
CHAPTER IX. 
Foreign Bodies in the Vagina... 364 
CHAPTER X. 
Intestino-Vaginal Fistulye 368 DISEASES 
OF THE 
Female Urethra and Bladder. 
BY 
F. WINCKEL, M.D. DIS E A S E S 
OF THE 
FEMALE URETHRA AND BLADDER. 
CHAPTER I. 
HISTORICAL RETROSPECT. 
milE history of our knowledge of the diseases of the female urethra 
and bladder shows us that, as in so many other branches of human 
knowledge, there were methods of exploration and treatment known 
to physicians hundreds and thousands of years ago, which in the course 
of time were entirely forgotten, to be rediscovered by succeeding genera- 
tions. Obstetrics and gynecology suffered perhaps more than any other 
specialties in this respect, and our knowledge of diseases of the urinary 
apparatus, which was fairly well developed in remote times, shared their 
lot. Thus for instance, the Cnidian school possessed a fairly accurate 
knowledge of bladder derangements; they described both acute cystitis 
and chronic catarrh with ammoniacal decomposition of the urine; and 
they were aware of the fact that calculi were of less common occurrence 
in females on account of the short size and the large calibre of their 
urethrae. They did indeed consider a wound of the bladder as necessarily 
fatal; but they are said to have practised nephrectomy. The ancient 
Indians (circa 1000 B.C.), were aware of the occurrence of lithiasis, and 
practised the urethral or vagino-cystic incision for the extraction of the 
stone. Erasistratos (304 B.C.), is said to have been the first to employ 
the catheter; and Soranos (100-150 a.d.), recommended the use of the 
instrument to increase the efficiency of the expulsive pains. The Talmu- 
dists endeavored to cure cystic concretions by solvent injections into the 
bladder; and Celsus (25-50 a.d.), mentions the frequency of ischuria in 
the female and the spontaneous evacuation of calculi. Aetius (502-575 
a.d.) described ulcerative affections of the internal surface of the bladder, 
and Paul of Aegina (670) treated various cystic troubles by means of in- 
1 2 
THE FEMALE URETHRA AND BLADDER. 
jections through the catheter. Local therapy of the bladder, therefore, is 
of ancient date. 
In view of all this, it is remarkable that many easily recognized anoma- 
lies of the organ, such as urethral tumors and vesico-vaginal fistulas, were 
entirely unknown until the end of the Middle Ages. It is easy, however, 
to understand why. The study of diseases of the female urethra and 
bladder suffered from the same unfavorable circumstances that the prac- 
tice of obstetrics did. For although the practice of accouchement by 
men was common among the Indians, neither the Greeks nor the Arabs 
deemed it worthy of their care. Hippocrates causes the young physician 
to swear never to cut for stone himself, but to leave this not very honora- 
ble operation to the surgeons. This contempt for certain surgical opera- 
tions has survived until recent times; and hence the organs in question 
were left to the care of midwives or untutored " stone-cutters," who could 
contribute but little to a scientific knowledge of their abnormalities. 
" Physicians even of the 16th century did not hesitate to practice uroscopy 
daily; but they were ashamed to display any surgical or obstetrical 
ability."1 Another cause is to be found in the prolonged influence of 
Arabian medicine (600-1600 a.d.), which was undoubtedly unfavorable; 
since it is well known that the Arabs regarded even the thought of post- 
mortem examination as sinful, and the practice of obstetrics and gynecology 
by men was forbidden by their religion. And if they were compelled to 
treat maladies of this class, midwives made their examinations and con- 
ducted their treatment. Thus Kurt Sprengel declares2 that Abulkasem 
was the first to declare the necessity of cutting for stone in women. He 
thinks the midwife necessary, since no surgeon would dare to offend 
female modesty by operating himself. But even when in the 17th cen- 
tury, the practice of obstetrics by men became the fashion in Paris, and 
spread thence over Europe, an ocular examination of the female genitals 
was interfered with in every possible way, even to the extent of fastening 
a sheet around the necks of the lying-in woman and the accoucheur, so 
that her modesty should not be offended by his gaze. The author him- 
self has lately had occasion to observe how long such prejudices survive, 
when examining a young American woman; it being suggested to him to 
introduce the speculum through a small hole in a sheet spread over the 
patient. 
But in spite of all these difficulties, by the end of the Middle Ages 
much progress had been made in the study of the maladies we are con- 
sidering. Benevieni (1502) of Florence had dilated the female urethra 
to extract a stone. Rembert Dodoius of Mechlin had demonstrated post- 
mortem the existence of sclerosis of the kidney, enlargement of the cali- 
Baas, Grundriss der Geschichte der Medicin, p. 367. 
2 Versuch, etc., II. 364. HISTORICAL RETROSPECT. 
3 
bre of the ureter, and hypertrophy of the bladder. Salins Diversus had 
described inflammation of the ureters as a cause of retention of urine. 
Peter Franco (1561) had figured a special dilator for the enlargement of 
the female urethra, and a gorget with forceps, whose arms would open in 
the bladder and seize the stone. 
Several authors of the 17th century proved by necropsies the occur- 
rence of vaginal cystocele with prolapsus uteri.1 Felix Plater and Ludo- 
vicus Mercatus (1605) first recognized the vesico-vaginal fistula, and Johann 
Fatio cured several of them by the quilled suture. Andreas a Laguna 
(1499-1560) wrote a work entitled: Methodus cognoscendi, exstirpandique 
excrescentes in vesica callo carunculas, Rome, 1551, and another upon 
urethral strictures and their treatment by means of bougies. Finally, 
Francesco Diaz (Madrid, 1588) was the author of an excellent monograph 
upon the diseases of the bladder and kidneys. 
Thus we have in esse catheters of copper and silver (Abulkasis), lithotrites 
(the mythian-like instruments of the post-Celsian times), dilators of the 
urethra and forceps for the extraction of foreign bodies (1500 and 1561), 
bougies of paper and metallic sounds (Heliodorus). What then re- 
mained to invent, and why were not the most recent exploratory methods, 
such as G. Simon's gradual dilatation with specula, and Rutenberg's 
illumination of the interioi' of the bladder, discovered much sooner, since 
the ground was apparently prepared for them centuries ago ? It is un- 
doubtedly due, in addition to the above-mentioned reasons, to the absence 
of instruction in gynecology, until late in the 18th century. Even to-day 
most gynecologists leave the bladder out of consideration in connection 
with the female genitals, and at most describe urethral caruncles, dis- 
placements of the bladder with the vaginal wall, and vesico-vaginal fistulse; 
while the text-books on internal medicine hardly mention the numerous 
specific affections of the female urethra and bladder. We possess but a 
single monograph, published by Scanzoni in 1854, upon diseases of the 
female urinary passages; and in his introduction the author rightly com- 
plains of the neglect of this branch of special pathology on the part of the 
gynecologists. Scanzoni's book went through a second and last edition 
in 1859; it is therefore entirely incomplete to-day, though we shall often 
have occasion to make use of its admirable contents. 
But however useful and important historical studies may be, and how- 
ever they may save us from the error of presenting as new what has 
already long been known, we must admit that there are writers who 
can find the germ of each and every medical discovery in Hippocrates 
and Aretans, and who can so wonderfully elucidate and explain the dark 
and disputed points in their writings, as to prove that all that living men 
have done is to rehash their material ! Ideas may often have been printed 
1 Peyer, Ruysch, ini Sepulchret, observ. 5. 4 
THE FEMALE URETHRA AND BLADDER. 
without having ever been carried out; and the proper execution of them 
is often much more meritorious than an impracticable or dangerous idea. 
This is the case, for instance, with the urethral dilatation introduced by 
Simon; the idea was an old one, but we know how often the older methods 
by dilators and compressed sponges caused incontinence of urine. But 
Simon laid down exact rules for its use, and for the first time the method 
became really practicable. Here is another illustration: I mentioned above 
the opinion of Kurt Sprengel, that Abulkasem was the first to teach the 
method of cutting for stone in women. Baas1 thus describes the manner 
in which the midwife of Abulkasem's time is to perform the operation under 
the direction of a physician: " In a virgin the finger is to be introduced 
into the rectum, in other women into the vagina; and the cut is to be made 
in the first case through the lower part of the left labium, in the second 
case between the urethra and the pubis, so as to give a transverse wound." 
Now although Baas2 has noticed what Sprengel overlooked, that 
Celsus has described the stone operation in women, he does not seem 
to have observed that Abulkasis, 1100 years after Celsus, has copied his 
directions for the performance of the operation almost word for word. 
In proof thereof I will quote the passage in question,3 "De calculis 
feminarum: Hac vero curationes in feminis quoque similes sunt; de qui- 
bus parum propriae quaedam dicenda sunt. Liquidem in his, ubi par- 
vulus calculus est, scalpellus supervacuus est; quia is urina in cervicem 
compellitur quae et brevioi' quam in maribus et laxior est. Ergo et per 
se saepe excidit et si in urinae itinere quod est angustius, inhaeret, eodem 
tamen unco sine ulla noxa educitur. At in majoribus calculis necessaria 
eadem curatio est. Sed virgini subjici digiti tanquam masculo, mulieri 
per naturalia ejus debent. Turn virgini quidem sublima sinisteriore ora; 
mulieri vero, inter urince iter et os pubis, Incidendum est sic, ut utroque 
loco plaga transversa sit. Neque terreri convenit, si plus ex muliebri 
corpore sanguinis profluit." 
This passage proves that Celsus appreciated the dilatibility of the fe- 
male urethra, and was aware that calculi might pass through it either un- 
aided or with the help of a hook or forceps-shaped instrument. But his 
directions for the performance of the operation in the virgin are by no 
means explicit; they might refer to a vestibular incision as well as to the 
lateral cut. And even the method of Abulkasis, described almost 1100 
years later in Altasrif, and used throughout the middle ages, is not much 
plainer; since we are not told whether the incision is to be made outwards 
from the mtroitus vaginae, or externally beside the tuber ischii. We find 
that Hiob van Meeckern, in 1659, still operated according to the rule 
1 Grundriss der Geschicte der Medicin, p. 185. 
2 Ibid. p. 122. 
3 Celsus, Liber VII., Cap. 26, 4 (Ed. of Th. J. ab Almeloveen,) Rotterdam, 1750, 
p. 481. HISTORICAL RETROSPECT. 
5 
of Celsius; so that in 1500 years the need of a clear description of the 
operation in the place of these vague directions was not felt. We will all 
admit that science and its representatives honor both themselves and 
their predecessors by a proper knowledge and appreciation of what has 
been done in the past (Baas); and it is unfortunate that in recent times 
the study of the history of medicine in universities of the German ton- 
gue has been neglected (Billroth). Nevertheless it is unjust to depre- 
ciate the achievements of recent date, on account of obscure historical 
discoveries. The following chapters will, I think, prove that in the special 
field which we are studying, the most important progress has been made 
in very recent times. We will consider the past history of every disease 
and anomaly in its appropriate chapter. 
Since the appearance of the first edition of this book, a single mono- 
graph only has appeared upon the subject. It is that of A. J. C. Skene 
upon Diseases of the Bladder and Urethra in Women, New York, 1882, 
W. Wood, 374 pp. 8vo. Besides this there is a general disquisition upon 
the subject by C. Cushing: Diseases of the Female Bladder and Urethra. 
A clinical lecture. Pacific Med. and Surg. Journ. San Francisco, 1881- 
82, xxiv p. 449-456. CHAPTER II. 
PRELIMINARY REMARKS UPON THE ANATOMICAL AND 
PHYSIOLOGICAL PECULIARITIES OF THE FEMALE URE- 
THRA AND BLADDER. 
rpHE female urethra averages 1 to inches in length, and runs in a 
straight or slightly-curved line from below upwards and from be- 
fore backwards. (See Fig. 1. p. 7.) Its anterior extremity is. 4 of an inch 
below the symphysis; it is kept in place by the ligamentum pubo-vesicale 
medium, which fills the space between the urethra, the ligamentum arena- 
turn, and the rami of the clitoris. The urethral wall is tough, and about 
|th of an inch thick; the septum becomes thicker at those spots at which 
it is united to the vagina. Its mucous membrane possesses, according to 
Robin and Cadiat, more elastic fibres than any other in the body. Its 
lowest part is lined with stratified pavement epithelium, like that of the 
vagina; while the epithelium of its upper part resembles that of the 
bladder. Oberdieck, however, found in three out of four cases a single 
layer of cylindrical epithelium, consisting of long prismatic cells, between 
whose pointed lower ends small round cells were scattered. Besides this 
the urethra shows longitudinal folds, vascular papillae, and among the 
numerous lacunae near the external orifice various projections, especially 
in pregnant and puerperal women. 
To Prof. Skene (see page 5) is due the credit of having specially 
described the two chief lacunae near the orificium urethree externum; he 
considers them glandular, and found concretions in them. But Ober- 
dieck and Schuller claim that they possess no real glandular epithelium. 
Kocks declares them to be simply Gartner's canals; but this has been dis- 
proved by Dohrn, Oberdieck, Rieder, and Schuller. The latter calls 
them urethral passages. He found them most developed in pregnant 
women, being short and narrow in children and those who had reached 
the climacteric. Their orifices are about one twenty-fifth of an inch in 
diameter; they then enlarge, dip deeper down into the tissues than do 
the ordinary lacume of the urethra, and run upwards along the walls of 
that channel. They are about inches in length, though a probe can 
only be inserted to the depth of about one inch. As they go upwards 
they subdivide until eventually there are seven to eight epithelial-lined 
tubes present. The ultimate tubes lie in the circular muscle of the 
urethra, being sometimes among its outermost fibres. Their diameter PRELIMINARY REMARKS. 
7 
before division is about one line; in children it is half a line. The epi- 
thelium is transitional, and is easily distinguishable from the single or 
double layered and occasionally ciliated cylindrical epithelium of Gart- 
ner's canals. 
Fig. 1.- Profile cut of a frozen Female Subject, Published by Furst (Arch. f. Gyndk, Bd. VII.) 
to demonstrate the course of the Urethra, and the Position and Shape of the empty Female Bladder. 
The remaining urethral lacunae are irregular in number, symmetry, 
and. position. Sometimes several of them open into a pocket, which may 
be large enough to entangle the point of a catheter (Oberdieck). At 
their blind end the epithelium is in single layers and cylindrical; it 8 
THE FEMALE URETHRA AND BLADDER. 
then becomes stratified cylindrical, and near their mouth becomes pave- 
ment. 
Besides this the mucosa contains a multitude of small mucous glands, 
which in elderly persons often contain small black particles, similar to 
the prostatic concretions. 
Below the mucosa is a submucous elastic network, into which the ends 
of the above-mentioned glands project, surrounded by a network of min- 
ute veins. External to the submucosa is a layer which varies in thick- 
ness at various periods of life, and is composed of a longitudinal and a 
circular layer of muscular fibres, united by connective and cavernous tis- 
sue. It is the corpus spongiosum urethra. Dr. Uffelmann found, be- 
sides the organic circular muscular layer a layer of voluntary fibres lying 
outside it, and composed of transverse and longitudinal portions. The 
transverse are innermost, and form the voluntary or outer sphincter of 
the bladder. They form a complete ring from the bladder end of the ure- 
thra to its middle. This discovery explains the fact that, when injuries 
to the urethra reach | of an inch from the external orifice, continence of 
urine may be attained by operative union. Luschka claims also to have 
discovered an especial sphincter urethrae et vaginae, which is ring-shaped, 
flat, and situated immediately behind the bulbi vestibule?; it is | to | of 
an inch broad, and surrounds not only the introitus vaginae and urethra 
but closes the latter by compressing it against the septum urethro-vagi- 
nale. Bordering on the cavernous venous plexus surrounding the ure- 
thra, it inosculates with the anterior end of the transversus profundus 
muscle. 
The internal or cystic opening of the urethra is a slit, the mucous 
membrane lining which is thrown into longitudinal folds; the external 
orifice is an oval vertical opening | inch long. There are often two pro- 
jections of the mucous membrane from the anterior orifice, which, meet- 
ing behind in the urethral wall, join the hymen externally, and give a 
rosette appearance to the orifice of the urethra. The diameter of the 
urethra, some inch, can be greatly increased by means of instruments. 
The following are the most important differences between the female 
and the male bladder: in the woman the organ is broader and rounder, 
and is less deep antero-posteriorly, since the genitals are placed between 
it and the rectum. As a rule the capacity of the female bladder is greater 
than that of the male; 6| pints have been found in it in cases of reten- 
tion. In the male the fundus of the bladder rests securely against the an- 
terior rectal wall; but in the female this is not the case. Here the anterior 
and posterior vaginal walls are so subject to dislocations and lesions, that 
the bladder is often displaced, and its fundus loses all support when there is 
considerable pressure from above and the labial cleft is open. There 
is also some difference between the sexes in regard to the extent to which 
the peritoneum covers the posterior bladder wall. It does so to a much PRELIMINARY REMARKS. 
9 
less extent than in the male, being reflected at the level of the internal 
os from the bladder to the uterus. The relations of the female bladder 
to its surroundings are very important; as we see if we examine Fig. 1 
p. 7 and Fig. 3 p. 11. The round and broad ligaments, the uterus and 
the ovaries, the small intestine and the vermiform process, are all in relation 
to one another. So often does disease in these neighboring organs affect 
the bladder, that there are a large number of maladies of that organ which 
occur in women, and do not occur in men. We need only call to mind 
the various changes in shape and position caused by uterine displace- 
Fig. 2.-Schematic Drawing showing the Normal Form and the Relations of the Empty Bladder 
(bb) and Urethra (ur) to the Symphysis (s) and the Uterus (w). (After B. S. Schultze.) 
merits, or the perforations of the bladder caused by extra-uterine foetal 
sacs, or stones caused by perforating foetal bones or by hairs from dermoid 
cysts of the ovary. And so also we may mention inversion of the vesical 
mucous membrane as an example of a disease that only occurs in the fe- 
male bladder. 
As regards the mucous membrane of the bladder, we notice that be- 
sides the few round or oval crypts, and the simple or branched acinous 
glands, there are found at the fundus in some cases solitary lymphatic fol- 
licles and closely-packed rounded papillae. According to Landau the 
epithelium of the urinary bladder is extremely elastic, so that it can suffer 
very considerable extension without solution of continuity. Oberdieck, 10 
THE FEMALE URETHRA AND BLADDER. 
experimenting with rabbits, found that it consisted of four layers; first 
one of large, flat, irregular cells with round or oval nuclei; then one of 
cubical cells with long processes at their lower borders; then a layer 
with thin processes that di]) down into the connective tissue; and lastly 
a layer of small round or oval cells with large nuclei and karyokinetic 
figures. These latter are the replacement cells of the epithelial layer of 
the vesical mucous membrane. Stretching the bladder obliterates the 
folds of the mucous membrane, and diminishes the thickness of the epi- 
thelium, chiefly through a change of position of the cylindrical cells of 
the third layer. In five cases Oberdieck could demonstrate only once 
the presence of crypts lined with cylindrical epithelium in the rabbit's 
bladder. As is well known, the bladder possesses a triple muscular layer, 
whose thickly interlaced fibres form the detrusor urinas muscle, and 
at the ostium urethrale form a perfect sphincter. About one inch behind 
or above the orificium vesicale urethrae two small tumors are formed by 
the ureters as they bore their way through the vesicular wall; they are 
united together by the so-called ligamentium inter-uretericum (compare 
p. 17 Fig. 7). It was formerly supposed that the closure of the ureters 
was effected only by the fold of mucous membrane which the oblique 
position of the ureter in the vesical wall caused; but Jurie's later inves- 
tigations show that it is brought about by the elastic tension of the muscu- 
lar fibres among which the vesical extremity of the ureter lies. 
In many vesicular diseases it is of importance to decide how the inner 
surface of the bladder acts as an absorbing organ. L. Schafer (In. Diss. 
Giessen, 1870) believes that under normal conditions of urination, there 
is a constant though small absorption of water by the walls of the bladder; 
and he believes that he has proved this by finding that after the produc- 
tion of a vesical fistula in animals, the urinary secretion was increased 
2.3 to 4.5 per cent. On the other hand Susini1 injected solutions of 
iodide of potassium and infusion of belladonna into his own bladder, but 
was unable either to detect the former in the sputum, or to appreciate 
any physiological action from the latter, even after several hours reten- 
tion. The results obtained by Allen2 agree with this, as do the experi- 
mental conclusions of P. Dubelt concerning the origin of vesical catarrh. 
It seems hardly to be doubted that while the urethral mucous membrane 
readily absorbs when in its normal state, the vesical mucous membrane 
with uninjured epithelium does not absorb substances like strychnine, 
morphine, atropine, and iodide of potassium, save when its epithelium 
has been injured or is diseased. Cazenave and Lepine, on the other hand, 
found that not only the normal constituents of the urine, but uric and 
phosphoric acids, were absorbed; and Landau could, after the injection 
1 De l'impermeabilit6 de IGpithelium vesicale. These de Strasbourg, 1867. 
2 Gaz. des Hop., p. 610, 1871. PRELIMINARY REMARKS. 
11 
of | of one per cent, solution of iodide of potassium and chloride of lithium 
in two cases, demonstrate* iodine once in the sputum, and prove the 
absorption of lithium once by spectral-analysis. 
There exists considerable variety of opinion as to the method of closure 
of the bladder. Rosenthal and von Wittich no longer regard the sphinc- 
ter vesicae (so-called) as a muscle which is kept by the nervous system in 
a tonic state of contraction; they look upon it as intended to completely 
Fig. 3.-Position of the Organs at the Pelvic Brim. (After Hasse, Breslau), v, Vesica. 
Uterus, i, Tuba, o, Ovarium, c. Caecum, r, Rectum. Ir, Lig. rotundum. pv, Processes ver- 
miformis. d, Cavum Douglasii. pu, Plica ureterica. I, Fossa paruterina. II, Fossa paravesicalis. 
Ip, Lig. infundibulo-pelvicum. 
empty the urethra of urine. It is assumed on the other hand, that the 
ring of elastic fibres prevents the outflow of the urine through the urethra; 
but that as soon as the tension of the bladder wall, from the contained 
urine, overcomes the elasticity of these parts, a drop of urine attains the 
urethra, the desire to empty the bladder is set up, and the act now occurs 
voluntarily. But the cases of healed urethro-vesico-vaginal fistula, when 
the neck of the bladder and the upper part of the urethra have been de- 12 
THE FEMALE URETHRA AND BLADDER. 
stroyed, and when the lower portion of the canal has sufficed to retain 
the urine, shows that the muscular tissue of the urethra is sufficient, of 
itself, to prevent an involuntary outflow. 
The bladder, when empty, lies against the symphysis pubis, projecting 
somewhat above its highest point. Its wall is about | inch thick, and its 
shape according to Furst is such, that a short portion (^ inch) is 
vertical, a longer portion (1 inch) is arched from the symphysis, and 
a portion half an inch in length stretches to the level of the internal 
os uteri. The form of the cavity is, therefore, that of a narrow slit 
with three processes, of which the anterior is the longest.1 According 
to B. S. Schultze,2 the form of the empty bladder (comp. Fig. 2) is 
slightly different. The anterior vaginal wall is attached to the lower 
posterior one of the bladder; and where this ends, begins the attach- 
ment of the bladder to the anterior uterine wall, which reaches to 
the point where the peritoneum is reflected from the uterus on to the 
bladder, up to or a little beyond the height of the os internum. The 
posterior vesical wall, when the organ is empty, forms a sharp angle at 
the point where the vaginal attachment merges into the uterine attach- 
ment; so that if we imagine the woman to be standing upright, the lower 
wall of the bladder will be attached to the vagina, and the upper wall to 
the uterus. When the bladder is moderately full, so that it is raised 
but a little above the entrance of the pelvis (comp. Fig. 3, Hasse,), the 
sinking of the posterior vesical wall, to which Kohlrausch has drawn at- 
tention, is well seen. This same drawing effectively demonstrates the 
flattening of the bladder by the uterus, and the manner in which the 
bladder, with the round ligaments, and the peritoneal covering, holds 
the uterus in place. Berry Hart has lately affirmed that the normal 
empty female bladder shows an oval figure on median section, and forms 
with the urethra a more or less extended canal; its vault is therefore 
convex. The arrangement of the muscular tissue would favor this idea. 
Only in the puerperal state is the Y shape the rule.3 
1 See Fig. 1, after Furst. Arch. f. Gynakologie, VII. p. 419, Tafel II. 
2 Klinische Vortr. von Volkmann, No. 50, p. 409. 
3 Comp. Ed. Med. Journ. xxi. p. 794, March, 1881, and xxv. p. 892, April, 1880; 
further, Croom J. Haliday, on the bladder during the early puerperal period.- 
Edinb. Med. Journ. xxviii. p. 883, April, 1883. CHAPTER III. 
THE EXAMINATION OF THE FEMALE URETHRA AND 
BLADDER. 
rpHE means for the exact exploration of the female urethra and bladder, 
have been much improved in recent times. Formerly we had to 
content ourselves with the inspection of the mouth of the urethra 
and the anterior vaginal wall, and could only use touch and sight in the 
diagnosis of abnormal conditions of the bladder wall in those cases in 
which traumatism exposed its surface; and were in other cases confined 
to the use of metallic cathetersand sounds. We are now able to examine 
with the finger and the eye almost the whole surface of the vesical mucous 
membrane. To G. Simon belongs the merit of having elaborated a method 
for the rapid and certain dilatation of the female urethra, and of having 
given exact rules as to the amount of dilatation which is permissible, and of 
proving its safety. From the oldest times, indeed, it had been customary 
to dilate the female urethra for the extraction of stone. (See page 2 et seq.) 
The Italian surgeon Benevieni (1502), and after him Marianns Sanctus 
(1506), described it; and Franco (1561) used a special dilating instrument 
for the purpose. In the earlier years of this century dilatation was effected 
by compressed sponge, by laminaria, or by Weiss's metallic dilators. 
Nevertheless Hybord in 1872 could only find recorded twelve cases of 
bloodless dilatation for the extraction of stone, and the exploratory 
method was but very seldom used. 
Simon's method begins by making an incision inch long with the 
scissors at each side of the mouth of the urethra, which is the most re- 
sisting part, and another inch deep down through the urethro-vaginal 
wall. The specula are inserted, one after the other; they are made of 
hard rubber, and are hollow; each is fitted to a mandrin. (See Figs. 4 
and 5.) Simon has 17 different numbers, ranging from of an inch to 
t3o of an inch in diameter. After the thickest has been introduced, the 
index finger is inserted into the bladder, the corresponding middle fingei' 
being in the vagina, the other hand pressing the vault of the bladder 
against the index finger. Every portion of the bladder save the highest 
corners can be explored in this way; and the narrowest urethrae can be 
dilated in from 5 to 7 minutes. While Heath, when he dilated with his 
finger alone, always found the mucous membrane of the urethra torn 
under the arch of the pubis, and usually had twenty-four hours of incon- 14 
THE FEMALE URETHRA AND BLADDER. 
tinence of urine, by Simon's method ruptures of the mucous membrane 
rarely occur, and the patients can retain their urine completely after 
the operation. Simon has laid down exact rules as to the extent to which 
dilatation may be carried without causing incontinence. He found that 
in the full-grown woman, plugs of 2| inch circumference, = | inch 
diameter, can be used without danger; and that in extreme cases, where 
somewhat hazardous means are justifiable, dilatation up to 2.G or even 
2.8 inches might be done. In young girls the diameters must be propor- 
Fig. 4.-Urethral Speculum. (After G. 
Simon.) 7-10 inch diameter, 2 2-5 inch circum- 
ference. Natural size. 
Fig. 5.-Urethral Speculum. (After G. 
Simon.) 4-5 inch diameter, 2 1-2 inch cir- 
cumference. 
tionately diminished. With this degree of dilatation incontinence need 
not be feared, and it is amply sufficient in most cases for diagnostic and 
therapeutic purposes. I have had occasion often to make use of Simon's 
method, and can vouch for the accuracy of his statements. In spite, how- 
ever, of the prescribed incisions made at the edges of the external orifice, 
one or other of them has always torn further, and a lesion has occurred 
at the base of the clitoris. But from the pressure exercised upon the 
parts by the speculum, the bleeding has been usually insignificant, and 
has soon stopped after withdrawal of the instrument. These incisions, THE EXAMINATION. 
15 
therefore, are not always necessary; and they should, with all other 
fissures, be sutured immediately aftei- the operation with fine silk. In- 
continence has never occurred in my cases. I must add that while I was 
unable after the ordinary dilatation of the urethra, for the extirpation of 
a papilloma vesica?, to introduce an instrument into the 
bladder, alongside the index finger of the left hand, I could 
easily do it after dilatation with Simon's specula. Noi' is 
this instrumental dilatation tiresome for the operator. As 
I show in my gynecological operative course, the dilatation 
of the urethra, and the palpation of the internal surface of 
the bladder can be well demonstrated and practised on sub- 
limate preserved subjects. 
Seneca (New York) has lately described a new urethral 
dilator, which figured in the lllustr. Monatschrift der Artzl. 
Polytechnik, 1882, part'7, which consists of four rounded 
steel rods, each one of which is united to a central axis by 
a cross arm. The dilating part is four inches long, and the 
highest degree of dilatation attainable is two inches, which 
may be read off upon a graduated quadrant. Similar, but 
covered with a rubber hood, is the dilator of Kurtz.1 
Neither instrument possesses any advantage over that of 
Simon; in fact, they are not so good, since they do not 
dilate the whole uterine periphery evenly. 
If urethral dilatation does not suffice for the accomplish- 
ment of our object, we must have recourse to the method of 
vagino-cystic incision, which has also been recommended by 
Simon. By this means we can invert the bladder in the 
vagina and even between the vulva, and can employ not only 
palpation, but inspection for its examination. Simon's cysto- 
tomy with artificial inversion is done by making an incision 
yY of an inch in front of the anterior lip of the os uteri in 
the anterior vaginal wall, and some inches in length. From 
its middle a cut f of an inch long is made to the urethra, 
giving a T-shaped incision. A thin double hook is inserted into the bladder 
through the cut, and is hooked into the mucous membrane; at the same 
time the other hand depresses the bladder forcibly above the symphysis. 
The incisions are best done when the vagina is dilated by a Simon's di- 
lating instrument, or a Bozeman's speculum, and the bladder wall is 
tightly stretched; or it may be accomplished by dragging down the uterus 
and the upper part of the vesico-vaginal wall. The bleeding is stopped 
by ligature or torsion, and after the operation upon the internal surface 
of the bladder is finished, the cut edges are united with thread. Union 
takes place easily, since the parts fit together well. 
Fig. 6.-The va- 
rious numbers and 
sizes of the Ure- 
thral Specul® of 
G. Simon. 
1 Centralblatt fur Chir., 1883, No. 41. 16 
THE FEMALE URETHRA AND BLADDER. 
Simple dilatation of the urethra is of service principally in the diagnosis 
of diseases of the vesical mucous membrane, and in the detection of for- 
eign bodies and stones, and in their extraction. It is also useful in the 
cure of fissures of the urethra, for the recognition of defects in the vesico- 
vaginal wall, when the vagina is closed, for the diagnosis of the seat and 
extent of growths and tumors of the bladder wall, for their extirpation, 
and for the cure of vesico-intestinal fistulas by the cauterization of the 
vesical mouth of the fistula. Besides this it has been recommended for 
the treatment of obstinate vesical catarrh by local application of concen- 
trated caustics (Heath), for the finding and extraction of renal calculi in 
the vesical end of the ureter, and finally for the opening of haematometra, 
whose evacuation between the bladder and the rectum is impossible or 
dangerous (as Spiegelberg and others have used it). The method is, 
therefore, of great diagnostic and therapeutic value. If Silbermann (l.c.) 
in 48 cases of rapid dilatation of the female urethra, found incontinence 
occurring 8 times, this was because most of his operations were not done 
in accordance with the rules laid down by Simon, nor with his instru- 
ments; and they cannot reflect upon the value of Simon's method. 
In cases of very large stone with considerable vesical tenderness, or in 
the extirpation of tumors situated so high up on the lateral vesical wall 
that they cannot be reached through the dilated urethra, and in cases of 
operation for vesico-intestinal fistula, the T-shaped incision above described 
will be necessary. Sims, Emmet, Bozeman, Simpson, Hegar, and Simon 
have employed it also in cases of obstinate vesical catarrh with ulceration 
of the mucous membrane, to prevent the stagnation of decomposed urine 
in the bladder. Simon remarks, however, that the results obtained from 
the operation for this indication, were such as to cause him to regard it 
as being yet sub judice. 
After dilatation of the urethra to the extent of admitting a finger and 
instrument into the bladder, a further exploratory method, also intro- 
duced by G. Simon, may be undertaken. It is the sounding and catheter- 
rization of the ureters, which may be of use in diseases of the ureters and 
kidneys. The orifices of the ureters will be found about 1 inch from the 
vesical orifice of the urethra in the so-called lig. interuretericum (Fig. 7). 
They may be felt as prominences about half an inch from the median 
line. These prominences being fixed with the index finger of the left 
hand, the head of a small sound is carefully guided to the spot; the hand 
is now carried to the side opposite to the one of the ureter that is being 
sounded, and against the arcus pubis, and by a gentle pressure the sound is 
inserted in the ureter. With the finger tip the entrance of the sound is to 
be guided. With instruments of sufficient length the pelvis of the kidney 
may be attained. The sound must first be carried some three inches from 
within outwards; and when the bony margin of the true pelvis is reached, 
the handle must be depressed and carried towards the thigh on the same THE EXAMINATION. 
17 
side. Thus the anterior portion of the sound is held parallel to the spinal 
column, and its head is directed somewhat towards the anterior ab- 
dominal wall, and easily reaches the pelvis of the kidney. Simon has 
provided two instruments, a urethral sound, and a urethral catheter, for 
this purpose. (Figs. 8 and 9.) They are ten inches long, and inflexible, 
since a flexible metallic instrument could not straighten out the curve 
which the ureter takes in its passage from the bladder to the margin of 
the pelvis. 
With these instruments Simon accomplished the operation 17 times in 
11 different women, introducing the sound 9 times, and the catheter 8 
Fig. 7. 
times; and in no case did he do the slightest damage by the operation. 
It is true that he had no further opportunity to use catheterization of 
the ureter; but he believed it to be possible by this means to ascertain the 
presence of calculi in the ureters, and even in the pelves of the kidneys. 
He also claimed an especial advantage in obtaining urine direct from the 
kidneys without its having passed through the bladder. Stones found 
in the vesical end of the ureters could be cut out or extracted; or if they 
were near the renal mouth of the ureter, they might possibly be crowded 
back into the pelvis of the kidney. Strictures also might be dilated; and 
hydronephrosis occurring as it commonly does, with a pervious ureter, 
might be evacuated by means of the urethral catheter. These anticipa- 
tions, however, were a little too sanguine. The operation would certainly 18 
THE FEMALE URETHRA AND BLADDER. 
not always be harmless. The straightening of the bend above-mentioned, 
would necessitate a more or less extensive laceration of the mucous mem- 
brane, at least. Nay, perforation of the ureters might occur, es- 
pecially when strictures of the ureters, or changes of position from 
tumors of the uterus, vagina, ovaries, pelvis, etc., were present. 
Even sudden movements of the deeply narcotised patient, as of 
vomiting, might cause an accident of so serious a nature as to ren- 
der us very cautious in view of the problematical advantages of 
the exploration. Luckily the diseases calling for catheterization 
Figs. 8 and 9.-G. Simon's Urethral Sound and Catheter. 
Fig. 8. 
Fig. 9. 
Fig. 10.-Rutenberg's 
Speculum. 
are rare. Indeed I must admit, that although I have tried in every 
case in which I have dilated the urethra, I have never, in spite of the 
greatest patience, been able to introduce a sound into a ureter. THE EXAMINATION. 
19 
The attempt has been made in the past to illumine the female urethra 
and bladder, and so lay them open to inspection. Griinfeld used a 
straight tube of varying diameter with a funnel-shaped mouth, and pro- 
vided with a reflecting glass at its inner end. He claimed to be able to 
recognize with this instrument the most delicate changes of color of the 
mucous membrane of the bladder and urethra. Ultzmann and Furth 
confirmed his assertions. With the aid of a gas or oil flame we can, with 
Simon's mirrors, obtain a good view of the posterior and lateral bladder 
walls. But the anterior and antero-lateral portions of the vesical mucous 
membrane can not be readily brought into the field of view; nor can we 
in this mode of examination fix our position, since the posterior bladder 
wall is applied to the opening of the speculum. Rutenberg, therefore, 
suggested the stretching of the bladder, and first tried to do so with water; 
but he was soon satisfied that air, being more transparent, was more 
appropriate, and constructed the apparatus figured on Fig. 10. This 
apparatus consists of the speculum itself, with a stopper, a part to be 
screwed to this with a fenestrum, and the mirrors. In order to obtain 
the greatest possible amount of light with a certain diameter, the specu- 
lum is made not of hard rubber, like that of Simon, but of German sil- 
ver. It is of the same size front and rear, and has an internal diameter 
of of an inch, the metal being of an inch thick. It is | inch longer 
than Simon's instrument, so as to leave room to handle the instrument 
when the other piece is screwed on. This latter part is 1^- inches long, 
and has a glass fenestrum f inch long; the glass is of the purest, and is 
one line in thickness. There is also a tube i inch in diameter, to which 
is attached a rubber tube for the purpose of inflation. The patient, un- 
less her urethra has been previously dilated, must be deeply narcotized, 
and must be kept so during the whole examination. Since inflation of 
the bladder is extremely painful, and may cause disturbing contractions 
of the abdominal and vesical muscles, it is advisable to narcotize the pa- 
tient even in those cases in which the urethra has been already dilated. 
The patient is placed in the dorsal position, with thighs flexed and fixed 
by two assistants. After dilating the urethra up to Simon's largest spe- 
culum, the bladder is emptied of urine, and the silver tube is introduced. 
The upper part is now screwed on, without the mirror, the fenestrum 
having been heated in the flame of a spirit lamp to prevent the condensa- 
tion of moisture. One of the assistants then inflates the bladder by a 
powerful expiratory effort applied to the rubber tube, or a bellows may 
be employed for that purpose. Using the Rutenberg apparatus in this 
manner I have once seen the bladder immediately blown up upon intro- 
duction of the mirror. The other assistant holds the light above the 
symphysis, which is reflected by a concave mirror like that used in laryn- 
goscopical examinations into the bladder. By moving the speculum in 
various directions, a large part of the posterior and lower bladder wall 20 
THE FEMALE URETHRA AND BLADDER. 
can be plainly seen. If we wish to see the remaining portions, the mirror 
must be introduced, tbe upper piece being of course unscrewed, and the 
glass warmed. Examining the living subject Rutenberg found the pos- 
terior bladder wall before inflation to be of a dirty, grayish-red color; but 
little was to be seen save the larger folds and indistinct vessels. But when 
the air entered the gray color gave place to an increasingly vivid red, and 
through the stretched and transparent epithelial coat the finest vascular 
net-work can be seen, running along the muscular bundles. Towards 
the base of the bladder the color of the mucous membrane became 
darker, the vascularization richer, and through the mucous mem- 
brane could be seen the interlaced bundles of muscles. Without using 
the urethral sound Rutenberg was never able to find the urethral opening. 
But beautiful as may be the effect of lighting up the vesical mucous 
membrane in this manner, it is questionable whether or not there is danger 
in it. Firstly it may be feared, that under the heavy pressure which is upon 
the air in the bladder, some of it might enter the ureters, reach the pelvis 
of the kidneys, and possibly cause pyelitis, or pyelonephritis, an affection 
which in many cases endangers life. I have used Rutenberg's method in 
ten cases, and in several of them repeatedly. Instead of a gas lamp I 
used an ordinary round, low oil lamp, which, as I demonstrated to a num- 
ber of physicians at the Naturforscherversammlung at Hamburg, gives a 
sufficient volume of light. My experience is that Rutenberg's method of 
exploration is absolutely harmless, that it gives splendid results, is easy 
to exercise, and I therefore welcome it as a valuable addition to our means 
of diagnosis in diseases of the bladder. 
But the question has been asked as to tne necessity for any such method 
of exploration, since the entire inner surface of the bladder can be pal- 
pated with the finger, and the speculum exposes to view fairly large por- 
tions of the vesical mucous membrane. But wherever we can use both 
touch and sight in our examinations, the latter becomes undoubtedly 
more exact. And all anomalies cannot be felt; hypersemias, superficial 
ulcerations, diphtheritic sloughs cannot, though they can be readily recog- 
nized with the eye. Palpation of the bladder surface presents consider- 
able difficulty; the speculum shows us only a single fold of the mucous 
membrane; and if we introduce a small mirror through the cylinder to 
inspect the anterior wall of the organ, the mucous membrane falls down 
on all sides, and covers the surface of the mirror. It is necessary to dilate 
the bladder if we desire to obtain a clear picture, especially of the anterior 
wall. Besides this, the mirror may be moved around in all directions, 
without in any way injuring the mucous membrane. 
So far I have not succeeded in seeing the orifices of the ureters by 
means of the mirror in the dilated bladder. Further, it is possible to 
fasten a small sponge or brush to the metal rod that carries the mirror, 
and so to apply medicaments directly to the diseased spot, without at the THE EXAMINATION. 
21 
same time involving all the rest of the organ. Certainly Rutenberg's 
method has a future before it. 
Matthews Duncan uses ordinary glass specula of large size, with oblique 
ends, for inspecting the vesical mucous membrane. 
W. Noeggerath is the only one among the authors who have studied 
the methods of bladder inspection after urethral dilatation, who claims 
that there is always a reaction after' opening the urethra in the manner 
described. He claims that retention of urine, sensations of burning and 
heat in the urethra and labia, occasionally cystitis, sometimes abdominal 
pain, and even perimetritis may occur. I have often noticed a burning 
pain and dysuria, and once a distinct vesical catarrh, after these ex- 
aminations; but I can very positively assert that these ill consequences 
may be easily remedied by washing out the bladder for a few days with 
Hegar's funnel. Though the method has some drawbacks, they are not 
to be feared in ordinary cases; they are avoidable, and are of little weight 
in comparison with the advantages to be obtained. Bridge's so-called 
case of peritonitis, after rapid dilatation of the female urethra, is note- 
worthy in that incontinence occurred, although Simon's rules were exactly 
followed, the patient dying in a typhoid condition a month later. I have 
recorded a case in my Pathology of the Female Sexual Organs, Leipzig, 
1881, p. 407, in which, in a woman fifty-four years old, who had suffered 
for eighteen months from violent dysuria, and whose urine is said to have 
often been mingled with mucous and blood, a fatal acute double nephritis 
with anuria was caused by palpation of the bladder after rapid dilatation. 
The patient had a uterine myoma and a tubo-ovarial cyst, and bladder 
trouble was suspected, but not found. Hence exploration of the bladder 
may evidently, under certain circumstances, be dangerous. 
One more explorative instrument remains to be mentioned, by means 
of which the abnormal contents of a bladder may be appreciated without 
dilating the urethra. We refer to W. Donald Napier's sound, the beak 
of which is covered with a coating of pure lead, which is to be polished so 
highly with a piece of leather as to become extremely sensitive to the 
touch of any hard substance. The beak is then dipped in a 1 per cent, 
solution of nitrate of silver, and is thus provided with a coat of black so 
delicate that the slightest touch of a foreign body makes a perfectly dis- 
tinct impression. A magnifying glass must be used before the instru- 
ment is introduced to make sure that there are no impressions upon its tip. 
The exploration of the bladder with the manometer, first described by 
Schatz, has recently been revived by Hegar, Odebrecht, and Dubois.1 
Dubois, following Schatz, introduced a metallic or elastic catheter into 
the bladder, and united it by means of a rubber tube to a glass tube some 
1 On the Pressure in the Bladder, Deutsches Archiv. fur Klin. Medicin, von 
Ziemssen und Zenker, vol. XVII., p. 148, 1870. 22 
THE FEMALE URETHRA AND BLADDER. 
60 inches long. The O point of the graduated index was placed at the 
symphysis, and the height of the column of urine gave the pressure. But 
he soon found that the level of the top of the bladder did not always 
coincide with the symphysis, in one case reaching that point only when it 
contained 23 cubic inches of urine. It was ascertained that the bladder 
pressure is nearly a constant one, and is independent of age and sex. It 
rises 4 to 1 inch with each ordinary expiration, and falls again with expira- 
tion. In the recumbent position, it amounts to 4 to 6 inches; standing it is 
12 to 16 inches; while laughter, coughing, or voluntary effort increases it to 
20 to 60 inches. Dubois believes that the pressure of from 4 to 6 inches is 
not due to the weight of neighboring organs, but marks the tension exerted 
by the elastic muscular bladder upon its contents. In proof thereof he 
demonstrated that after removing the organs from the abdominal cavity 
of a suitable subject, a pressure of 4 inches was attained by the tension 
of the bladder alone. He also found that the pressure in the rectum is 
independent of that in the bladder, since it remains the same while the 
bladder pressure is being diminished by emptying the organ. In a case 
where the pressure in the abdominal cavity sank to nothing after the 
evacuation of a considerable amount of ascitic fluid, that of the bladder 
remained at 8 to 10 inches. Finally, in a case of cystocele vaginalis with 
prolapsus uteri, in which the influence of the abdominal pressure was 
excluded, since even the deepest inspiration had no influence upon the 
height of the column of water, the pressure of the bladder, which con- 
tained 9 cubic inches of urine, was 4 inches. Of course the intra- 
abdominal pressure influences the bladder, and is increased by ascites 
and meteorism. In myelitis and in fractures of the spinal column, Dubois 
proved that there was a distinct diminution of vesica) pressure. But he 
always found a positive pressure even with absolute paralysis of the blad- 
der and the abdominal muscles. And he could never, by sudden and 
intermittent pressure, cause a negative pressure, as Odebrecht claims to 
have done. Dubois explains the entrance of air into the bladder through 
the catheter, as being due to variations in pressure of the stream of urine, 
by which bubbles of air pass between it and the walls of the catheter, and 
then ascend into the bladder. Hence the important practical rule in 
catheterization, not to depress the handle of the catheter too much; and 
if manual pressure upon the abdomen is used to promote evacuation, the 
catheter must be withdrawn before that pressure is relaxed. 
Odebrecht has, however, in one case demonstrated the existence of a 
pressure less than that of the atmosphere. Here the fundus vesicas was 
largely adherent to neighboring portions of the serosa, causing traction 
upon the bladder, and elongation of the organ. The uterus was adherent 
to the bladder. Experiments have shown that depressions of the posterior 
vaginal wall diminish the vesical pressure, since the descending uterus 
tends to pull the bladder with it. It is to be noted that the introduction THE EXAMINATION. 
23 
of a finger or a catheter into the rectum has the same effect. The escape 
of gases and fluids cause the anterior rectal wall to sink towards the pos- 
terior one, the uterus follows, and the consequent traction causes a 
diminution of vesical pressure. 
We must then admit that it is possible to have a negative pressure in 
the bladder; but it can seldom occur, and needs a number of concomitant 
circumstances to effect it. We may easily see that the examination of 
the vesical pressure in normal and in abnormal conditions of the bladder 
may be of great importance; its practise is simple and easy, and does not 
entail any disagreeable consequences upon the patient. 
Finally, the bladder may be examined by percussion and auscultation. 
As Rutenberg has shown, the organ may be very considerably inflated 
with air, without there being a tympanitic percussion note above the 
pubis. Marked dullness at that place and above it depends upon the 
amount of fluid in the bladder, upon the position of the organ, and upon 
the thickness of the abdominal walls. At its greatest distension the dull- 
ness reaches to above the navel, and is melon-shaped. The introduction 
of the catheter may cause the appearance of two auscultatory signs; firstly 
the clicking noise occasioned by the contact of the metal with a calculus, 
and secondly the gurgling noise caused by the entrance of air. 
When the organ is distended, and it may contain as much as 128 ounces 
of urine, it may be palpated for through the abdominal walls; and where 
its walls are diseased and hypertrophied, it may be possible even after 
complete evacuation to feel its uneven surface from without. 
0. Kiistner has constructed a urine thermometer 6.4 inches long, the 
lower end of which consists of a German silver catheter which contains a 
small maximum thermometer. This enables us in twelve seconds, during 
urination, to take the temperature. The instrument may be obtained of 
Hofmechanicus C. Zeiss, in Jena, for 10 marks; it is to be recommended, 
especially since catheterization is so frequently necessary in the urethral 
and vesical diseases of females. 
Thus we see that exploration of the female bladder has been greatly 
perfected in the most recent times. We no longer rely upon external 
palpation and microscopic and chemical examination of the urine alone. 
We palpate its internal surface, and examine it closely with the eye; and 
we are thus enabled to have far better prospects of curing its maladies. 
These new exploratory methods have already been used for the diagnosis, 
through the bladder wall of diseases of the organs lying behind it, the 
uterus, the uterine ligaments, the tubes, and the ovaries. (Noeggerath, 
Croom.) CHAPTER IV. 
STATISTICAL INQUIRY INTO THE FREQUENCY OF OC- 
CURRENCE OF THE VARIOUS DISEASES OF THE FE- 
MALE URETHRA AND BLADDER. 
rpO decide the question of the frequence of occurrence of the various 
1 diseases of individual organs, we rely partly upon the reports of 
large institutions, partly upon the monographs of specialists, and partly 
upon the mortality tables of the various states. The reports of the 
large hospitals are, however, too imperfect to be of much assistance. 
Thus the medical report of the Imperio-Royal General Hospital in Vienna 
of 1874, those of the Rudolph Hospital in the same city, and those of the 
Royal Charite in Berlin of the same year, give only the following list of 
cases of urethral and bladder disease: 
General Hospital. 
Rudolph Hospital. 
CharitS. 
Males. 
Females. 
Males. 
Females. 
Males. 
Females. 
Catarrhus vesicae urin. 
. 22 
3 
4 
1 
- 
Cystitis " " . 
. 6 
4 
1 
- 
17 
10 
Paresis " " . 
. 4 
0 
1 
- 
- 
- 
Dysurie " . 
. 1 
-Urethritis - 
2 
- 
- 
Enuresis conti nua . . 
. 4 
- 
Mite 
1 nocturna 1 
1 
Retentio urinae . . . 
. 4 
- 
- 
- 
1 
- 
Incontinentia urinae . . 
- 
- 
- 
- 
6 
1 
Haematuria 
. 3 
- 
1 
- 
2 
- 
Strictura urethrae . . . 
. 42 
- 
8 
- 
13 
- 
Fistula " ... 
. 8 
- 
2 
MM 
2 
- 
Ruptura " ... 
- 
- 
- 
- 
1 
- 
Lithiasis " ... 
. 29 
1 
- 
1 
- 
- 
Fistula vesico-vaginalis . 
- 
17 
- 
2 
- 
3 
" " -abdominalis 
- 
- 
- 
- 
- 
1 
Total, 183 Men and 48 Women 
among 25,733 Men and 16,097 Women sick. 
Making 0.7# of Men and 0.3# of Women sick. 
Such figures may be of some importance in estimating the relative oc- 
currence of these diseases in men and in women. They teach us that 
urethral and vesical diseases are much more infrequent in women than 
in men. It would however be erroneous to conclude that 0.5 percent, 
of all the sick have maladies of these organs; though the Charite shows 
59 cases in 15,013 recorded, the Rudolph hospital 24 in 6,254, and the 
general hospital 141 in 20,563. Such a conclusion we will show in fu- 
ture pages to be precipitate and unwarranted,. 
We must exercise care in accepting the statistics of the various spe- STATISTICAL INQUIRY. 
25 
cialists, Simon, Sims, Bozeman, and others, since many cases came to 
them that were pronounced incurable by other physicians; and their sta- 
tistics as to the occurrence, frequency, and causes of the various diseases 
will vary with the conditions prevailing in the regions whence their patients 
are drawn. Where authors have collected all the cases to be found in cur- 
rent literature, their statistics are apt to exclude ordinary cases, which 
are not reported, and hence to be erroneous. Thus, to cite but a single 
instance, the excellent article by Ed. F. Boucque on the treatment of 
uro-genital fistula in women by secondary union (Paris, 1875) often men- 
tions pregnancy as a cause of fistula, without specifying any of the cir- 
cumstances of the delivery, since the physicians reporting the cases them- 
selves mentioned none. Then, again, among his 204 fistula only 8 per 
cent, are non-puerperal, the author not mentioning or taking into ac- 
count in a monograph upon the cure of fistula incurable ones such as 
those caused by epithelioma. So that not even upon the points specially 
discussed do we get reliable data, though they are the best available to us. 
I know of only one set of disease reports from which any certain facts 
can be gleaned, and they are those of the medicinal district of Meissen 
from 1867-72. They show that among 58,466 sick people, 353 had kid- 
ney disease, 399 had bladder disease, and 577 had gonorrhoea. This 
makes vesical diseases rather more frequent than those of the kidneys, 
and rates them at 0.68 per cent, of the whole.' The more attention is 
directed to any special affection, the more frequently it is found. In 
my reports on 3775 sick females, there were 246 cases or 6.5 per cent, of 
diseases of the urethra and bladder; but 118 of these, or 15 per cent, 
occurred in the last 776 cases. It is worthy of remark that cystocele 
vaginalis was noticed 68 times, being 27 per cent., since it is so seldom 
found at the autopsy (see below). 
If we now finally turn to the tables of mortality for information as to 
bladder and urethral affections, we shall obtain but little satisfaction, 
since the question is so general a one. Thus in Vienna, in 1874, out of 
17,316 deaths only 33 men and 6 women, or 0.2 per cent, of the whole, are 
registered as having succumbed to diseases of these organs.2 
In order to obtain statistics of some accuracy, I applied to the former 
Pro-sector of the Dresden City Hospital, Professor Birch-Hirschfeld, who 
kindly placed the records of his department at my disposal. 
In the Dresden City Hospital in the twenty-five years from 1851 to 
1876 there were made 6861 autopsies, 4147 being on males, and 2714 on 
females. In 209 of the latter the records were not properly kept, leav- 
ing us 2505 autopsies as a basis for our statistics. 
1 Report of the K. S. Landes Med. Colleg. for 1874, Leipz., H. Vogel, 1875. 
2 Innhauser-Nusser, Jahresb. des Wien. Stadtphysikates for 1874, Wien. Brau- 
muller, 1875. 26 
THE FEMALE URETHRA AND BLADDER. 
Of these 184 or 7 per cent, showed post-mortem evidences of urethral 
or bladder disease: 
I. Affections of the Urethra: Malformation, malposition, inflamma- 
tion, new growth, once each, 4 times=2.1 per cent. 
II. Affections of the Bladder: (a.) Malformations (acquired,) 10 times 
= 5.7 per cent.; diverticulas, 4 times; dilatations, 5 times; scar, 1 time. 
(5.) Fistulae due to violence, 2; due to carcinoma, 36=38 times=26.5 
percent, (c.) Malpositions, 0 times, (d.) Inflammations, 72 times=39.1 
per cent.; hyperaemias, 4 times; haemorrhages and ecchymoses, 21 times; 
catarrhs, 16 times; cystitis purulenta, 6 times; cystitis diphtheritica, 4 
times; cystitis crouposa, 4 times; ulcers of mucous membrane, 2 times; 
abscess of bladder wall, 4 times; cystitis chronica, 4 times; oedema of 
wall, 1 time; pericystitis, 2 times; tuberculosis, 4 times. (e.) New 
growths, 41 times=22.3 per cent.; carcinoma vesicae, 37 times, (non- 
perforating); muscular hypertrophy, 4 times. (/.) Functional anoma- 
lies, 6 times=3.2 per cent.; incontinence, 3 times; paralysis, 3 times. 
(g.} Abnormal contents, 13 times=7 per cent.; stony concretions in vesi- 
cal mucous membranes, 7 times; calculi, 6 times. 
Gurlt found 1 in 101,411 sick cases in the three largest Vienna hopsitals, 
16,637 suffering from tumors. 11,140 of these were women, and 16 had 
tumors of the urethra, 1 fibroma, 3 papillomata, 3 polypoid growths, 1 
sarcoma, and 8 carcinomata. 20 had cancer of the bladder, as against 46 
men that suffered from it. 
I myself found among 575 female autopsies the following diseases of 
the urethra and bladder: 
Malpositions: cystocele, .... 7 times. 
Malformations: dilatation, . . . . 42 " 
diverticulae, . . . . 10 " 
New growths: cysts, . . . . .1 time, 
fatty polypus, ... 3 times, 
carcinoma,' . . . . 12 " 
Disturbances of) hypertrophy, . . . 29 " 
nutrition: ) inflammation, . . . 31 " 
tuberculosis, . . . 5 " 
Wounds: fistulas, . . . . 2 " 
perforations, ... 1 time. 
Foreign bodies: calculi, . . . . 1 " 
Thus 25 per cent, of all female autopsies showed some trouble in the 
bladder. 
3 Langenbeck's Archiv., vol XXV., part 2. PART I. 
MALFORMATIONS AND DISEASES OF THE FEMALE 
URETHRA. 
CHAPTER V. 
THE CONGENITAL MALFORMATIONS OF THE 
FEMALE URETHRA. 
TTNDER normal circumstances, the Mullerian ducts at the seventh 
week of embryonal life adhere to the wall of the genital cord, 
and open into the sinus uro-genitalis. At the tenth week occurs the 
separation of the intestine from the uro-genital system, by the formation 
of the recto-vaginal septum (perineum). The urethra, at first absent, is 
Fig. 11.-v. Embryonal part of the allantoic Vesicle, d, Tail end of the Intestinal Canal, m, 
Mullerian ducts, k, Blind sac on the outer side of the rectal septum. C, Cloaca, f, Fold between 
the intestine and the allantois. S, Sinus uro-genitalis. In 5 k is on the intestine instead of on the 
allantois. In 6 and 7 the Mullerian ducts open. 
formed by the development of the parts constituting the neck of the 
bladder so as to form a canal, the septum urethro-vaginali being made in 
the same way. (Fig. 11.) E. Rose believes that the urethra is formed 
of three separate parts. The first is the neck of the bladder; the second 
an infolding of the external skin, forming the glandular part; and the 28 
THE FEMALE URETHRA AND BLADDER. 
third a projection from the posterior extremity of the alimentary canal, 
a vaginal piece, which projects to meet the anterior portion just as the 
allantois grows towards the excretory ducts of the primordial kidneys. 
The congenital anomalies of the female urethra may, therefore, occur 
in various ways. Both portions, vaginal and glandular, may be absent, 
defectus urethrae totalis; or the inner portion only may be absent, de- 
fectus urethrae internus; or the invagination of the skin may not occur, 
defectus urethrae externus; or the vaginal and glandular pieces may miss 
each other, atresia urethrae. In the latter case there is a septum urethrae, 
which is oblique. If both portions simply develop insufficiently, the sep- 
tum urethrae will be vertical. 
Total absence of the female urethra, defectus urethrae totalis, may occur 
in otherwise normal organs, or it may exist together with other congeni- 
tal defects. The vestibule shows no meatus, while in the vagina near the 
symphysis, is a transverse slit, the opening of the bladder. Petit has re- 
corded such a case in a girl four years old, in which clitoris, nymphae, 
and urethra were wanting; the vagina was large, and incontinence of urine 
existed. M. Langenbeck has reported a case of imperforatio hymenis, 
in which in a girl nineteen years old, vagina and bladder formed a com- 
mon canal, and incontinence at first existed. Smith (See Hepner, 1. c.) 
found in a girl seven weeks old, a clitoris 1 inch long, under which was a 
triangular opening, which led into the vagina; and the vagina, 2 lines in 
diameter, had an opening in its anterior wall, which led into the bladder. 
Behncke's case belongs to this latter class. 
Though Heppner classes his case, in which the vestibule showed traces 
of the anterior and lateral walls, as an example of true female hypospadia, 
it is to be doubted if he does so correctly, since the patient in hei' third 
year was operated upon for stone. The incontinence of urine from 
which the patient suffered was not influenced by the operation. Hepp- 
ner's drawing of the malformation gives one the idea that it might be due 
to a traumatic destruction of the urethra, rather than a congenital defect. 
Congenital atresia urethra? occurs when the middle or vaginal portion 
of the urethra is wanting, or when the vaginal and glandular pieces miss 
each other, or are imperfectly developed. Duparcque found the first 
variety of atresia, defectus urethras internus; the urethra was open to the 
bladder, the bladder was closed, and both that organ and the ureter were 
markedly dilated. A case of E. Rose's illustrates the second variety, in 
which the glandular and vaginal portion had missed each other, the 
urethra was crooked, was solid for a certain extent, and thus caused hydrops 
vesica? urinaria?, hydro-necrosis and ascites. Besides this there was uterus 
bicornis septus, vagina septa. To this category belongs also Schatz's case: 
double uterus, double vagina, double bladder, double congenital vesico- 
vaginal fistula, the first case on record of a complete division of the entire 
uro-genital system ! The external genitals were normal, and an opening CONGENITAL MALFORMATIONS. 
29 
leading into a cul-de-sac 4 of an inch deep represented the meatus urina- 
rius. This was the normally developed glandular portion of the urethra. 
Each bladder opened into the corresponding urethra. (Fig. 12.) 
Hypospadia is a further malformation of the female urethra. Van 
Mosengeil has described such a case. The girl was eight years old, and 
had a large clitoris with a well-developed prepuce. The meatus was not 
situated at the usual distance from the opening in the hymen, but formed 
a half canal, the lower wall of which was absent to a considerable extent. 
Deep down behind the orifice of the vagina was the completely closed 
portion of the urethra, about .4 of an inch in length. The bladder itself 
was large, and had many diverticula. Lebedetf's case, shown in Fig. 13, 
is still more instructive. Lebedeff succeeded in giving her the power to 
Fig, 12. 
Fig. 12.-Total Splitting of the Uro-genital System. (After Schatz.) u' and u, Uterus, v' 
and v, Vesica urinaria, t' and t, Tuba, s' and s, Vagina, m, Glandular portion of urethra. 
retain urine for a considerable time in any position. He did several 
plastic operations, and later used electricity, placing one electrode on the 
symphysis, and the other in contact with the vaginal scar. 
The other form of hypospadia may be regarded as persistence of the 
sinus uro-genitalis. There is an orifice between the clitoris and the peri- 
neum which leads into a canal, and then divides into two passages, one 
being the bladder, and the other the vagina. Willigk (0. Heppner) has 
given us the best description of this monstrosity: A woman forty-six 
years old died of a phlegmon. Her penis-like clitoris was 2^ inches long. 
The uro-genital canal was of the thickness of a catheter at its entrance, 
ran in bow-shape under the arch of the symphysis, and 4 inch behind 
its opening in the skin it divided into an anteriorly placed urethra 1 inch 
long, and vagina 2 inches and 10 lines in depth. In this class we must 
place the cases of Debout (S. Furst), Huguier, Jumne, Coste, Debrau, and 
Engel. There was atresia vaginae, and the passage opened into the 
urethral canal. 30 
THE FEMALE URETHRA AND BLADDER. 
Symptoms of these malformations.-The most important consequence 
of a total urethral defect is the inability to hold water. According to 
Heppner's reports those persons who with the defect have stricture of the 
vagina are better situated than those that otherwise than it have normal 
genitals; since very probably the bulbo-cavernosus muscle that encircles 
the sinus uro-genitalis is capable of voluntary contraction. The patient's 
condition is a miserable one if there is permanent incontinence of urine. 
(See symptoms of vesico-vaginal fistula.) 
If the atresia urethrae has occurred within the uterus, there is usually 
hydropsy of the bladder, the ureters, and the kidneys, together with 
Fig. 13.-Hypospadia. (Lebedeff.) a. Opening of bladder, b, Furrow in place of urethra. 
ascites. The stomach of the foetus is enormously swollen, and may form 
a serious obstacle to delivery, so that sufficient force to rupture the ab- 
dominal walls, or tapping, is necessary before the child can be born. 
Examples of such cases have been recorded by Paul Portal, Delborier, 
Moreau, Freund, Hecker, and others. (See Bose, 1. c.) Such children 
of course are usually born dead. Very different is the case, however, 
when from the tension of the bladder the urachus has opened, and a 
urachus-fistula been established. The urine then issues from the region 
of the navel continuously, the orifice being surrounded with comb-like 
outgrowths. (See Cabral's case.) In Bonnett's very interesting case1 
'Recorded by Huxham and Oliver in Philosoph. Transact., Vol. XXXII., for 
years 1722, 1723, No. 379, p. 408-418. CONGENITAL MALFORMATIONS. 
31 
the urine issued in numerous hair-like streams from the urachus-fistula, 
which was about nine inches long, as soon as the prolapsed uterus was 
replaced, and with it the bladder carried upwards. Oberteufer knew a 
woman forty-two years old, who had since birth only urinated through 
the navel. Vagina and menstruation was normal; the urethra was 
wanting. 
If the persistent sinus uro-genitalis is large enough, coitus may be 
effected, and conception occur. But if the vagina is narrowed, the penis 
may penetrate the urethra, and each coitus be followed by dysuria and 
temporary incontinentia urinal. Jumne (Heppner, 1. c.) has described 
such a case. We must be careful not to mistake these cases for instances 
of hermaphroditism, as Smith did. 
More than simple inspection is usually necessary for the diagnosis of 
malformations of the urethra. The inner surface of the labia.minora and 
the space between the clitoris and the rectum must be carefully looked 
over, and then all orifices must be explored with the finger, or, where 
that is impossible, with elastic and metallic catheters and sounds. The 
external genitals should then be carefully palpated; and the existence of 
any hard resisting body is to be carefully searched for in the labia majora, 
since they might be testicles or ovaries. This is necessary, since in child- 
hood we are not aided by the presence of menstruation or the female 
habitus. In the above-mentioned case of Debout, there was a hernia 
ovarialis sinistra. 
A persistent uro-genital sinus may be mistaken for atresia hymenis, 
and acquired atresia vulvee. In either case conjoined vesical and rectal 
examination will inform us whether there is a tumor or only a thin mem- 
branous septum between the two organs. If with finger, sound, or cathe- 
ter, two openings can be demonstrated, the diagnosis is not difficult. If 
the entrance of the sinus uro-genitalis is very narrow, rapid dilatation 
with Simon's urethral specula may be tried, and an ocular examination 
made for another opening. Finally the secretion must be examined 
chemically for urea, and microscopically for pavement and cylindrical 
epithelium. 
Treatment.-This may be palliative or radical. When there is com- 
plete absence of the urethra, and the bladder opens into the vagina by a 
fissure; and also when the urethra is partially developed and the sinus 
uro-genitalis persists, the construction of an artificial urinal canal might 
be attempted. From either side of the vagina, a flap about half an inch 
broad is to be stripped up to the symphysis, and, with its mucous surface 
turned in, is to be united above to the pared margins of the vesical cleft, 
and at the middle is to be united to its fellow of the opposite side. 
Heppner considers the operation difficult, but possible. It is doubtful, 
however, whether the possession of a urethra devoid of muscular fibres 
and incapable of voluntary contraction, would better the patient's oondi- 32 
THE FEMALE URETHRA AND BLADDER. 
tion. Nevertheless, the formation of the new channel would prevent the 
urine flowing into the vagina, and would facilitate retention and the ap- 
plication of a suitable receptacle. Lebedeff has successfully performed 
the operation. 
On the other hand Heppner suggests the formation of an artificial ure- 
thra by means of a trocar-puncture into the bladder, and the subsequent 
closure of the fissure by suture. There is great danger by this proceed- 
ing of wounding important vessels, and the unavoidable contraction of 
the opening will cause retention, a far worse evil than incontinence of 
urine. Heppner disapproves of an operative reduction of the vesical 
fissure to the size of the normal urethra, since the anterior wall of the 
slit contains very probably no muscular structure, and our experience 
with patients with fistula teaches us that linear slits, even when of large 
calibre, retain urine better than do small circular openings. His patient 
suffered only from incontinence at night; he caused her to wear a bandage 
similar to the one Sawostitzki recommends. It consisted of an abdominal 
band, to which was attached a spring bearing an olive-sized pad. The 
pad, introduced into the vagina, compressed the posterior edge of the 
fissure against the symphysis; it fulfilled its purpose perfectly, and the 
patient soon became accustomed to it. Schatz's incontinence-pessaries 
might also be of use in these cases. 
Operative procedure is of course our only resource in atresia urethra?. 
Cabral operated in 1550 on a servant at Beaucaire, who had had atresia 
from birth, and in whom the urine issued from a cocks-comb-like growth 
at the navel some two inches long, causing a frightful smell. He per- 
forated in the region of the urethra, and tied the growths so that they 
dropped off in twelve days. Middleton had a girl seven days old who 
had never urinated, and whose abdomen was enormously swollen. He 
plunged a trocar in the direction of the urethra, emptied the bladder, 
and maintained the patency of the artificial passage. Oberteufer's 
patient wore a sponge fastened by a bandage over the fistula. In fact all 
the apparatuses which we shall describe in connection with urinary fistula, 
may be used in incontinence. 
The abnormalities called epi- and anaspadia in women, are really vesi- 
cal fissures, and will be considered under that head. 
Duplexity is a rare developmental anomaly of the female urethra. 
The single undoubted example of it has been recorded by L. Furst.1 
Furst found in a preparation taken from the body of a virgin female, 
that the urethra, single at the bladder, at 1 line from it bifurcated, a thin 
septum running from right to left, dividing the canal. This septum grew 
thicker as he advanced forward, and the meati were over a line distant one 
from the other at the vestibulum vaginae. The superior urethra also 
1 Archiv. ftir Gynakologie. CONGENITAL MALFORMATIONS. 
33 
curved to the right, and the posterior one to the left. The left urethra 
had a meatus |th inch in diameter exactly in the median vaginal line, 
while the other meatus only measured ^th of an inch. The total length 
of both urethrae was 1 inch. It is extremely rare for the duplexity of the 
first allantoic appendages to persist in this way, and not to undergo fusion 
during the various changes the sinus uro-genitalis passes through. Uterus 
and vagina were normally developed. In 1875 Lewis published a case in 
which a puerperal woman came under his observation, who besides a 
normally patent urethra, had one that ended in a blind sac. She is said 
to have undergone an operation for retention of urine immediately after 
birth, and one of these urethra is as probably an artificial product. CHAPTER VI. 
ABNORMAL SHAPE AND POSITION OF THE FEMALE 
URETHRA. 
TAILATATIONS, strictures, diverticula?, dislocations and prolapses of 
certain portions of the urethra are to be considered under this 
caption. 
1. Abnormal dilatation of the urethra may affect its entire length, the 
surrounding tissues giving way upon all sides: Dilatatio urethra? totalis; 
or it may be limited to a portion of the canal, usually the central part, 
while the orificia externum and internum are of normal calibre; dilatatio 
partialis, diverticulum urethras, urethrocele. 
a. Total dilatation of the urethra is usually caused by the penis, in 
cases where the vagina is closed or is unusually narrow. I have seen it 
twice, and in both cases in married women, who had practiced coitus for 
years, but who suffered from atresia vagina? with defectus uteri. With a 
little trouble the index finger could be introduced into the bladder. 
There were no erosions or lesions near the urethra, and both women 
could retain their urine perfectly. Scanzoni asserts that when dilatation is 
caused by the frequent introduction of a foreign body, the mucous mem- 
brane is the seat of a catarrhal inflammation, with more or less secretion. 
Hyrtl mentions a like case, which he believes to be unique. They are, 
however, not rare. Lachapelle has described one in a puella publica; 
Scanzoni one in a young girl who was in the habit during her daily acts 
of masturbation, to introduce a small wax candle 3 lines thick into the 
urethra; and Willemin (1864) one with defectus uteri and rudimentary 
vagina. In all these cases the forefinger could be passed through the 
urethra into the bladder. C. Knight (1860) has reported such a case; 
and Freund (1866) had a patient who practiced coitus for ten years per 
urethram, and never had incontinence, though she did suffer somewhat 
from ischuria at the beginning. Wegscheider has published a similar 
case. J. Saxinger has met a case in which a girl suffering from atresia 
vaginae and haematometra had a urethra so dilated by coitus, that two 
fingers could be introduced into the bladder; yet incontinentia urihae was 
not present. 
The urethra may also be gradually dilated from within by new growths, 
or from the direction of the bladder or the vagina. HyrtFs case is well 
known, in which a calculus 7 lines in diameter, escaped spontaneously ABNORMAL SHAPE AND POSITION. 
35 
from a woman's bladder. Scanzoni had a patient with stone in 1850 upon 
whom he intended to perform lithotrity; she was suddenly seized with 
severe bearing-down pains, and a calculus larger than a pigeon's egg ap- 
peared at the meatus, whence it was extracted with a polypus forceps. 
Here the urethra remained so dilated for several days, that the bladder 
could easily be reached with the finger. I myself had a case of papilloma 
of the bladder, who before the operation spontaneously evacuated a por- 
tion of the growth over 7 lines in diameter. Ponfick's case belongs also 
in this category; she had atresia vaginae, haematometra, and cystitis with 
stone in the bladder; and her urethra was so dilated that various physi- 
cians mistook it for the vagina, and ascribed the incontinence from which 
she suffered to a supposed communication between the vagina and the 
bladder. With the lax, dilated, and displaced vagina caused by frequent 
child-bearing at short intervals, we usually find the urethra dilatable and 
enlarged, especially in young persons. 
If total urethral dilatation does not give rise to incontinence, it causes 
no special trouble. Patients who have used the urethra for coitus, are 
naturally unaware of that fact, and consult the physician because they 
have never menstruated, or because they have no children. As a rule 
they suffer at most from a transient dysuria, and can generally fulfill their 
marital duties. It would, therefore, be useless to attempt to reduce the 
calibre of the urethra. It is different, however, when vesical continence 
is affected by total dilatation. Kinny claims to have cured three cases 
by cauterizations with chromic acid; but since I have not seen the original 
article, I cannot tell whether pure or diluted acid was used. Cauteriza- 
tion with solid lapis mitigatus would probably do as well. If, however, 
this is insufficient, I would recommend Jobert's urethrocele operation, 
which will be described later on. Astringent and tonic injections, and 
the sitz-bath, as well as scarification of the mucous membrane has been 
recommended; but Scanzoni reports that in an old case with relaxed 
genitals, all his efforts were in vain. He obtained most satisfaction from 
an ointment containing tannin or ergotin, to be applied partly to the 
vaginal walls, and partly in the urethra. In one of his cases, where the 
dilatation was caused by onanism, and resisted all methods of treatment, 
it yielded almost completely to injections of sulphate of copper. If all 
these means fail to restore continence, we must excise a strip 1 to inches 
long, from the urethro-vaginal septum from the external to near the in- 
ternal opening. Its base in the vagina should be fth in the urethra |th 
of an inch broad. The edges of the wound should then be carefully sown 
together over a metallic catheter. The operation is easy, and its results 
are good. We will return to it when we come to consider incontinence 
and urinary fistulas. 
b. Partial dilatation of the female urethra, diverticulum urethrae, 
urethrocele, affects the posterior wall of the organ a few lines from the 36 
THE FEMALE URETHRA AND BLADDER. 
meatus. I know of but four cases so far recorded. The first, that of 
Foucher (1857), occurred in a woman twenty-seven years old, who had 
had dysuria for four years, and in whose anterior vaginal wall, | inch 
from the orificium urethra?, there was a tumor which became smaller on 
pressure, urine exuding from the meatus. On introduing a catheter, it 
entered this cavity, and only after traversing it attained the bladder. 
Foucher treated it as Jobert would a cystocele. He incised the vaginal 
wall the whole length of the tumor, dissected up a strip of |th of an 
inch wide on either side, cut off the loosened portions, and sutured the 
edges of the wound. The patient was cured when cicatrisation had oc- 
curred. Gilette's case is very similar. A woman thirty-one years old, 
confined three times, was cured by the excision of a triangular piece from 
the vaginal wall. 
The third case has been described by G. Simon. The woman was forty- 
four years old, had borne eleven children, and had had involuntary urina- 
tion on vigorous motion for sixteen years. In the last three years the 
incontinence had so increased, that at certain times all her urine flowed 
off continuously in any position, even when lying down. In the anterior 
vaginal wall there was a tumor as large as a hen's egg, reaching from the 
region of the meatus urinarius to the vesical neck. The catheter or the 
finger introduced into the orifice entered a wide sac, which was continu- 
ous, without any line of demarcation, with the bladder. Only the meatus 
was normal in size, and had its proper muscular tonicity. This dilata- 
tion had been caused by large varicosities in the urethro-vaginal septum, 
which were so near to the urethral mucous membrane that a brisk hem- 
orrhage followed catherization. They projected as dark blue coils. In 
two sittings Simon cut ten veins, double ligaturing four of them, and 
cauterized the wound with chloride of iron. The patient did not even 
have to keep to her bed. The tumor visibly diminished in size, through 
the cicatricial contraction of the wound. The -woman no longer* lost 
urine while lying, sitting and standing, and during ordinary motions. 
Six months later she had remained well, but Simon did not regard the 
relief as permanent, believing that the dilatations would reappear, or that 
other neighboring veins would become varicose. I have often seen con- 
siderable varicosities of the bulbus urethrae and of the anterior vaginal 
wall, but have never seen such a partial dilatation of the urethra result 
therefrom. 
The fourth case was observed by Priestley. He found an elastic tumor, 
half the size of a hen's egg, in the vulva, springing from the upper part 
of the posterior vaginal wall; it disappeared on pressure, pus and urine 
flowing out of the meatus. Priestley applied a Barnes dilator, the pressure 
of which prevented the tumor from refilling, and relieved the patient. 
In another similar case Priestley found a urethral cyst with atheroma- 
tous contents; a condition that might well be confounded with urethro- ABNORMAL SHAPE AND POSITION. 
37 
cele. But in these cases the urethral canal will hardly be dilated, and 
the tumor will simply open into it. Since 1877 I have encountered two 
cases like these, which were indubitably affections of the urethral follicles, 
hi the first the tumor was of the size of a walnut, was placed upon the 
lower part of the posterior urethral wall; pressure caused the appearance 
of pus at the meatus. The patient improved by frequent compression of 
the tumor with her finger, and a lead-water lotion. In the second case, 
however, the tumor, hazel-nut in size, was the source of great pain during 
cohabitation, and caused bearing-down feeling when the patient was 
standing. I therefore excised it. It was situated under the urethral 
mucous membrane, near the external orifice, and contained abundant 
greenish, slightly foul-smelling pus. Its walls were muscular, its inner 
surface being covered with pavement epithelium. These cases, I think 
are nqt urethroceles; they are cases of inflammation of urethral lacunae. 
They have doubtless often been confounded with urethroceles and urethral 
cysts. 
We must also remember that other openings may be found in an other- 
wise normal urethra, which must be distinguished from an urethrocele. 
Thus, as in the above-mentioned case of Debout, (page 29), the vagina 
may open into the urethra, so that a catheter introduced into the urethra 
may reach the uterus. Cusco has mentioned a case in which there was in 
the posterior urethral wall an opening of an inch in diameter, which 
led into a blind sac a few lines deep, the rudimentary vagina. Besides 
this, this servant girl, who was eighteen years old, had a uterus duplex 
rudimentarius solidus, and a hernia ovarialis simistra. Incarceration of 
the latter led to operation, and she died of peritonitis. Such adnexa may 
be dilated by the pressure of the urine, may deform and dilate the urethra, 
and may cause catarrh. Most often the differential diagnosis can hardly 
be made during life. Compression of the sac, as soon as it is proven that 
it has no other opening above, in the manner described by Foucher, will 
be our best method of examination. 
2. Much rarer than dilatation of the urethra is narrowing, stenosis et 
strictura urethrae in women. 
The causes are chiefly three; and they mark the three forms of the 
malady. First we have lesions of the urethro-vaginal septum, followed 
by cicatrization; they are seen chiefly after severe labors. Cicatricial 
bands are found at the vaginal entrance. Thus in Scanzoni's case (1858) 
there was a urethral stricture 4 to 5 lines from the meatus, which could 
be felt with the finger, as a cartilaginous prominence along the line of 
the urethra; it had been caused by a gangrenous colpitis after a forceps 
delivery. In Gayet's case an analogous injury caused a circular stricture 
at the ostium vaginas, and there was so much callous tissue under the 
arch of the pubis, that the urethra was almost entirely closed. Ledetsch 
reports a similar ease. 38 
THE FEMALE URETHRA AND BLADDER 
A tumor in the urethral wall is a much rarer cause. These may be 
phlebectasies, polypi, vascular or fibrous tumors.1 They only obstruct the 
lumen when small, causing dilatation where they are more developed. 
A still more rare cause of stricture of the female urethra is a urethral 
chancre. Scanzoni found such a one in a prostitute 5 lines from' the 
meatus; it caused a stricture so close that only with difficulty could a 
crow-quill-sized sound be introduced into the bladder. Similar to this is 
the case of Velpeau and one of Larcher's (in his other three cases the 
cause was unknown.) Lewin found among G12 women treated at the 
Berlin Charite for pseudo-syphilis, 6 with urethral ulcerations, and 5 with 
ulcerations of the urethra and of the labia pudenda. Boucher found in 
a case that had long suffered from leucorrhoea and ulceration of the os 
uteri (though the record does not say whether she was specifically infected 
or not), two hardened and strictured places near the anterior mouth of 
the urethra, which could only be passed by the minute olive of a small 
bougie with considerable pain. 
Stenoses of the urethra itself occur with chronic vesico-vaginal fistula?. 
The passage is often so narrow as hardly to admit the smallest-sized 
bougies. Very lately I examined two patients with lesions of this kind. 
The vesico-vaginal fistulae resulted in both cases from operative confine- 
ments, and the callous urethro-vaginal stenosis was such that only with 
the greatest of difficulty could a very fine sound be introduced. 
Compression of the urethra in retroflexion of the uterus, by present- 
ing parts during delivery, by luematocolpos or hsematometra, etc., need 
not detain us; their results mainly affect the bladder, and will be con- 
sidered under that head. 
Like the causes, the symptoms of urethral strictures and stenoses are 
very various. Those due to vesico-vaginal fistulse, simply render cathe- 
terization difficult. Those caused by cicatricial tissue obstruct urination; 
the stream becomes smaller, the bladder can only be emptied by a con- 
siderable exertion of the abdominal muscles, and finally the urine can 
only be voided in drops, and retention may occur. It is well known that 
in the female also hypertrophy of the bladder occurs under these circum- 
stances. Scanzoni lays stress upon the deleterious influence exercised by 
hypertrophy of the bladder, following stricture upon the neighboring 
organs, the uterus and the vagina; he has often noticed descent of the 
anterior vaginal wall in consequence of it. 
If we made a thorough examination of every patient that conies to us 
complaining of difficulty of urination; if we carefully examined the 
meatus and palpated the urethra from the vagina, and then introduced a 
catheter, following its advance with our finger in the vagina; it would 
be almost impossible to mistake stricture of the urethra for any other 
1 See Th. David's case, Gaz. des Hop., 73, 1870. ABNORMAL SHAPE AND POSITION. 
39 
condition. The urine should then be carefully examined, since vesical 
catarrh and irritation may not only cause frequent desire to urination and 
dripping, but may hinder the entrance of a catheter by reflex contrac- 
tions of the urethra and bladder. It must of course not be forgotten to 
examine per vaginam for a urethral tumoi' before passing the catheter, 
and if it is present, to push it if possible to one side during the operation. 
The treatment depends partly upon the cause. Stenoses due to vesico- 
vaginal fistulas, and those due to oedema of the urethral mucous mem- 
brane, may be completely cured by repeated careful catheterizations. 
If it be caused by cicatrices in the introitus and the vagina, we can 
follow Scan zoni and use lukewarm vaginal injections, followed by an 
iodide of potassium salve applied to the anterior vaginal wall, and by re- 
peated introduction of bougies of gradually increasing sizes. Thus Gold- 
schmidt almost entirely cured in four weeks a syphilitic urethral stricture 
by catheterization and the removal of a tumor that pressed on the ex- 
ternal meatus. But in more serious cases this will not suffice. We must 
then carefully cut the chief cicatricial band at its point of greatest tension 
from without, and then undertake methodic urethral dilatation after 
Simon's method. (Page 13.) 
For stricture caused by chancre Scanzoni used first a course of treat- 
ment with sublimate, and then for three weeks a daily inunction of iodine 
ointment, which was warmed and poured into the catheter, and then 
blown into the urethra by means of a syringe filled with air. The treat- 
ment was successful. Boucher's patient had been once completely cured 
in six weeks by means of gradual dilatation; but the strictures returned, 
and had to be redilated. In such cases incision together with dilatation 
is certainly indicated. The urethra should be dilated with the urethral 
specula, until the little finger could be passed through the stricture; then 
a short knife is to be introduced flat under the finger, and then returned 
and pressed against that part of the cicatricial ring that feels hardest. 
No especial hemorrhage need be anticipated; but if it did occur, the ap- 
propriate urethral speculum might be left for a few hours in the can£l. 
Then bougies, medicated with iodide of potassium or salycilic acid, could 
be employed. The patient should be warned to return as soon as the 
least difficulty in urination occurred, or, if that be impracticable, she 
should use elastic bougies of gradually increasing sizes herself to prevent 
a recidive. 
3. Change of position of the urethra, partial or total, may occur in any 
direction, above, below, sidewards, or anteriorly. Again the entire 
urethra, or only its mucous membrane, may be dislocated. This latter 
is the most important displacement, and will be first considered. 
a. Prolapse of the urethral mucous membrane in females was acci- 
dentally found twice during autopsy by Morgagni nearly 100 years ago. 
Since then such cases have been seen by Seruin, Solingen, Hain, Lee, Ki- 40 
THE FEMALE URETHRA AND BLADDER. 
wisch, Burns, Streubel, Ried, Scanzoni, Patron, Basler, Day, Hudson, In- 
gerslev, and Olivarius. It must be rare, since the author has seen but one 
case, though small partial protrusions of the mucous membranes of the 
lower part of the urethral wall occur often enough. The entire mucosa 
can only protrude at the external orifice where it has been loosened from 
its base and forcibly torn or pushed out. The protruded part is pea, 
walnut, or pigeon-egg-sized (Basler), bluish or dark red, and round, half- 
moon-shaped, or globular. At its middle or towards its upper border is 
the orifice of the canal. Thus the condition is exactly similar to that of 
prolapse of the rectum. As in the latter case the mucous membrane can 
usually be easily replaced; and like it also it may recede of itself, but in 
some cases may be difficult or impossible to reposit. The surface of the 
tumor sometimes bleeds, and may be sore and suppurating; in long- 
standing cases it grows and becomes oedematous and may appear con- 
stricted. (Patron's case.) It is usually very sensitive. 
The causes of this malady are partly those of urethral dilatation (see 
ob. 5), partly diseases of the bladder, and partly constitutional affections. 
As a rule, the patients have already long suffered from urinary difficulties, 
dysuria, and vesical catarrh; and it is especially the catarrhal condition 
that predisposes the mucosa to a prolapse. In 15 sick persons suffering 
from this affection, were 7 girls between the ages of 8 and 15 years, weak, 
chlorotic, and relaxed individuals. Of Streubel's 4 patients three were 
" much used prostitutes with vaginal gonorrhoea, dilated meati urinarii 
and hyperaemic urethral mucous membranes." Displacement of the geni- 
tals, such as prolapsus uteri, cystocele vaginalis (Scanzoni), have repeatedly 
caused the affection. On the other hand there do occur cases like those 
of Basler, when a young women twenty-two years old had a urethra so 
dilated five weeks after her first and normal delivery, that he could intro- 
duce his finger, and bring to view a prolapse of the mucous membrane, 
the size of a pigeon's egg, the other genitals remaining normal. Excit- 
ing causes are contractions of the bladder with marked desire to urinate, 
expressing the mucous membrane; abdominal and vesical muscles here 
working together. It has been claimed that calculi may cause it (Scan- 
zoni); I know of no such case. Solingen's one case had had a number 
of severe confinements, had suffered blows upon the abdomen, and in con- 
sequence thereof suffered from difficult urination and defoecation. Larger 
growths in the urethra cause prolapse of the mucus membrane, but usu- 
ally only to a small degree. 
Diagnosis.-To recognize that the little tumor between the labia mi- 
nora and under the clitoris belongs to the urethra, and is not simply a tu- 
berculum vagina, it is first necessary to find the urethral canal. In cir- 
cular prolapses it is a slit or round opening in the middle of the tumor; 
in crescent-shaped ones it is situated at its upper margin. A catheter is 
now introduced and reposition attempted. ABNORMAL SHAPE AND POSITION. 
41 
In a case published by Guersant in 1852 in which an emaciated and 
sickly girl had a prolapse of the mucous membrane nearly one inch in 
length cut away with the scissors, he found after her death, which oc- 
curred from tuberculosis, that her urethra, of normal length and diame- 
ter, was only covered with mucous membrane over its posterior (lower) 
third. This would go to prove that the meatus may occasionally be found 
at the lower portion of the tumor. Exactly defined the condition is not 
a simple prolapse, but is an invagination with prolapse. Inversio cum 
prolapsu mucosa urethra. 
The tumor and the difficulties it causes increase in time; and the pro- 
truded portion may be dry, smooth, soft, and undergo the change of the 
mucous membrane described in prolapsus vagina (Reid and Streubel). But 
this is rare, and the malady is painful, obstinate, and debilitating. The 
cure, though slow, is sure and radical, and the prognosis, therefore, not 
unfavorable. 
Therapy.-We must first try to replace the part. It must be carefully 
compressed with three fingers, assisted by the well-oiled and blunt end 
of a thick catheter. After reposition the causes of the disorder must be 
remedied; such as vesical tenesmus, etc. It is a good plan to rinse out 
the bladder several times a day by means of Hegar's funnel, using a 1- 
1000 solution of salycilic acid. In the milder cases, when the prolapse 
remains reduced, involution of the mucous membrane and narrowing of 
the lumen of the urethra may be helped by the use of mildly caustic and 
astringent remedies, such as arg. nitrat., decoction of oak bark, sulphate 
of copper or zinc, tannin, etc. If the inverted portion is eroded or ul- 
cerated we must proceed to more vigorous cauterization, and may use 
the lapis mitigatus in substance. Reposition must be effected immediately 
after each cauterization. 
If in spite of this the prolapse returns, it has been proposed to treat it 
radically by ligature, the actual cautery, or ablation with subsequent ap- 
plication of chloride of iron. (Scanzoni.) We may discard the method 
of ligature over the metallic catheter, since it is slow and painful. The 
knife should be used. A large metallic catheter is carried into the blad- 
der, fixed by an assistant, and a sharp hook inserted into the tumor on 
each side of the staff so as to prevent too great retraction of the mucous 
membrane. The mucous membrane is now dissected up from without in- 
wards, beginning at the edge of the meatus, so that it can be cut off cir- 
cularly. Scanzoni recommended the use of chloride of iron as a styptic. 
It seems to me to be easier and better to unite the cut edge of the mucous 
membrane to the edge of the wound at the meatus with a few silver liga- 
tures. The stitches may remain in 5-6-7 days. There is no danger of 
pushing eschars caused by the caustics with the catheter into the bladder. 
If serious hemorrhage is feared a wooden staff may be introduced into 
the urethra, and the prolapse taken off with the galvano-caustic wire. 42 
THE FEMALE URETHRA AND BLADDER. 
b. Malplacement of the whole urethra is of more common occurrence 
than the partial dislocations that we have been so far considering, since it 
is usually secondary and unimportant, following changes in position of 
the bladder. Still, one primary dislocation of the female urethra alone 
may be cursorily mentioned here. We refer to its dislocation by the pre- 
senting part of the child, which bends the urethra at an acute angle. We 
then see it as a dark, bluish red tumor under the symphysis, together with 
the tuberculam vaginae. Both the bending and the swelling of the 
vaginal and urethral walls are of importance in connection with retention 
of urine. Another and more frequent cause of this trouble is believed by 
Mattei and Ohlshausen to be the sudden descent of the uterus after de- 
livery. The puerperal ischuria that occurs therefrom is exactly analogous 
to that so very often seen after the puncture of large ovarian tumors. 
The bend in the urethra forms an obstacle to catheterization which is very 
liable to be mistaken for vesical spasm. An attempt to force the catheter 
into the bladder may injure the urethral mucous membrane, and cause 
hemorrhage. But if the tuberculum vaginae be first pushed up out of the 
way, and the catheter carefully introduced two or three times, the urethra 
will be sufficiently stretched to obviate the retention. But in all these 
changes of position, with or without changes in the bladder, the urethra 
is lengthened, and its walls may be thickened and infiltrated, or they may 
be atrophic. So that even in the later days of the puerperium there may 
be deficient contractility of urethra and incontinentia urinae after such 
contusions. I had recently such a case, in which repeated cauterization 
of the urethral mucous membrane with solid lapis infernalis soon restored 
continence. CHAPTER VII. 
DISTURBANCES of nutrition of the female 
URETHRA. 
LI YPER^EMIA, acute and chronic catarrh, ulceration and hyper- 
Jtrophy, hyperaemia urethrae, ulcera, hypertrophia urethra?, often 
occur in the female. But from the comparatively small area affected, they 
are neither symptomatically nor therapeutically as important as the cor- 
responding affections in the male. These affections are often only stages 
of one and the same process, and we will therefore not treat them each 
one separately. Their etiology, symptoms and treatment are closely re- 
lated. 
The causes of these disturbances of nutrition lie either in the individual 
affected, or they come from without. Certain states of the urine may 
affect the urethral mucous membrane. A water rich in salts, or ammo- 
niacal, one containing fungi, or rich in membranous threads (diphtheritis 
of the bladder) or one containing infected blood clots, may naturally cause 
hyperaemia, catarrh and ulceration of the mucous membrane. Diseases 
of the bladder and kidneys are, therefore, important predisposing causes 
of the affections that we are considering, especially as many of them ne- 
cessitate introduction of the catheter, and possibly a direct lesion of the 
mucous membrane. The urethra often partakes of affections in its neigh- 
borhood, such as chronic and acute inflammations of the labia minora, 
catarrh of the vagina, and of the cervix. Thus urethritis has been found 
as a complication of the scrofulous diathesis, and with impetiginous 
skin eruptions, (Streubel); and specific catarrhal inflammation of the 
membrane has been seen in scarlatina and measles. Variolous pustules 
occur there in small-pox. Scanzoni found them twice. The same observer 
found in the urethra of a girl nineteen years old, dead of measles with 
acute disintegration of the blood, more than twenty follicular ulcers. 
Typhus, dysentery, and puerperal septicaemia often cause considerable 
nutritive disturbances in the walls of the urethra. There may spread from 
the labia minora and the introitus the ulcerations of syphilis, lupus, car- 
cinoma, tuberculosis, diphtheria, and elephantiasis. Besides this it is 
well known that in pregnancy, in consequence of active and passive hy- 
peraemia and mechanical displacement, the urethra is often affected; and 
it may be contused and even torn across in a non-instrumental delivery. 
Again, dislocations of the unimpregnated uterus, tumors of other pelvic 44 
THE FEMALE URETHRA AND BLADDER. 
organs or inflammatory conditions affecting them, and hemorrhoids, may 
involve the urethra to a greater or less degree. 
The following external injuries may cause urethral diseases: lesions 
from cohabitation, especially in young women, catheterism, the attempt 
to introduce foreign bodies (masturbation), wounds from falls and blows, 
etc. It is easy to see that catarrhal conditions of the urethra may ensue 
from the use of unclean specula, or the careless employment of the finger, 
or compressed sponge, for dilatation of that canal. 
Most frequently, however, these affections occur conjointly with mala- 
dies of the vagina, and especially together with virulent vaginal catarrh. 
Suchanek found in 166 cases the vagina and urethra both affected in 122, 
urethral gonorrhoea alone being present only in 3 cases. Hence we see 
that the virulent urethritis feminae is usually secondary, and spreads 
from the mucous membrane of the introitus or the vagina; the urethra 
itself being usually too well protected to be directly infected. 
Symptoms.-Under normal conditions the mucosa of the orificium 
externum urethrae is pale red in color. In conditions of hyperaemia it 
becomes rosy, cherry, or brownish red; the mucous membrane swells; and 
the canal per vaginam is felt to be warmer and thicker than usual. At 
first the amount of secretion is not increased. In urethral catarrh not 
only is the meatus reddened and the small glands swollen, but there ap- 
pears a light mucous or muco-purulent fluid, often containing bubbles of 
air, which flows in considerable amount, as soon as pressure is applied to 
the urethra, from the orifice. From the non-dilated, healthy urethra 
no drops can be expressed; but in the catarrhal secretion of urethritis we 
find pavement epithelium, mucus and pus corpuscles, and vibriones. 
When ulceration has occurred we may find in addition according to cir- 
cumstances connective tissue and elastic fibres (Barensprung in chancre), 
and larger cells with nuclei (in lupoid ulcers) and multi-nucleated giant 
cells with detritus and blood-corpuscles (in epithelioma). 
In gonorrhoea of women, urethral gonorrhoea proper, urethritis viru- 
lenta gonorrhoea, the mucous membrane is at first reddened; then the 
woman feels an itching, which soon becomes a prickling, burning pain, 
which is accompanied by frequent micturition and dysuria. A few (3 to 
4) days later there appears a serous, sticky, albumen-like secretion, which 
in 6 to 8 days becomes purulent and greenish, in 20 days begins to de- 
crease, and may have entirely disappeared in 30 to 40 days. (Boys de 
Loury.) Blood may be mixed with the secretion, haematuria and vesical 
catarrh may occur; but from the shortness of the female urethra, and the 
absence of the associated organs which are so prone to give trouble in the 
male, the symptoms are not usually violent. There is often seen around 
the meatus a number of vividly red projecting points, which are the in- 
fected^md swollen orifices of the glands of the part. (Streubel.) This, 
as Scanzoni asserts, is a true folliculitis of the inner surface of the upper DISTURBANCES OF NUTRITION. 
45 
parts of the nymphse. Occasionally these inflamed glands cause small 
abscesses, the affection spreads to the rest of the vulva, an abundant pur- 
ulent and foul-smelling secretion appears, and finally the entire vulva is 
infected. With this there usually occur dysuria and strangury, the spas- 
tic contraction of the sphincter vesieae causing the patient much trouble. 
The pain caused by urination leads the patient to retain her water as long 
as possible, and besides this, the urine flowing over the inflamed parts 
around the external urethral orifice causes violent itching and burning, 
often leading the patient to rub and scratch the affected parts violently. 
But rarely do abscesses of the vesico-vaginal septum occur. (See Cory's 
case.) Lewin has found that many women having urethritis and ulcera- 
tion of the urethra suffer from an exudative erythema from reflex vaso- 
motor stimulus. 
If the process becomes chronic, the secretion decreases in amount, the 
redness diminishes, and the color of the parts becomes a livid blue. The 
entire canal is hard and infiltrated, though it is not painful. A sort of 
hypertrophia urethrae may gradually appear, the parts around the urethra, 
especially the anterior vaginal wall, being involved. Loosening of the 
mucous membrane leads to varicosities in it, and also to varicosities around 
the orificium externum; finally there may occur partial or total prolapse 
of the mucosa. 
The diagnosis of hyperaemia and catarrhal or virulent urethritis, can 
only be made with the aid of sight. The labia minora are to be spread, all 
secretions carefully cleaned away, and the mucosa of the vulva and its 
neighborhood carefully inspected. Then the finger must be introduced 
into the vagina, and the. urethral canal tested as to thickness, hardness, 
and sensibility. Pressure is then made upon it from before backwards, 
to express any fluid which may be in it. If urine has been recently 
voided, no fluid may be obtained, and some time must be permitted to 
elapse before pressure is again applied. The secretion thus obtained may 
be examined for gonococci with the microscope, to decide whether we 
have a simple or a virulent urethritis, or perchance a urethral chancre to 
deal with. Inoculation with virulent pus may cause virulent catarrh 
and soft sores, but a negative result does not prove the absence of the 
chancre. The proof of its existence must chiefly depend upon the de- 
monstration of elastic fibres in the secretion; though small and frequent 
urethral hemorrhages, with obstinate oedematous swelling of the mucous 
membrane around the meatus, have been claimed as important data in 
the diagnosis of urethral chancre. (V. Biirensprung.) Swelling of the 
inguinal glands is important, and the occurrence of a bubo will help us 
in the diagnosis. Scanzoni claims as the seat of the acute hyperaemias and 
inflammations the lower and outer portions of the urethra, the inner and 
upper parts being the location of the chronic forms. On the other hand, 
0. A. Martin and Leger claim that the commonest seat of chronic ure- 46 
THE FEMALE URETHRA AND BLADDER. 
thritis is in the cryptis mucosis of the urethra and of the meatus uri- 
narius. 
Opinions differ much as to the occurrence of gonorrhcea in women. 
The syphilographers are authorities upon the matter, and we have already 
quoted Suchanek's figures. Boys de Loury and Costilhes also affirm that 
urethritis is not so uncommon as is thought, llicord found it 8 times in 
12 gonorrhoeas; but Zeisl only 5 to 6 times in a hundred cases of vaginal 
blenorrhoea. Lewin states that in 242 blenorrhoeic women only 8 had 
urethritis, and in 612 cases of female pseudo-syphilis only 11, =1.8 per 
cent, had urethral sores. Sigmund (Vienna) found in 1850 in 758 women 
urethral gonorrhoea occurring only 5 times alone, but 476 times with 
other catarrhs, etc. Thus it seems that gonorrhoea is common in prosti- 
tutes, and forms f of the total number of infected cases. Scanzoni re- 
marks that chronic urethral catarrh especially is very often overlooked by 
gynecologists. Nevertheless I must agree with Hourmann, that urethritis 
occurs but seldom in comparison with vaginal and uterine catarrhs. In 
425 cases of blenorrhoea Hourmann found a urethral flow but once. 
The prognosis in hypertemias, catarrhs and sores of the female urethra, 
is much better than it is in corresponding affections in the male. The 
canal is shorter and more accessible, the disability is less, and the chances 
of cure are more numerous. In some individuals the hypersemia and the 
catarrh soon disappear when the cause that brought them on is removed. 
This is especially the case with the newly married, and in the cases that are 
connected with menstruation. Virulent catarrhs last 4 to 5 weeks. Boys 
de Loury twice saw a tight stricture following one. Streubel saw in ne- 
glected cases erosions, ulcerations, and that folliculitis to which we have 
above drawn attention. Knoblauch reckoned that the treatment of ure- 
thral gonorrhoea took 21.8 days. Energetic cauterization has caused it 
to disappear in 12 to 18 days. (Cullerier.) 
Treatment.-There is yet considerable difference of opinion as to the 
results of various methods of treatment in hyperemias and catarrhs of 
the female urethra. While Streubel, Boys de Loury, and Huet favor the 
use of balsams, opining that they render the urine bland more readily 
than in the male, and Boys and more recently Daffner claim that cubebs and 
balsam are just as efficacious as they are in man, Scanzoni obtained no 
results, and discarded them. The slighter cases of female urethral blen- 
orrhoea need no treatment; they get well of themselves. Most recent 
authors rely entirely upon a local treatment for those that are more obsti- 
nate, only general dietary rules being prescribed. We begin by removing 
the cause, and ordering rest, abstinence from intercourse, and cool muci- 
laginous drinks. Milk of almonds, emulsions, and soft food are to be 
used. To relieve the burning and itching there should be given 2 to 4 
vaginal injections of linseed tea daily, and lukewarm or cold sitz-baths 
containing decoction of white-oak bark should be taken. To further relieve DISTURBANCES OF NUTRITION. 
47 
the irritation and pain, we may use suppositories of cocao-butter or gelatine, 
or glycerine and starch, containing each extract of hyoscyamus 3 grs. or 
extract of belladonna gr. | or extract of meconium gr. Dr. Saxe (Cali- 
fornia) recommends rest in bed, hot applications to the feet, and hot 
drinks, to favor diaphoresis; he orders calomel and ipecac | to 3 grs. every 
two hours; he moves the bowels with decoction of senna, and gives light 
diet and mucilaginous drinks. As sedative he applies cold cloths to the 
vulva, and gives opiates. If there is no improvement in twelve hours, 
he orders saline purgatives. 
If there is much hyperaemia, secretion and pain, cold applications, cold 
injections, and even the introduction of ice into the vagina is the next 
best thing to a narcotic. Scanzoni's advice to apply a few leeches to the 
part of the anterior vaginal wall corresponding to the urethra has received 
little attention from recent authorities, and has probably rightly been 
displaced by cold and local treatment of the affected mucous membrane. 
Hourmann accomplishes this latter object by first emptying the bladder, 
and then filling the urethra with a tampon of cotton 5 lines long, and the 
thickness of an ordinary catheter. By the repeated use of this method, 
he claims to have effected a cure in fourteen days. But Bois de Loury 
found that this procedure did no good at all in 10 cases, and that it was 
very troublesome, since it had to be renewed at least thrice daily. Streu- 
bel cauterized the mucosa, rolling the point of a waxen bougie in pul- 
verized sulphate of copper, then dipping it in oil, introducing it 1 
inches into the urethra, and leaving it there for a few minutes. 
Injections are less useful in the female than in the male, from the short- 
ness of their canal, and their inability to retain the fluid. 
To quickly cure marked hyperaemias or acute or chronic urethral gon- 
orrhoeas in women, our best remedy is the solid stick or the lapis miti- 
gatus. It should correspond in size to the urethra, be rounded off in 
front, and should be drawn through the whole length of the canal two or 
three times. It is true it is very painful. In 3, 4 to 6 days the slough is 
cast off, and the process is to be repeated. Knoblauch saw a vesical 
hemorrhage follow this treatment which lasted 4 days, and was accom- 
panied by ischuria; but no one else mentions any drawback. In very 
sensitive individuals bougies of mucilage, of tragacanth or butyrum cacao, 
containing iodoform or chinoidin, with astringents such as alum, zinc, 
and sulphate of copper (1:40-20), may be used. C. A. Martin recommends 
the application of a solution of nitrate of silver in an equal amount of 
water to the urethra by means of Clerc's caustic holder. Many authors, 
as Costilhes and Cullerier, use cubebs and copaiba internally, as well as 
external remedies. Huet uses colophonium soap. Colophonium has also 
been given dissolved in boiling soda, and made with some calcined mag- 
nesia in 3 grain pills, 15 to 30 to be taken daily. But I think we can 48 
TH# FEMALE URETHRA AND BLADDER. 
usually do without any internal treatment. Besides a bland diet, tonics 
and quinine and iron for weakly individuals is all that is necessary. 
If an abscess forms in the urethral wall, it should be incised from the 
vagina as soon as fluctuation is perceptible. 
We have already mentioned inflammation of the lacunse. Pawlik's case 
(Med. Wochensch- 1883, No. 25, 26) belongs here also. CHAPTER VIII. 
THE NEW GROWTHS OF THE FEMALE URETHRA. 
rpHE urethra- of the female is much more frequently the seat of new 
growths than is that of man. Attention was early directed to them, 
Morgagni describing some in 1719. But they excited universal attention 
when Clarke, in 1814, described their symptoms and importance, and des- 
ignated them by the appropriate name of vascular tumors. It is true that 
since that time a number of growths have been included under this name; 
and though not by any means alike in structure or importance, they have 
either been called carunculae (John Hunter), or spongy excrescences, or 
fleshy or varicose growths (Schutzenberger), or cellulo-vascular tumors 
(Boivin-Duges) or fungous excrescences (Kiwisch.) They should be di- 
vided into various groups in accordance with their structure. They 
almost without exception grow from the mucous membrane of the canal; 
and hence we may distinguish them as those in which the papillary bodies 
are especially involved, without much vascular hypertrophy, or condylo- 
mata; those in which the glands are diseased or enlarged, retention cysts, 
myxadenomata, mucoid polypi; those in which the chief disease is in 
the connective tissue, fibromata, and sarcomata; those formed by affec- 
tions of the vessels, angiomata, varices, phlebectases; those in which 
papillae and vessels together are involved, fungous or vascular tumors and 
polypi; papillary and polypoid angiomata, erectile tumors; and, finally, 
tumors originating in the epithelium, epitheliomata, carcinomata. 
With the exception of sarcoma and myxadenoma, Kiwisch had already 
distinguished these various tumors from one another. We will now pro- 
ceed to a more detailed description. 
a. The condylomata have a warty surface, are reddish or bluish-red, 
pedunculated, not sensitive, do not bleed readily, and project singly or in 
numbers from the orificium urethrae. They consist of a fibrous or homo- 
geneous connective tissue, a capillary network, and a thin epithelial 
covering. 
A The retention cysts of the female urethra have lately been described 
by Englisch. They have been found in the foetus at 6 to 7 months; in 
new-born girls they are seen at the anterior, in latei- years at the posterior 
portion of the urethral canal. They do not always project above the 
surface; sometimes their orifices only can be seen as a small black point. 
They are composed of a substantia propria, the inner surface being cov- 50 
THE FEMALE URETHRA AND BLADDER. 
ered with pavement epithelium, and being papillated. If they are of large 
size, they may protrude as round tumors from the urethra, and may ac- 
quire a stalk and become polypoid. They are then usually covered with 
a normal mucous membrane. 
c. If the connective tissue is especially involved, more solid tumors or 
fibromata, are formed; they have been described by Neudorfer, Metten- 
heimer, and Hennig. Neudorfer extirpated such a growth in a syphilitic 
woman, which was the size of a pigeon's egg, and which was composed of 
connective tissue with pyramidal processes, concerning the exact nature 
of which N. does not make himself very clear. The pedicle of the tumor 
was attached to the canal, near the orificium vesicale. Mettenheimer 
found the surface of the tumor he described covered with a thick layer 
of pavement epithelium, the stroma being a fibrillated connective tissue. 
Hennig relates two cases of congenital polypoid excrescences of the female 
urethra, one of which had a pedicle 1.2 inches and the other one line in 
length. Hardened in methylated spirit they showed a fine net-work of 
connective tissue. I myself have seen an exactly similar case, No. 544, 
1876, in which in a newborn girl a cyst the size of a grain of corn hung 
from the meatus attached to a pedicle about 2 lines in length. 
C. Ruge found in a tumor the size of a hazel nut extirpated by A. 
Martin (see Stechaw) a central mass of firm, vascular connective tissue. 
From this centre there projected numerous papillae of two kinds, one 
being pointed, and the other broad and club-shaped. They were covered 
with pavement epithelium, the more superficial layers of which were 
composed of small flattened cells, while the deeper layers were composed 
of large, succulent and nucleated ones. Numerous nuclei were also 
present in the connective tissue. 
These connective-tissue tumors are the largest neoplasms which occur 
in this locality. They may attain the size of a goose's egg (Velpeau, 
Scanzoni, Simon (Rostock). They are of rare occurrence. 
d. A glandular and connective-tissue proliferation of the mucous mem- 
brane gives us the so-called myxadenoma, a case of which has been described 
and pictured by Biegel. The scarlet-colored, cherry-sized vascular tumor 
was composed of a loose-meshed myxomatous tissue which contained the 
remains of the degenerated glands. 
e. Beigel has also described and figured the single case of sarcoma 
urethrae that is recorded. The tumor (T.) was walnut-sized, composed 
of thin lobes, and was attached to the outer border of the meatus (U.). 
(See Fig. 14.) The dense portions of the tumor showed a delicate stroma, 
the meshes of which were filled with very small cells. In the peripheral 
portions of the tumor, the tissue was looser, the meshes larger, and there 
were numerous spaces of varying size, filled with a colloid fluid. It was 
extirpated; but our author does not say whether it returned. 
f. If there is much enlargement of the urethral veins, the varices may NEW GROWTHS. 
51 
drag with them a portion of the urethral mucous membrane, and form 
tumors of considerable size, as we have already in G. Simon's case of pro- 
lapsus of the urethral mucous membrane. The growths are bluish-red, 
painless, and compressible, are covered with normal mucous membrane, 
and may be situated anywhere in the urethral canal. They are in fact 
true urethral hemorrhoids. Bichet, who has lately studied urethral 
angiomata, and who claims to have seen 8 cases, lays special stress upon 
their resemblance to rectal hemorrhoids. They may, as in Simon's case, 
cause considerable hemorrhage on catheterization. If such a varix breaks 
without rupturing the mucous membrane that covers it, the blood is 
poured into the tissue of the tumor, and a haematoma polyposum urethrae 
is found. I have seen one such case, the history of which is as follows: 
An old widow, sixty years of age, who had not menstruated for several 
years, had never had urinary difficulty, had had six easy confinements, 
Fig. 14.-Sarcoma Urethra. (After Beigel.) 
her last pregnancy ending in abortion fifteen years ago, carried suspended 
to a yoke two heavy pailfuls of fluid on April 19th, 1867. While stepping 
across a narrow ditch, she suddenly felt a pain in the anterior portion of 
the vulva, followed immediately by involuntary emission of urine and 
some hemorrhage. The pain at the spot increased, and soon the patient 
noticed a tumor. On April 26th I saw her, and found the urethra di- 
lated, and a walnut-sized, dark-blue, painless tumor projecting from it. 
Its surface was apparently fenestrated, but smooth, and it was attached 
by a thick pedicle to the posterior urethral wall. Judging by palpation, 
it seemed to be mainly composed of effused blood. In several places the 
mucous membrane covering it was necrotic. On April 29th in the clinic 
I applied the ecraseur to the growth, the patient being narcotised. There 
was but little hemorrhage. A cotton plug was put into the vagina, so 
as to moderately compress the urethra. Urine was passed voluntarily, 
the patient soon recovered, and, when I saw her years later in Rostock, 
had had no recidive. Section of the tumor showed it to be composed of a 52 
THE FEMALE URETHRA AND BLADDER. 
coagalum covered with mucous membrane. The blood had hardened in 
layers, as in a placental polypus. No large vessels were to be seen. 
Undoubtedly this was a case of ruptured urethral varix, since there 
was nothing abnormal save dilatation of the urethra and relaxation of its 
mucous membrane. The rupture was caused by the extra exertion of a 
long stride while carrying a heavy load. If I should have another such 
case, I should use the Paquelin cautery or the galvano-caustic wire, as 
A. Martin did; or I should use the knife, excise the mass, and suture the 
wound. This Martin has repeatedly done successfully with larger urethral 
tumors. 
Besides these, venous angiomata and other vascular growths around 
and in the urethra have been described. Ch. Clarke, Ashburner, Rigby 
and Langier have described bulbous swellings of the urethra, some of 
which attained the size of a walnut. Pain, erectibility (Langier's case) 
and varicosity of the veins have been noticed. Virchow is of opinion 
that two conditions have here been confounded; that hemorrhoidal 
urethral tumors and congenital malformations have been classed together. 
The rudiments of the embryonal duplexity of the vagina sometimes un- 
dergo considerable development, and fall into a true telangiectatic con- 
dition. 
g. But the most important of all urethral tumors are the so-called vas- 
cular tumors or polypi, or papillary polypous angiomata. These are new 
growths that vary from a pea to a hazel nut in size, and form pale cherry 
or raspberry colored tumors at the orificium urethrae. Their surface is 
usually granular; they may be more or less pedunculated, and they bleed 
readily. G. Simon found them microscopically composed of vascular 
loops, which had proliferated among the papillae and the connective- 
tissue layers of the mucous membrane. Wedl also found enormously 
developed and tortuous vessels; he compared them to the vasa vorticosa 
of the choroidea, and designated them as dendritic papillary connective- 
tissue new growths with thin-walled vessels. " They are related to telan- 
giectases, inasmuch as a very large number of vessels enter into their com- 
position. But they differ in that the vascular wall is not thickened, and 
is not usually ectatic. The surface of the growth is covered with pavement 
epithelium; the basis is a soft mucoid or connective-tissue. Glands are 
infrequent; occasionally they are dilated or cystic, with mucoid contents. " 
(Virchow.) Not all tumors of this kind are covered with pavement 
epithelium; Verneuil found one covered by a thick layer of cylindrical 
epithelium. Medoro long ago noticed that they occasionally increased in 
size, and were to be included in the class of erectile tumors, and Scanzoni 
has observed this in one of them during menstruation. 
As a rule but one tumor is present; but 2 or 3, or even more, have been 
found. Besides this there occur, though not so frequently as West con- 
cludes, small similar excrescences in different parts of the vestibule. Simp- NEW GROWTHS. 
53 
son has given us an instructive drawing of such a case. West says that cases 
have been known in which almost the whole length of the urethra was 
the seat of these growths. These tumors being extremely sensitive, nerve- 
fibres have been sought in them; but Verneuil found none, though Dr. 
John Reid, according to Simpson, for whom he examined one, found "a 
very rich distribution of nervous filaments " in it. The most frequent 
seat of these neoplasms is near the orificium urethrae externum, on the 
posterior wall, a few lines from the entrance. 
h. Lupoid and carcinomatous neoplasms are of extremely rare occurrence 
in the female urethra, and when they do occur, they have usually spread 
from the external genitals or the vagina. Rayan says that the meatus 
urinarius may be affected by cancerous and syphilitic disease. The de- 
scriptions of urethral carcinoma in the female, which we find scattered 
in the literature1 are such as to render doubtful the correctness of the 
diagnosis. Though affection of the bladder is extremely common in car- 
cinoma uteri, Gusserow finding it 128 times in 311 cases; though fis- 
tulae are frequent, being present 56 times in the above 311 cases; it is 
very rare for any portion of the urinary apparatus save the trigonum colli 
and the posterioi' bladder wall to be involved. It is evident enough that 
death is close at hand by the time that perforation of the bladder occurs; 
and carcinoma of the external genitals is itself too rare to be frequent 
cause of the appearance of urethral cancer. Schlesinger has recently 
described a case of the latter kind, when a woman fifty-eight years old, 
who had long suffered from prolapsus uteri, had a long rounded tumor 
in the vulva 1 inch long, which extended from the root of the fraenulum 
clitoridis down to the meatus. The urethra was shorter than usual, and 
its entire posterior wall was enclosed in a chestnut-sized tumor, which 
Klob decided to be a pavement-epithelium cancroid. 
More recently 5 cases of peri-urethral carcinoma have been published; 
4 by Melchiori and 1 by Riberi in 1869. These observers found that peri- 
urethral cancer in woman appeared as nodules in the vestibule near the 
urethra, and extended thence in the cellular tissue along the urethra, 
without, however, affecting the walls or the mucous membrane of the 
canal. Secondary ulceration of the meatus from extension of the growth, 
may however occur. The nodules are at first hard, painless, and non- 
ulcerating; in fact it is only the occurrence of occasional lancinating pains 
that leads to their discovery. They are often not noticed until they have 
grown to a considerable size and have ulcerated. Finally the entire 
vestibule is occupied by the new growth. In the earlier stage the can- 
cerous nodules do not extend downwards to the depth of more than half 
the length of the urethra, about £ an inch; in the second stage they 
reach the pelvic fascia and the neck of the bladder; in the third stage they 
extend over the symphysis and the rami descendentes pubis. 
1 Brayne's case, in Busch's Geschlichtsleben, III., 26. 54 
THE FEMALE URETHRA AND BLADDER. 
In Badenheuer's case the exulcerated tumor was the size of a hazel 
nut, embraced the orificium urethrae, and extended through the urethra 
to the bladder. In 1877 Thomas removed by galvano-cautery a peduncu- 
lated carcinoma of the urethra in a patient twenty-nine years old. 
I myself chanced to see in July, 1878, in a single day, two very rare 
cases of primary urethral cancer, which I have described in my atlas. In 
the first case I extirpated the still isolated urethral tumor, and cured my 
patient. The growth removed was inches long, f of an inch thick, 
and contained in its mass the urethra with an ulcerated mucous membrane. 
In one place near the meatus, the vaginal mucous membrane showed a 
plain transition to the greyish-white, warty tumor mass. Solid plugs of 
pavement epithelium were divided from one another by bundles of mus- 
cular fibres. Towards the urethra breaking down had begun; and at the 
free surface, turned towards the lumen of the urethra, a brownish granular 
pigment lay upon the degenerated cancroidal processes. The tumor was 
separated from the vaginal epithelium by the vaginal mucosa, which was 
normal save for the existence of a large number of leucocytes. Only in 
the neighborhood of the anterior portion of the urethra could any par- 
ticipation of the vaginal epithelium in the growth be noticed. There 
its lower surface showed deep inter-papillary depressions, some forked; 
and many were only separated by a narrow strip of connective tissue from 
the neighboring cancroidal processes. The patient was fifty-eight years 
old, and had been delivered naturally eight times. 
The second case is shown in Fig. 15. In both cases a pavement epi- 
thelioma had undoubtedly started from the urethral mucosa. In the 
second patient, who had urethral and vesical calculi, and soon died of 
uremia, the pelvic connective tisssue contained no cancerous nodules; 
there was present a fistula urethro-vaginalis carcinomatosa as well as 
secondary carcinoma vesicse. 
I have seen one case of lupus perforans vulvas, in which a hole was eaten 
through the right labium minus; and another in which the disease ex- 
tended from the base of the clitoris to the urethra, whose wall was much 
swollen and was filled with nodular thickenings and condyloma-like 
growths of the mucous membrane. The latter case had obstinately with- 
stood all manner of anti syphilitic treatment for years, and the urethra 
was much dilated. 
L. Mayer has seen destruction of the urethra from elephantiasis of the 
vulva. (L. c. case 9.) 
Symptoms.-Many of the new growths that we have described may 
exist without causing a single symptom save a slight burning. This is 
apt to be the case with small condylomata, fibromata, retention cysts, 
and mucoid polypi. If they grow to any size, besides the pain caused by 
their traction, a disturbance in the excretion of urine is the first symptom 
that attracts attention. The patients feel an itching and burning in the NEW GROWTHS. 
55 
urethra, together with frequent desire to micturate, and dysuria. The 
symptoms may become very marked. Simpson tells of a woman having 
a vascular tumor of the urethra, who, when she desired to urinate, used 
to leave the house, so that she could groan and cry out undisturbed. 
He also mentions the case of a girl sixteen years old, who retained her 
urine twelve hours so as to avoid the frightful pain. As the growths 
Fig. 15.-Primary Urethral Carcinoma; Secondary Vesical Carcinoma; Urethro-Vaginal 
Fistula, a. Anterior bladder wall, b, Oriflcium urethrae. c, Fistula urethro-vaginalis. d, Vagina. 
e, Cavum uteri. 
enlarge, the urethra is dilated, and its mucosa becomes irritated, hyperse- 
mic, and catarrhally inflamed. Thereupon follow erosions, fissures, and 
sores. The pains now radiate to hips, back, and thighs, even to the feet; 
they are increased by standing, by motion, and sometimes by menstruation. 
In spite of the urethral dilatation the stream of urine is often very small, 
or it may be forked; often the urine is tinged with blood. 56 
THE FEMALE URETHRA AND BLADDER. 
If the tumors occur in little girls, the troublesome itching may drive 
them to masturbation. Reid says that varicosities of the urethra increase 
the sexual desire, though its satisfaction almost invariably causes pain. 
In fact the polypoid angiomata of the urethra usually render cohabitation 
impossible from their pain, since the slightest touch of the finger, and 
even that of the chemise, causes excessive pain, and leads to a spasmodic 
contraction of the sphincter cunei and levator ani, which renders ad- 
missio penis impossible, and produces sterility as certainly as does vagi- 
nismus. Nevertheless such tumors have been found in pregnant women. 
Later on the pains may be so great as to lead to convulsive attacks, and 
to insomnia; while the catarrh and hemorrhage have a very deleterious 
influence upon the general condition. In consequence of the retention 
of urine, inflammation of the bladder and the ureters and kidney disease 
may ensue. This, though happily rare, has happened (Medoro, Barden- 
heuer.) 
The following complications deserve mention: uterine and vaginal 
catarrh, vaginal polypi (Macdonnell), polypi of the vestibule (Simpson), 
and calculi in the bladder and the urethra. 
Besides the tendency to continuous growth, there is, especially in the 
angiomata, a great predisposition to a return. After extirpation these 
latter usually appear again in to 2 months. This has been observed 
by almost all authorities, even when the application of ferrum candens 
and energetic cauterization has followed the operation. (Kiwisch, 
Medoro.) 
One symptom of the malady which I have had an opportunity to observe 
for years at a time, and which is not mentioned by any author that I 
know of, is the hyperaesthesiae vulvas in the neighborhood of the tumor, 
which render sitting almost absolutely impossible to the patient. I had 
one case in which the tumor was repeatedly removed by me with the 
scissors, and followed by energetic cauterization with nitrate of silver. 
But the malady was occasioned by a myoma of the posterior uterine wall, 
dislocating the organ, so that it pressed upon the neck of the bladder; 
and it always grew again. This patient could not possibly sit on a chair 
in the ordinary way; she only sat upon one tuber ischii, and had been 
engaged for years in attempting to arrange a chair to fit herself. Finally 
she spent nearly the entire day either standing, or lying upon a sofa. 
She could not go into society, since she could only sit upon the edge of a 
chair for a few minutes at the most; and she always eat standing. Coitus 
was absolutely impossible; she was nearly sixty years old, and though 
married thirty years, still virgin. She could not on account of her ad- 
vanced age make up her mind to undergo an application of ferrum candens 
under narcosis; and the only relief she could obtain was always gotten by 
cauterization of the flat tumor with nitrate of silver or the lapis mitigatus. 
Diagnosis.-Ocular inspection of the meatus is never to be neglected NEW GROWTHS. 
57 
when women complain of painful micturition, of frequent desire to uri- 
nate, of pain on sitting, or of any irregularity in making water. Any 
tumors of the urethra, if present, will then be seen. Condylomata will be 
recognized by their painlessness, by their bluish-grey, cauliflower surface, 
which does not bleed when touched, etc.; and usually analogous growths 
will be found in other portions of the vestibule to confirm the diagnosis. 
Fibromata and cysts are painless, have a smooth surface, and are elastic; 
varices are bluish and compressible, and usually very sensitive. Sarcomata 
and angiomata are excessively painful, of a brilliant red color, and char- 
acteristically bleed when touched. They could only be mistaken for 
vaginismus if inspection or palpation of the parts has been imperfectly 
accomplished; for in that disease the hymen or its remains are usually so 
sensitive that the mere attempt to introduce the finger causes severe spasm, 
while with urethral angioma an examination can be quite freely made if 
only the meatus be avoided. Only in cases where these tumors lie hidden 
within the canal can a mistake be made. In sensitive patients narcosis 
is required for the recognition of grovrths in the upper part of the urethra; 
vaginal pressure will then usually cause the tumor to appear, or it may 
be dragged out with a pair of forceps. If this does not suffice to render 
the diagnosis clear, the urethra must be dilated, either with Espezel's 
instrument, shaped like an ear speculum, or with Simon's specula. There 
is some danger of confounding some of these tumors with prolapse of the 
urethral mucous membrane (see page 38); but it may be avoided by 
carefully noting the position and shape of the meatus, and by endeavor- 
ing to reposit the tumor, finding out whether it is sessile or not. Of 
course a tumor and a prolapse may coexist. 
The want of proper ocular inspection often causes non-recognition of 
the malady upon the part of the physician; other trouble, or the radiating 
pains of so many uterine affections, may be supposed to explain the symp- 
toms. A very exact examination of the affected part ought to render a 
mistake in diagnosis impossible. 
Etiology.-The neoplasmata of the urethra occur at all ages. Eng- 
lisch, Hennig, and I have found them in young children, and at birth. 
Mettenheimer has seen them in a girl 6 years old, and Denuce in 4 girls 
from 7 to 13 years. West records one case under 20, 5 between 20 and 
30, 6 between 30 and 40, 4 between 40 and 50, and 5 over 50; and I 
have had one at 60, one at 70, and one at 92 years. 
The small number of cases renders it impossible to say whether single 
or married women are more prone to them. Besides the above recorded 
cases of congenital urethral polypus, I have seen 20 cases of urethral 
neoplasm; all but one of these were in married women, and the one ex- 
ception had had a child; 5 were sterile, and 5 had been 5 times confined. 
Scanzoni remarked that, as a general thing, other affections of the genital 
apparatus were present at the same time as these tumors; he found only 58 
THE FEMALE URETHRA AND BLADDER. 
2 out of 13 cases in which this was not the fact, and I found it to be so 
in every one of mine. But Scanzoni went further. Since in almost everv 
case there was some chronic catarrh of the urethral mucous membrane, 
he claimed that this catarrh was the etiological moment of the new growths. 
My experience is opposed to this. Velpeau also thought that syphilitic- 
(more correctly gonorrhoeal) infection was their most frequent cause, and 
Schiitzenberger and Kiwisch agree with him. But Simon, Normann, 
Streubel, and I believe that as a rule (with the exception of course of the 
condylomata), the new growths are not the result of infection, and the 
mucoid flow from the urethra occurs simply in consequence of their pres- 
ence. The same holds true of masturbation; it is just as likely to be an 
effect as a cause. (Englisch, Normann, against Mettenheimer.) 
There can hardly be any doubt that catarrh of the vagina may lead to 
urethral catarrh, and may thus be the cause of certain new growths. Nor 
is it difficult to understand that cohabitation, pregnancy, childbed, and 
the puerperal state, causing frequently, as they do, urethral lesions, are 
predisposing causes of these affections. This Richet has especially em- 
phasized for venous angiomata. Both my cases of primary urethral car- 
cinoma occurred in multipart (8 and 9 pregnancies respectively) aged 
thirty-six and fifty-eight years, and without any history of heredity. 
Winiwarther did not find a single case of urethral affection among 258 
cancerous women. In rarer cases tumors of the uterus, ovaries, and other 
pelvic organs cause these neoplasms by the active and passive hyperae- 
mia they set up. Verneuil observed a case of uterine fibroid, and in the 
same category belongs the case that I have described. The patient was 
ninety-two years old, and had haematometra senilis. Old. relaxed, and 
scrofulous individuals with phlebectasies of the genitals are predisposed 
to urethral tumors. 
If gonorrhoeal affections were really the most important causes, men, 
who rarely suffer from these new growths, should have them very often. 
Virchow here cites Goulard, already mentioned by Morgagni, as his 
authority. More recently Plum found a vascular polyp in the male 
urethra.1 In A. Martin's (Stechow) second case gonorrhoea was said to 
be the cause. 
It is especially m regard to etiology that the above-mentioned case of 
Neudbrfer is of interest. There was hypertrophy of the clitoris and of 
its prepuce, and below that the five pyramidal projections from the ure- 
thra. It is possible that the latter might be due to the permanent irrita- 
tion caused by the former. 
Hutchinson's published case of a polypoid papillary angioma in a woman 
of thirty-three, who belonged to a family of bleeders, is of interest here. 
There was undoubtedly in this case a hereditary predisposition; but 
nevertheless most new growths are due to local irritation. And we are 
'Virchow-Hirsch, Bericht, f. 1870, II., 197. NEW GROWTHS. 
59 
by no means agreed as to which kind of irritation is the most frequent 
agent. The exact etiology is not very clear. Biegel claims that there are 
but few women who are not affected with one or other of the growths 
under consideration. I have not found them so frequently. Hyper- 
trophy of the lower portion of the urethra is extremely common in women; 
but true tumors are not of everyday occurrence. In 2700 puerperal 
women, whom I carefully examined myself at the time of discharge, I 
found 493 or 18 per cent, with erosions, fissures, oi' cicatrices in the im- 
mediate neighborhood of the urethra; but only 18 showed varices, pointed 
condylomata, or small polypi of the urethra. Prolapse of the urethral 
mucosa was present, however, in 10 per cent, of all cases. 
Course and Prognosis.-Most neoplasms of the female urethra, as con- 
dylomata, fibromata, mucous membrane polypi, and cysts can be easily 
and safely extirpated; they cause but little trouble, and their prognosis is 
good. Occasionally, as Spalderer has noticed, the polypi pass off spon- 
taneously with the urine, their bases having necrosed. On the other 
hand the venous and capillary angiomata not only cause numerous and 
very painful symptoms, but they also show a very great tendency to re- 
turn, and their prognosis is not nearly so good. It is true that operative 
removal is an easy affair; the hemorrhage is usually unimportant; but 
they begin to grow again in six or eight weeks, and the hemorrhage 
during and after the operations, both externally (Biegel) and into the 
bladder (Lisfranc-Forget) does impair the patient's strength. And there 
are cases in which the patient's life is imbittered and endangered by every 
new return of the malady, in spite of the most energetically radical 
treatment. Happily, these cases are the exceptional ones; and, save as 
regards the lupous, elephantiatic, and carcinomatous growths, a radical 
cure can be effected within a short time. 
Therapy.-If the urethral tumor causes no trouble, there is no reason 
to interfere with it; but if it causes uneasiness, pain, or disturbance of 
function, energetic and speedy action should be taken. The following 
methods of removal have been employed: 
1. The ligature: Guersant, Reid, Guerin. 
2. Extorsion: Streubel. 
3. Ablation with knife or scissors: Velpeau, Schiitzenberger, Espezel, 
Forget, Kiwisch, Normann, Simpson, Englisch, Reid, Macdonnell, Neu- 
dorf er, and others. 
4. Ferrum candens: Medow, Lee, Dalamin, Retzius, Simpson. 
5. Excision and energetic cauterization of the base with arg. nitrat. or 
lapis mitigatus, or acid. nitr. or ferrum candens, or the galvano-cautery: 
Velpeau, Macdonnell, Reid, Wetzer, Schuh, Thore, Berard, Simpson, 
Guerin, Veit, West, Baker-Brown, Menetrez. 
6. Severe cauterization alone, with arg. nitrat. in substance, with con- 
centrated sulphuric acid: Graem, with chromic acid: Edis. 60 
THE FEMALE URETHRA AND BLADDER. 
In the larger and more deeply situated ones the urethra has been incised 
before extirpation; Warner, Schuh, Wetzer, Macdonnell. 
According to the most recent authorities No. 5 is the best of these 
methods; No. 1 (ligature), and No. 2 (torsion), being obsolete. The 
patient is deeply narcotized and placed in the dorsal position. The as- 
sistants exposing the urethral orifice fully, the tumor is to be drawn for- 
ward with a tenaculum, and cut off at its base with knife or scissors. 
The base is then cauterized thoroughly for several seconds with ac. nitr. 
concentr., or ac. chromic, or with a small, pointed, red-hot iron. The 
bleeding is usually inconsiderable; if it is too free the repeated application 
of the ferrum candens, or the use of the liquor ferri sesquichlorati will 
stop it, or pressure may be made upon the urethra from the vagina first 
with the finger and then with tampons. If the tumor be situated high 
up in the urethra, and cannot be dragged down to the meatus, the urethra 
may be dilated; if it still cannot be drawn out, the galvanocaustic wire 
must be passed around its base. If the prominences in the urethra should 
be so flat as not to be seizable by the wire, we can dilate the urethra, 
and use Simon's spoon to curette them. 
In the retention-cysts of young children the use of bougies and catheters 
would necessarily precede excision. 
In hemorrhoidal tumors of the urethra dilatation by the dilatator urethra 
or by tampon is indicated. If this method involves too much trouble and 
pain, the tumor may be drawn down, the veins tied off, and the tumor 
excised. Finally, the actual cautery, or the gal vano-caustic wire may be 
used to remove them. Richet has cured them by the use of a dilatator, 
shaped like the Frere-Come lithotome. 
Finally, in epitheliomata of the urethra caustics are always contra- 
indicated. Bardenheur used the sharp spoon upon his patient. Excision 
is the best remedy, so long as the tumor is small and isolated. 
Melchiori has even operated in the second and third stages, to ease 
the patient's sufferings. He made a sickle-shaped cross-cut, with its 
convexity directed upwards, separated the soft parts with the exclusion of 
the urethra, and, after severing all adhesions, drew down the tumor. He 
then cut through the exposed urethra at the place fixed upon, closed 
every spurting artery by ligature or torsion, and stilled the oozing by 
means of ice-water and styptic solutions. Only when the bleeding was 
obstinate did he use catheter and tampons; and he removed them at latest 
in 24 hours. Healing took place by the contraction of the neighboring 
soft parts around the urethral stump, so that finally only traces of a ves- 
tibule were left. Incontinence is not to be feared so long as the neck of 
the bladder is not injured; and thorough cleanliness will prevent any 
difficulty with the urine. If operative treatment is no longer possible, a 
symptomatic treatment of the pain, dysuria, and foul odor, by means of 
narcotics, catheterism, and antiseptics must be carried out. In the ex- NEW GROWTHS. 
61 
tirpation of a urethral carcinoma the size of a walnut I passed a catheter 
into the bladder, and then passed three needles from the vaginal mucosa 
under the catheter, drew them together with strong thread, and dissected 
out the urethra underneath them. Five bleeding arteries Were tied with 
catgut, and then the urethral mucous membrane was united to the edge of 
the wound by means of seven deep-seated silk sutures. The catheter was 
left for several days in the bladder. Primary union took place rapidly. 
Internal remedies have never effected anything in the maladies that we 
are considering; and even the local palliative treatment, such as dilute 
hydrocyanic acid (1:4), aconite, chloroform, and morphine in salve form, 
and warm sitz-baths (Simpson), have given no relief. 
To prevent a recidive, energetic cauterizations every 3 to 4 days are to 
be recommended. We may use undiluted lig. plumbi. (West), liquor 
hydrargyri nitrici (Veit), argentum nitricum in substance, zincum muria- 
ticum (Mettenheimer); but better than any is the actual cautery. CHAPTER IX. 
NEURALGIAS OF THE FEMALE URETHRA. 
TTRETHRALGIA and spasmodic contraction of the urinary canal 
are usually only symptoms of one or other of the affections already 
described, and are especially apt to occur with displacements, hyperae- 
mias, catarrhs, ulcerations, and new growths. They were formerly con- 
sidered independent affections more frequently than is really the case, 
perhaps because the pain and spasm occasioned by catheterization was 
referred to the nerves in default of a more exact diagnosis. Ohlshausen 
believes that both Scanzoni and I confounded the angular bending of the 
urethra caused by the descent of the pregnant uterus with spasm of the 
organ. This may be the case. But it is hardly to be doubted that 
the female urethral mucous membrane does occasionally show hyper- 
sensibility without demonstrable organic disease; and also that after very 
careful introduction of the catheter, and, as Scanzoni has observed, after 
cohabitation in the newly-married, the urethra does sometimes become 
the seat of a painful spasmodic contraction. So also certain states of the 
urine may affect the urethral mucous membrane and cause spasm, exactly 
as it occasionally does in men after drinking sour wines or beers, or 
an exposure to cold. But, of course, local irritations will always remain 
the most important cause of such hyperaesthesias. A most thorough local 
examination, if necessary with dilatation and palpation and inspection of 
the urethral mucous membrane, must be undertaken. The diagnosis of a 
pure neurosis should not be lightly made. 
Neuralgia can only be diagnosticated when none of the affections which 
we have previously described as causing abnormal sensations and spas- 
modic contractions of the organ are present. Locally we can use luke- 
warm or warm sitz-baths, vaginal injections of hot water, suppositories of 
cocao butter with extr. belladonnas (gr. iv. - 3 i) or ext. hyoscyam. 
(gr. x- 3 i), or morphine, (gr. ii- 3 i). Besides this, bougies with extr. 
opii or morphine may be placed in the urethra, or rectal injections of 
linseed tea ( 3 ii with 10 to 20 drops of tra. thebaica) given to relieve the 
pain. A solution of chloral (1 to 50) has been used per rectum for the 
same purpose. 
If the urine irritates very much, mucilaginous drinks or camomile or 
orange blossom teas may be drank. It is useful also to give hourly tea- 
spoonful doses containing extr. hyoscyam gr. j. or extr. opii gr. | to | in NEURALGIAS. 
63 
emulsio amygdalina. Lupulin, with or without opium, 3 to 44 grs. taken 
several times a day, and the tincture of cannabis indica 10 to 15 drops F.S. 
are to be recommended. The new local anaesthetic cocain ought to do 
good service in these cases; it should be applied to the mucous membrane 
with a brush. CHAPTER X. 
FOREIGN BODIES IN THE FEMALE URETHRA. 
rpiIE foreign bodies found in the female urethra may, like those of the 
bladder, either originate within the body, or be introduced from 
without. To the former category belong portions of the contents of the 
intestine, gallstones, renal calculi and portions of the kidney substance, 
echinococcus cysts, vesical calculi and fragments of the wall of the blad- 
der, hair, bones, and teeth derived from the ovaries. In the latter class 
articles of various kinds have been found, as catheters, hairpins, pins, 
bits of wood, etc., etc. These become impacted in the urethra either on 
account of their size or because they have been introduced in a direc- 
tion that has caused them to penetrate the walls of the canal. If a foreign 
body coming from the bladder is too large to pass, dysuria, strangury or 
anuria soon manifest themselves. Thus in v. Faber's case 1 there was 
excessive desire to urinate, with the emission every 5 to 10 minutes of a 
few drops of clear, yellow urine; after several hours, however, about 
lbs. of urine was suddenly voided, in which was found a bunch of hair 1 
to inches long and about as thick as a stout pen-holder, which was 
twisted into a plug, and corresponded to the patient's urethra both in 
size and shape. Undoubtedly the hair had come from a dermoid cyst 
of the ovary which had penetrated the bladder. 
Scanzoni's case, to which we have before referred, shows how vesical 
calculi may become impacted in the urethra. Amand removed from the 
urethra of a puerperal woman an olive-shaped fleshy mass containing 15 
stones of various sizes. 
If the foreign body comes from without and penetrates the wall of the 
urethra, it may cause local inflammation and abscess, or it may lead to the 
formation of a calculus in the urethra itself. Of this kind is the case 
that Magario has recorded, where a woman 22 years old retained a needle 
in her urethra for a long time until it eventually penetrated into the vagina. 
Around it a concretion 3 inches long and 4 inches and 3 lines in circum- 
ference had formed, which could be felt for several lines through an 
opening in the urethro-vaginal septum. Micturition was dribbling, and 
occasioned much pain, although the urethra was greatly dilated; and co- 
habitation always hurt her. The stone was removed by vaginal incision 
1 Deutsche Klinik, 52, 1857. FOREIGN BODIES. 
65 
and the patient was cured. Portions of papillomata of the bladder-wall 
may occasionally plug the urethra, but their softness usually causes them 
to give way under the pressure of the urine. This is also the case with 
blood clots from vesical hemorrhage. 
Finally, in very rare cases a urethral foreign body may arise from the 
formation of a calculus or the growth of a neoplasm therein. This oc- 
curred in our second case of urethral carcinoma; and in a cysto- or 
urethrocele the urinary salts may be precipitated and form concrements. 
In Giraud's case it was probably the kick in the perineum which caused 
inflammation of a urethral lacuna with the subsequent formation of a 
stone. The calculi sometimes found in these lacunae cannot be considered 
extra-urethral. 
The existence of a foreign body in this situation may be ascertained by 
inspection, when it lies near the meatus urinarius, or by vaginal touch 
and the urethral sound. 
If the foreign body comes from the bladder, and is too large to pass 
out, the urethra may be dilated, and its extraction essayed with the for- 
ceps. If this does not succeed, it may be carefully pushed back into the 
bladder, crushed with the litho trite, and the fragments extracted. If 
the body cannot be dislodged, a sufficient vaginal incision is to be made 
longitudinally into the urethra, extraction .effected, and the wound im- 
mediately closed with silk or metallic sutures. It heals without difficulty. 
Foreign bodies that come from without are to be seized with the toothed 
forceps and extracted in the direction in which they entered, if necessary 
previously dilating the urethra. In most cases this latter procedure will 
be necessary to find out whether small fragments of the body have not 
reached the bladder, and if so, to immediately take them out. 
Vol. I.-5 PART II. 
DEFORMITIES AND DISEASES OF THE FEMALE 
BLADDER. 
CHAPTER XI. 
DEVELOPMENTAL DEFORMITIES OF THE BLADDER. 
A N ATOMICAL Condition.-By far the most frequent and important 
developmental deformity of the female bladder is vesical fissure, 
which depends upon a more or less extensive deficiency of the anterior 
vesical wall, and usually occurs in conjunction with abnormalities of 
neighboring organs. The navel as well as the anus is usually nearer the 
symphysis. The malformation occurs in various grades. There may 
simply be a cleft in the most dependent portion of the bladder; so that 
Desault, Paletta, Coates and Gosselin saw cases in which under the relaxed 
but not open symphysis there was a fissure f of an inch long. The cli- 
toris may be cleft: (Fissura vesicas inferior; Fig. 16.) In a more marked 
case, where the lower part of the abdominal cavity and the pelvis is nor- 
mal, and the external genitals, urethra, and the lower half of the bladder 
in their usual condition, the cleft is higher up, near the navel: (Fissura 
vesicae superior; Fig. 17.) Closely related to this latter is patency of the 
urachus: (Fistula vesico-umbilicalis.) It may be open throughout its en- 
tire length, and open externally at the navel ring. Finally, in the high- 
est grade of fissure of the bladder the entire anterior vesical wall seems 
to be absent. The lower abdominal region is usually shortened, the 
navel being approximated to the pelvis; the abdominal wall is cleft, and 
the gap is filled with a swollen red mucous membrane which is continu- 
ous with the external skin at the edge of the orifice. The mucosa of 
the bladder is wrinkled, thickened, moist, and shining; its edges may be 
dry and covered with a thick layer of epidermis. At the lower end of 
the bladder is the urethral orifice. The pubic arch is never completely 
closed; the imperfectly developed pubic bones are to 3 inches apart, 
and are only connected by a fibrous band. This diastasis of the pubis is DEVELOPMENTAL DEFORMITIES OF THE BLADDER. 
67 
found even in the new-born, as Dubois, Dupuytren, Mery, and Littre 
have shown. The urethra is usually entirely absent. The clitoris is 
bifurcated, each part being situated above the atrophied labium majus of 
that side, or it may be entirely absent. Below this is the hymen, with 
a vagina, or perhaps unperforated. The vagina may be absent, as in 
. a. 
b 
. c 
. cl 
-b 
<e 
f 
Fig. 16.- Epispadia. (After Kleinwachter). a, Vesical fissure, b, Lab. majus. c, Clitoris. 
d, Lab. minus, e. Hymen. /, Introitus vaginae. 
Herder's and Eschenbach's cases, or it may be, like the uterus, divided 
by a septum. Atresia of the vagina and imperfectly developed ovaries 
also occur with this, the most advanced form of vesical fissure. It may 
be called " eversia " or "extrophia vesicte." Occasionally the posterior 
bladder wall prolapses through the anterior opening, giving us inversio 68 
THE FEMALE URETHRA AND BLADDER. 
vesicae cum prolapsu per fissuram, which is to be distinguished from inv. 
v. c. prol. per urethram and i. v. c. p. per urachum, to be described 
later. As a rule they are much dilated, and can easily be found with the 
sound; Isenflamm found them dilated to 9| and 14 lines, Petit to 2 
inches, Flajani and Bailie to 4 inches, Desault to 3 inches, and Littre to 
2| inches with small calculi in them. Their course is usually altered, 
lying very deep in the pelvis, and then ascending to the bladder. But they 
are not always dilated. Bann in 1818 found them of normal length and 
diameter, and I have myself seen a case (l.c.) in which neither they nor 
the kidneys showed any change. 
The six cases of Roser, Gosselin, Kleinedacher, Moller, Moricke, and 
Frommel are very rare and peculiar varieties of female epispadias. The 
Fig. 17, A and B.-Epispadia. (After Frommel.) a, Clitoris, b, Labium minus, c, Labium 
majus. d, Urethra. 
external genitals, clitoris, frenum, and prepuce, were cleft, and between 
them was a deep furrow which led to an opening in the anterior vaginal 
wall behind the introitus. The urethra was absent or very defective. 
In Moller's case 1 there was an oval opening which stretched from the 
navel to the arch of the pubis, the muscular tissue, fascia transversalis, 
and peritoneum being intact; the clitoris was split, and the fissure ex- 
tended down to the anus. The pelvis was split; the urethra was short 
and wide, and opened into a very small bladder. In the case of From- 
mel's the anterior urethral wall was absent save a piece about inch long, 
and the posterior wall was occupied by a vividly red tuberculated mucous 
membrane. The pelvis was normal. 
2 Virchow's Archiv., Bd. 29, p. 205. DEVELOPMENTAL DEFORMITIES OF THE BLADDER. 
69 
Etiology.-To understand the origin of these vesical malformations we 
must glance at the manner in which the bladder itself is developed. The 
allantois, the original urinary bladder of the embryo, originating as a blind 
sac proceeding from the intestine, is derived from the intestinal layer. 
It arises in consequence of the pressure exercised by the urine excreted 
by the primitive kidneys and collected in the cloaca. In the human sub- 
ject it is only present for a short time, and is originally double. In the 
fourth week of pregnancy it has already disappeared; but it may retain 
its original double form beyond the usual time, in consequence of cer- 
tain hindrances to its fusion. Rose and Greve think the absence of the 
symphysis ossium pubis is the hindering cause. Meckel considered the 
bladder to be originally a simple plate, which only became a cavity from 
the growing together of its edges. Duncan, and later A. Bonn, and after 
them B. S. Schultze, Thiersch and others, claimed that the cleft was due to 
atresia of the urethra with dilatation of the bladder, which first parted 
the two recti muscles, then separated the cartilaginous pubis, and even- 
tually split the bladder. Klebs1 thought that there must be some more 
general cause existent, since it often occurred together with fissures and 
failures of development of other parts, such as fissura labii, anencephalus, 
spina bifida, etc. E. Rose, on the other hand, explains every case of vesical 
fissure as being due to the persistence of the urachus, which has remained 
patent in consequence of disturbances of urethral development. He calls 
attention to the fact that in fresh preparations the edges of the bladder 
are smooth, and show no traces of cicatricial tissue. He only admits 
rupture as a cause when plain traces of it are present. Mbrgelin also was 
inclined to think that overfilling of the bladder would lead rather to a 
reopening of the urachus or a rupture into the peritoneal cavity than to 
a splitting of the anterior abdominal wall. He therefore assumes that the 
allantois must rupture before the abdominal wall is closed in front. On 
the other hand we must notice that Heckei' (Klinik I. p. 122) extracted 
a foetus with atresia ani vesicalis and an enormously dilated but whole 
bladder, when there was a cicatrised rupture of the abdominal walls; this 
would doubtless have rendered possible a future rupture of that wall, 
and of the bladder. 
Rose's explanation does not account for those cases in which the um- 
bilical cord is normally constituted and no fistula of the urachus present, 
the navel ring closed, and the fissure confined to the lower portion of the 
bladder. 
Such cases have been described by Gosselin, Bertet, and others. In 
these cases stricture of the umbilical cord cannot possibly have caused 
the rupture. At all events, most recent authorities agree that it is some 
hindrance to the emission of urine, and as Rose has proven, this may 
1 Handbuch der Patholog. Anatomie, I., 688. 70 
THE FEMALE URETHRA AND BLADDER. 
either be due to atresia of the urethra, or to absence of that organ, 
formerly thought that the prolapse of large and firm organs into the true 
pelvis might hinder the development of the urethra or even compromise 
its existence. Thus E. Rose once found the right kidney in the true 
pelvis; and I demonstrated, in the case that my pupil Dr. Kruger has de- 
scribed, that the left lobe of a much enlarged liver and a whole bunch of 
small intestine filled the true pelvis, and protruded the diaphragma pelvis 
outward. Such an obstacle to micturition would of course only cause 
fissure of the bladder and not a fistula of the urachus, when it occurs 
after the complete closure of the urachus. Nevertheless, complete ever- 
Fig. 18.-BB, The two bladders. C, Membrana reuniens inferior, y, Apertura recti, u, Ureter. 
sio of this kind does occur very early, even before the two halves of the 
allantois are fused. This Friedlander, E. Rose, and I myself have ob- 
served. Between, in front of and above the double or single everted 
bladder, there were folds behind which a sound could be passed. (See 
Fig. 18.) They arise from the membrana reuniens inferior of Rathke, 
which closes the abdominal cavity before the skin and the muscle is de- 
veloped, and forms the covering of fistulae of the urachus, open bladder, 
and persistent allantoises. Where the pressure of the urine is strong, 
the bladders will touch one another, so that no solid body can exist be- 
tween them; where it is weak the abdominal walls (abdominal plates) are 
formed as usual around the open bladders, and, when there are two, be- 
tween them. From the instability of this inferior reuniting membrane DEVELOPMENTAL DEFORMITIES OF THE BLADDER. 
71 
the two bladders ultimately touch one another, and the remnants of the 
membrane form these bridge-like folds (Rose). 
In these cases the same cause as a rule that determines the patency of 
the urachus, or the vesical eversion, will cause the abdominal walls to 
remain open, the lower portion of the recti muscles to waste, and pelvic 
deformity to occur. Of course deficiency of the abdominal walls may 
occur without fissure of the bladder; the whole organ then protruding 
through the belly walls, forming ectopia vesicae, which we shall con- 
sider later. Ahlfeld's criticism of my case has, however, taught me other 
views. He objects to the assumption that an enlarged liver, a kidney 
lying in the pelvis, or a dilated stomach may cause a vesical fissure, since 
the cleft is always symmetrical and centrally located; which could not 
possibly occur with a varying cause. At the time at which the vesical 
fissure must arise, the liver is yet too small to exercise any pressure effects 
upon the abdominal viscera, and the small intestine consists of only a few 
coils; the navel ring is then the locus minoris resistentiae. We often 
find an enlarged liver lobe in cases of umbilical hernia, but no vesical 
fissure. Finally, at the time at which the vesical fissure must begin, the 
urachus, is as thick as the intestine; it would certainly crowd out the 
delicate allantoic bladder at the tail end of the embryo if subjected to 
much pressure. For Ahlfeld believes that vigorous traction upon the 
urachus, when it projects to an abnormal extent beyond the tail end, 
would crowd out the allantois in front of the rectum, and prevent the 
union of the symphysis and of the external genitals. 
As there is no excretory passage for the allantois, it will fill and burst; 
the anterior wall will atrophy, and only the posterior become covered with 
mucous membrane. The intestine will open into the posterior bladder 
wall by one or more orifices. The rectum usually opens underneath the 
posterior bladder wall. Kuge and Fleischer deny this, and look upon 
the tense cord in question as a continuation of the urachus. 
I myself believe that an early rupture of the urinary bladder occurs in 
consequence of urinary retention. To Rose's objection, that cicatrices 
are absent, I would reply that they are not present because the abdominal 
walls are not yet closed, and are thus not injured. Besides this I have 
several times seen children very shortly after birth, in whom the cord was 
quite normal, and yet a total inversion of the bladder was present. There 
seems to be no reason why rupture of the bladder from excessive disten- 
sion during very early embryonal life, should not occur, as it does in 
extra-uterine life, when there is an impassable obstacle to micturition, 
as in retroflexio uteri gravida. 
That urethral anomalies dispose to fissure of the bladder is demonstrated 
by the fact that in the male, where the urethra is much longer, and 
therefore more likely to suffer, vesical fissure is much more common than 
in the female. Thus Stadtfeldt found, among 14 cases of vesico-umbilical 72 
THE FEMALE URETHRA AND BLADDER. 
fistula, 12 in boys and only 2 in girls. It is interesting to note that Dr. 
Wunder of Altenburg, at the Zusammenkunft der osterlandischen Aerzte 
at Altenburg in 1831, presented two boys, aged respectively eight and 
eleven years, who both had inversio vesicse urinaria congenita, and whose 
mothers were sisters. (Schneider.) 
The pelvic deformities to which we have alluded, the fissure and atro- 
phy of the symphysis, the congenital luxation of both femora (as Voss has 
seen them with eversio vesicse), all occur as consequences of the same 
condition which causes the vesical fissure. The dilating bladder drives 
the horizontal rami of the pubes apart; the altered direction of the pubic 
bone and its atrophy leads to a lessening of the acetabular circumference, 
and a less perfect coaptation between it and the head of the humerus. 
(Voss.) 
Symptoms.-Vesical fissure and fistula of the urachuk are malformations 
which do indeed endanger embryonal life, but do not always lead to early 
death. Many of these children are born alive, and they may even attain 
a considerable age. Lebert, in the Salpetriere at Paris, saw this deformity 
in an old woman. The red mucous membrane is usually very sensitive to 
the touch in the newly-born; and the urine may be seen trickling from 
the mouths of the ureters in its midst. The mucosa swells out as the in- 
testines move about. If the opening is small, the mucous membrane may 
become inverted, either through the urachus, inversio vesicas per urachum, 
or through the vesical opening, i. v. per fissurum. If the orifice is very 
small, however, the trouble may subsist for years without inversion oc- 
curring, as it did in Mbrgelin's case. If we replace the prolapsed mu- 
cosa, and thus indirectly press upon the dilated ureters, the urine spurts 
out. Occasionally these persons can retain their urine to a certain extent. 
That occurs when there is umbilical hernia with the urachal fistula, and 
the posterior vesical mucous membrane is pushed by intestinal coils into 
the orifice of the fistula, and closes it for a time. Paget has described 
such a case, in which the hernial sac of the goose's egg-sized rupture was 
formed by the mucous membrane forming the posterior wall of the fistula; 
so no urine could escape when the hernia was prolapsed. If the patient 
desired to micturate, the hernial tumor receded as the first contractions 
of the bladder took place, and as it disappeared a fairly strong stream of 
urine came out of the opening. Then urine began to flow through the 
urethra, only coming through the umbilical opening again if the pressure 
was much increased. 
And even with complete eversio vesica? an occasional retainment of 
urine may be effected by the muscular tissue of the thickened bladder 
wall, it acting as a quasi sphincter. Thus Voss has recorded a case of a 
girl 20 months old whose urine did not easily flow off when lying quiet; 
her bladder wall was f of an inch thick in its middle, and the mouths 
of the ureters |th inch long. DEVELOPMENTAL DEFORMITIES OF THE BLADDER. 
73 
In more deeply situated vesical fissures the simultaneous occurrence of 
inguinal hernia, as Bertet saw, may form a kind of cover for the fissure, 
and enable the patient to retain her urine. No such case is known to 
me. 
As a rule the constant flow of urine keeps the lower margin of the fis- 
sure red, eroded, ulcerated, painful, burning, and itching, and patient 
spreads a most unpleasant smell. It is remarkable that after a short time 
the epidermis spreads from the edges of the skin into the true mucous 
membrane. Sometimes we can see by observation of the mouths of the 
ureters how completely independent of one another the two kidneys act; 
one secreting while the other is quiescent, or both acting at the same 
time. Occasionally the mucous membrane undergoes a change; fungous 
outgrowths appear, having a great tendency to bleed, and liable to be 
mistaken for malignant neoplasmata. Patients suffering from eversion 
of the bladder always have a peculiar, uncertain and unsteady gait, easily 
explained by the diastasis of the pelvic bones which accompanies it. 
Palette even noticed a marked limp. Of course the separation of the 
pubic bones alters the relations of the pelvic diameters to one another; 
the transverse will be considerably greater than the antero-posterior 
diameter; and this preponderance becomes greater as age advances, so 
that it may eventually become as 2 or 3 to 1 (Morgelin.) Females with 
vesical fissure may not only become pregnant, but may be delivered with- 
out special difficulty, as the experiences of Huxham, Olli ver, Bonnet,1 
Ayres, Litzmann, Gunzburg (2 cases) and Gusserow teach us. In Ayres's 
case, which was cured by operation, a prolapsus uteri occurred post par- 
tum. 
Diagnosis.-Long ago Tenon, Buxdorff and Castara recognized the 
tumor which they saw as the bladder; but they did not know that they 
were looking at its inner surface. Devilleneuve first had his attention 
called to it by the presence of the orifices of the ureters, and by the 
mucous membrane-like surface of the tumor. Bonn noticed that when 
he introduced his finger into the rectum, he could feel no bladder, but 
directly reached the inter-pubic space. The visible dribbling of urine from 
the surface, and the recognition of the mouths of the ureters and the 
diastasis of the pubic bones, ought to facilitate the diagnosis. Nor is the 
malady so extremely rare. In 12,689 new-born children with 27 mal- 
formations, Sickel found it twice; I had one case among the 3,500 
children that were born at the Dresden Institute from 1872-75. In 1833 
Velpeau could mention over 100 recorded cases, and Percy claimed that 
he had met with over 20 persons so affected in his practice. I have alto- 
gether seen it 5 times; 3 times in girls, 2 times in boys. Philipp has 
collected 21 cases of inversion of the bladder in girls. In Wood's 20 cases 
only 2 were in women. 
1 Philosophical Transactions, Vol. XXIII., pp. 142, 408. 74 
THE FEMALE URETHRA AND BLADDER. 
Prognosis is decidedly unfavorable. Most children thus affected 
are sickly from birth, and die early. During life they suffer much from 
ulceration; and this, with the inevitable odor, renders the life of such as 
survive but a pitiful one. In addition to this only complicated and very 
burdensome apparatuses can be used to retain the urine; and operative 
treatment is difficult, very tedious, and only partially possible. But for 
cases in which the eversion is not complete, cases of urachus fistula 
or simple fissure above or below the symphysis the prognosis is much bet- 
ter, and treatment not unfreq uently entirely successful. 
Therapy.-Stadfeldt has proved that out of 8 cases of fistula of the ura- 
chus treated by operative procedure, 7 are cured. He recommends in de- 
pressed fistulae to freshen up the edges of the mucous membrane and 
the skin, and unite them with sutures. When the edges are fungoid a 
ligature or clamp must be applied. But it seems preferable to me to 
remove the abnormal growths, and proceed at once as first recommended. 
Occasionally after renewing the margins the introduction of 1 to 3 hare- 
lip pins will cure the fistula in 2 to 4 weeks. (Paget.) M. Jacobi treated 
one case by pressure and another with the actual cautery, and was suc- 
cessful in both. 
If there is a fissura vesica? superior or inferior, we must first ascertain 
whether the tension upon the edges of the cleft will be relieved by longi- 
tudinal incisions through the skin some 1 to 2 inches distant. The edges 
may then be freshened and closed with a row of sutures. Unfortunately 
it is only in exceptional cases that we can obtain a complete cure by means 
of this operation. 
In cases of actual inversion of the bladder, an operation was formerly 
unthought of, and our efforts were restricted to the application of appa- 
rati to cover the vesical mucous membrane, and catch the urine. Such 
arrangements have been described by Fried, Stolte, Bonn, Lobstein, 
Rose, Stark, Jurin, Boyer, Breschet, Dubois, and others. A metallic 
capsule with a reservoir for urine attached to it is used, and the whole 
arrangement can only be of use when the patient is standing up. Wolfer- 
mann has constructed an apparatus after Deunne, which, when the patient 
is recumbent, exercises an antero-posterior pressure upon the bladder, 
closing the vesical fissure and dilating the bladder, and making side-pres- 
sure also upon the pubic rami, to draw them together. (See Fig 19.) 
Morgelin's cases were three boys, and the penis was used to close the vesi- 
cal fissure. Wolfermann's apparatus consists of (A) a metallic cup, pointed 
posteriorly, and fitting the perineum exactly, and reaching to just in 
front of the anus; (B) a metal plate extending from the upper edge of 
the vesical fissure down to the cup A, and united to it by a charnier, and 
like it, covered with a solution of rubber; (C) spring-band, with pad, I), 
to approximate the pubic bones; (F) a belly-band to fix B; and (E) a 
reservoir attached to A, and hanging down between the legs. This ar- DEVELOPMENTAL DEFORMITIES OF THE BLADDER. 
75 
rangement is said in three of Deunne's cases to have answered all the re- 
quirements " as well as could be expected in a palliative apparatus for 
fissure of the bladder/' In two cases the dilation of the bladder and the 
approximation of the pubes succeeded so well that there was no further 
obstacle to operative interference. Berend's apparatus is similar to this. 
Gerdy in 1844 was probably the first to rectify by operation an everted 
bladder. Since he could not replace it, he attempted by a partial excision 
of the ureters to form a sufficiently large sac posteriorly; but the patient 
succumbed to peritonitis and nephritis. The proposition of Jules Roux, 
Fig. 19. 
in 1853, to form an artificial cloaca by separating the ureters from the 
bladder, and implanting them in the rectum, was indeed once successfully 
done by J. Simon; but the patient died twelve months later of peritonitis 
and exhaustion. His attempt to close the vesical fissure by means of skin 
flaps was unsuccessful, they becoming gangrenous on the fourth day. 
Ten years later, however, the attempt was more successfully made by John 
Wood and Holmes; and their results have been already criticised by Podra- 
zki, (Vol. III. Part II. of this book). The first surgeon who claims to have 
cured a female patient by this method was Ayres of New York. He took 
a long flap from the lower median part of the abdominal walls, turned the 
epidermic surface towards the cleft, and then united it to the skin at the 76 
THE FEMALE URETHRA AND BLADDER. 
edges of the vesical fissure. After Ayres, Wood operated once upon a girl 
eighteen months old, in whom the urogenital sinus was exposed by the 
vesical fissure, so that the cervix and os uteri were always wet with urine. 
W. took a flap from the skin above and on one side, turned their epi- 
dermic surfaces to the bladder, and then covered both by a large flap from 
the other side; but the vesical mucous membrane pushed its way out 
below, bursting the delicate adhesions. 
Ashhurst's case had greater success. He took from the skin below the 
navel a flap large enough to completely cover the defect (Fig. 20, A), 
turned it down, and covered its outer surface with the two side flaps B and 
C, so that their upper borders a b and a' b' met in the median line. The 
Fig. 20. 
flaps were united by sutures, and on both sides of the upper one were 
passed soft iron wire sutures, which were then carried through the bases 
of the transplanted side flaps, and wound round small rolls of sticking 
plaster. Tension did not occur; the flaps healed by first intention; the 
last suture was removed on the eighth day, and the rest of the wound 
healed by granulation. Incontinence of urine persisted, however, in the 
upright position, so that the patient had to wear a urinal; when lying 
down, however, she could hold her water for two hours, and her general 
condition was greatly improved. 
Ashhurst reviews al] the 20 cases of eversion of the bladder that had 
been so far treated by operation, 14 of which by Ayres, Holmes, Wood, 
Maury and Barker were successful, 3 by Holmes and Wood failures, and 
3 by Richard, Pancoast and Wood with fatal terminations. In 2 of the DEVELOPMENTAL DEFORMITIES OF THE BLADDER. 
77 
last cases the fatal result is said to have been unconnected with the opera- 
tion. 
But all these operations with inverted flaps are liable to the disadvan- 
tage that the hairy growth will lead to continual deposits of salts. For 
this reason, and because injury to the peritoneum is very possible between 
the recti muscles, and the flaps when of large size readily mortify, Thiersch 
has abandoned this method. He proposed to cover the orifice with sim- 
ple side flaps. Each flap is to be large enough to cover the entire opening 
in the fresh state. The inner margin of the lower flap follows the inner 
margin of the rectus muscle closely above, and is accurately attached to the 
margin of the bladder. The outer border is parallel to it, and goes down 
to or beyond Poupart's ligament. This entire band of tissue is attached 
above and below, but is entirely free underneath. 
To secure the necessary amount of blood, the sheath of the rectus, the 
tendons of the external oblique and the fascia lata, must be denuded. 
The flaps may then be allowed to granulate in situ, or a plate of ivory 
or glass may be placed under the flaps, to keep the granulations short 
and healthy. After three weeks the upper connection of the flap is to be 
cut diagonally from below and within to above and outwards; the whole 
is then turned over the lower part of the bladder, the opposite edge of 
that organ is freshened to the symphysis, and stitched to the edge of the 
flap. The somewhat shrunken flap now covers the lower two-thirds of 
the bladder. In all his six cases Thiersch only then fixed his flaps 
over the bladder, and brought the surface of the wound into per- 
manent contact with the urine, where stationary granulation had set 
in in the flap. When the union of this lower flap is complete, he 
proceeds to close the upper part of the bladder. The second flap is 
taken from the other side, stretches from the inner incision to the 
point of origin of the lower flap; and the external incision is not carried 
so deeply as in the first case. At the same time the skin to the width of 
to 1 inch is to be carefully loosened from the recti muscles at the upper 
margin of the bladder, to get a granulating surface, which, like the granu- 
lations of the flap, must be kept from becoming exuberant. In 3 to 4 
weeks the upper end of the flap is to be divided as described, and the flap 
turned square over the bladder. Its lower margin is then in contact with 
the upper margin of the first flap; its freshened end is sewn to a freshened 
place in the skin lying opposite to it, its granulating surface covers the 
upper portion of the vesical mucous membrane, but also projects beyond it 
over the granulating surface which was formed at the upper margin of 
the bladder. Then, after freely freshening them again, the contiguous 
edges of both flaps are united by deep and superficial sutures. Hence- 
forward the urine can only flow below, and a short silver catheter should 
be introduced. 
In the male subject the plastic treatment of glans and scrotum takes twelve 78 
THE FEMALE URETHRA AND BLADDER. 
weeks more, so that Thiersch takes a whole year to completely close the 
male bladder. Then by using a compressorium to the glans the patient can 
retain urine to the amount of six ounces. Thiersch lays special stress upon 
the importance of making the flaps as long and broad as possible, since 
he found that the capacity of the bladder increased the less resistance there 
was from the anterior wall. The compressorium must therefore have a 
hollow, concave capsule attached to it, to permit the anterior bladder 
wall to dilate. 
In girls Thiersch's operation may be done more simply and in shorter 
time. Although even when the closure of the bladder is almost com- 
plete, continence cannot well be attained, since it is impossible to supply 
a sphincter, yet slight pressure with an instrument will in time cause a 
certain dilatation of the bladder under urinary pressure. That alone is 
of great benefit to the patient. She can keep herself dry, doesnot always 
smell of urine, does not get sore, does not suffer continual pain from the 
irritation of the mucous membrane-advantages which would certainly 
decide most of these patients to submit to an operation which does not in 
itself involve any danger. 
Vogt's attempt1 to construct an entire bladder of mucous membrane, 
by loosening it at its attachment to the anterior abdominal wall, uniting 
its edges, and then covering it with a flap of skin, was not successful. 
Billroth's method is simpler than that of Thiersch. He loosens two 
broad flaps, leaving them attached above and below, and in 10 to 14 days, 
when the under surface is granulating freely, unites them in the middle 
line. If the flaps are broad enough, no lateral stitches are needed; the 
side openings closing of themselves in 5 to 6 weeks. The bladder is thus 
completely covered, but a small fistula is left at the navel, through which 
the urine is passed until the urethra is completely closed below. The 
fistula then heals spontaneously, or is closed by freshening and sutures. 
In two of the rare cases of epispadia, which have been above described, 
the patients were cured by K. Schroder operatively, so that they could 
retain their urine four hours. In the case figured by Frommel, the whole 
surface freshened was of the shape of an equilateral triangle, the apex 
being at the mons veneris, and the sides running down to the lateral 
halves of the clitoris. From these latter points the line of denudation 
ran to the lateral borders of the urethral opening. The skin was dis- 
sected from the triangle; and to make a urethra a small needle was passed 
from below the urethral opening into the wound, and then carried out 
on the other side of the urethra from the freshened surface to near the 
edge of the wound. Four such stitches formed a urethra | to f inch 
long in addition to what was already there. While the sutures were being 
applied a metallic catheter lay in the urethra. Then the two sides of the 
Mittheilungen aus der Chirurgischen Klinik in Griefswald, 1884. DEVELOPMENTAL deformities of the bladder. 
79 
triangle were united by superficial and deep sutures. The wound healed 
per primam. From the beginning the patient could pass her urine spon- 
taneously; catheterism was not necessary, and she got well. 
Deficient Vesical Development, Double Bladder, Vesica Duplex, 
Partitioned Bladder, Vesica Bilocularis. 
" Cases of double bladder will become rarer as the knowledge of patho- 
logical anatomy advances," said Vidal, remarking that pathological septa 
have probably been taken for a double organ. He then mentions Molinetta, 
who in his Dissertat tones Anatomico-pathologtcce speaks of a woman with 
five bladders, five kidneys, and six ureters; and Blasius, who has de- 
scribed a case of complete division of the bladder into two halves, with a 
single urethra issuing from the joint neck, and a separate ureter for each. 
Besides this example, which Gerardus Blasius found at the autopsy of an 
adult man, double bladders have only been found in young children. 
Thus in Isaac Cattier's child, which lived to be fifteen days old, the two 
bladders were divided from one another by the rectum. Summering found 
the abnormality in the body of a child two months old; and Schatz found 
it recently in a marasmic female infant that lived twelve hours, together 
with complete division of the entire genital apparatus, and congenital 
double vesico-vaginal fistula. (See Fig. 12.) We noticed other double 
bladders when we considered vesical fissure (See Fig. 18). In these cases 
some obstacle has prevented the coalescence of the double rudiments of 
the allantois; and each portion has become a separate cavity, and has 
retained one ureter. This, of course, must occur during the first four 
weeks of embryonal existence, and Blasius's case shows that it does not 
always endanger life. The malformations which generally accompany it 
are of greater importance. It will probably never be the object of medi- 
cinal treatment. A diagnosis during life may be made by finding with 
the catheter two spaces in the bladder divided from one another, and 
feeling the partition through the abdominal walls. 
A less marked degree of defective development is that in which the 
organ is externally apparently single, or is simply furrowed, there being 
a septum inside; vesica bilocularis. Thus Karpinsky found a partition 
running from the fundus to the urethra, but incomplete below'; Ash 
demonstrated in one case the existence of a firm membranous wall, the 
opening between the two being so small that the two cavities could hardly 
be considered united; and Testa saw a complete septum. Scanzoni ac- 
cidentally found the bladder divided into parts in a woman dead of tuber- 
culosis; but he does not say whether it vras complete, or whether the ex- 
terior of the organ showed signs of division. 
In all these cases the partition was vertical. But horizontal septa have 80 
THE FEMALE URETHRA AND BLADDER. 
been found, arising from the ligature of some part of the bladder by a 
band, possibly the involuting urachus. 
The case of cyst of the urachus in the female, which Roser (Marburg) 
has recently described, belongs here. The canal was enormously dilated, 
was closed at the umbilicus, and communicated by a small opening with 
the bladder. Contractions of the latter viscus would cause urine to be 
spurted into the cyst, and so fill it, till finally the exertion of abdominal 
pressure emptied both it and the bladder per urethram. 
Of course many examples of diverticulaj of the bladder, of which we 
will speak later, have been mistaken for developmental faults. This E. 
Rose proved in the case that Tenon examined, where the bladder was 
divided by a septum perforated in its middle. A more exact examination 
showed that both great divisions consisted merely of projections of mucous 
membrane between the meshes of the muscularis. In the case of Vol- 
cherus Goiter, who described a girl with two bladders, there was really 
only one bladder and a cyst, and Rose believes that in Moliyetta's case 
with 5 kidneys, 6 ureters, and 5 bladders, there were possibly only multi- 
ple sacculated dilatations of the urethra. 
From all this it is plain that even upon the post-mortem table it is easy 
to be mistaken in the diagnosis of defective vesical development, and we 
must carefully examine the shape of the organ, look for external con- 
strictions and internal septa, and scrutinize the substance of the lateral 
walls of the bladder. The very slightest degree of the malformation is 
that described by Chonsky, in which there was a simple marked longitu- 
dinal constriction of the organ. 
Diagnosis.-A vertical septum of the bladder may be diagnosed by the 
catheter, and by the finger after urethral dilatation. A horizontal sep- 
tum can only be found after enlarging the canal of entrance. If there 
be a tumor above the empty bladder, concerning the nature of which we 
cannot make ourselves certain by external examination, again the urethra 
must be dilated,, and the point of communication examined with the fin- 
ger, and finally a long elastic catheter passed into the upper tumor. 
Treatment.-The removal of vesical septa is of course not to be thought 
of; if the bladder became diseased, it might be necessary to determine 
whether one or both halves were affected. This is to be done with the 
catheter and the specula, and finally with Rutenberg's illuminating ap- 
paratus, and a suitable treatment begun. If there is, as in Roser's case, 
a urachus cyst above the bladder, and if its constant dilatation by the con- 
tractions of the bladder give rise to trouble, the extirpation of the cyst 
from the external abdominal walls, with freshening and suture of the walls 
of the orifice communicating with the bladder, would be the only meas- 
ure that would radically cure the patient. CHAPTER XII. 
MALPOSITIONS AND MALFORMATIONS OF THE FEMALE 
BLADDER. 
I. Displacement of the Bladder, especially with Vesico-vaginal Fistula; 
Cystocele Vaginalis. 
rpiIE uninjured bladder may be displaced as a whole in any direction, 
upwards, downwards, anteriorly, posteriorly, or laterally; and finally 
it may be sub-involuted. 
Displacement upwards only occurs as a rule from traction from above, 
or pressure from below. Traction may be applied to the vesical wall 
through its peritoneal covering, which exerts a certain tension when the 
internal genitals are displaced upwards, or when there is adhesion of the 
vesical surface to the ovary, the uterus, or the intestine (page 26). Thus 
again, the pregnant uterus as it enlarges, a growing ovarian tumor, or a 
coil of intestine, may exert traction. But even without the pelvic organs 
rising out of the true pelvis they may influence the shape and position 
of the bladder; thus retro-flexion of the uterus may cause a dragging of 
the lower bladder wall backwards or upwards (see Fig. 25). Tumors 
located below the vesical neck, as small ovarian cysts, rectal tumors, and 
those growing from the pelvic walls, and others, may elevate the blad- 
der. The bladder has been found in large herniae, and even partly in the 
foramen ovale. 
All these changes of position are only of importance inasmuch as they 
dislocate the urethra, compromise its lumen, and cause dysuria and ischu- 
ria, and render the introduction of the catheter more difficult than usual. 
Remove the cause, and the vesical dislocation usually easily and quickly 
disappears. If the bladdei- is attached by adhesions to surrounding 
parts, careless catheterization, too rapid emptying of the organ, a too flat 
position on the part of the patient, and a failure to close the catheter at 
the proper time, may cause air to enter the bladder through the instru- 
ment, as we have already noticed in page 22, when discussing the different 
methods of examining the organ. Air, however, is not so hurtful as was 
formerly supposed, since repeated examinations by Rutenberg's method 
have been made without evil result. And in most cases it is undoubtedly 
1 S. Forster: Handbuch d. Pathol. Anat. II. 534. 82 
THE FEMALE URETHRA AND BLADDER. 
not the air, but the use of unclean instruments, that causes the malady 
of the mucous membrane. 
Fig. 21. - Prolapse of the Vagina. Cystocele with Retroversio Uteri, a, b, c, Bladder. 
(After B. S. Schultze.} 
The longer adhesions between the bladder and surrounding parts exist, 
the less harm do they do, since the continual traction caused by the alter- 
Fig. 22.-Incomplete Prolapsus Uteri, with Cystocle Vaginalis, a, Oriflcium urethrae, b. 
Lower border of cystocele, c, Oriflcium uteri externum. 
nate filling and emptying of the viscus continually tends to make them 
less resistent, longer, more extensile, and less hindersome. MALFORMATIONS OF THE FEMALE BLADDER. 
83 
By far the most important anomalies of position is that which is known 
as vesico-vaginal-prolapse, cystocele vaginalis. 
The"causes as a rule are to be found in an antecedent pregnancy and 
child-birth. In this condition the vesico-vaginal septum becomes hy- 
peraemic, loosened, lengthened, and is exposed to pressure from above, 
which pushes down the bladder wall and the tuberculam vaginae, espec- 
ially at the time of delivery. Thus the upper part of the urethra is car- 
ried downwards (Fig. 23); all the structures of the pelvic floor are so 
stretched, and the introitus vaginae so dilated, that the other organs de- 
scend for want of an efficient support. This of course occurs to its great- 
Tig*. 23. 
Fig. 23.-Prolapsus Uteri Incompletus. Inversio par vaginae anteriosis. Cystocele: a and b, 
Parts of the bladder, c, Urethra, d, Uterus. (After B. S. Schultze.) 
est extent when the rima vulvis is enlarged by a rupture. Given such 
predisposing conditions, the direct causes of vesico-vaginal hernia are 
usually increased abdominal pressure during the lifting and carrying of 
heavy objects or by efforts at defecation, which latter are especially prone 
to do damage when the bladder is partly or entirely full. It is easy to 
convince oneself, by requesting the patient to press down, that when the 
tuberculam vaginae descends, the genital orifice begins to gape, and the 
tumor that dilates it grows rapidly. As a rule the primary displacement 
is that of the vesico-vaginal wall, followed by descensus and prolapsus 
uteri incompletus. But in many cases the reverse occurs. Hypertrophy 
of the neck of the uterus, or tumors situated upon it or in its walls, drag 84 
THE FEMALE URETHRA AND BLADDER. 
or press the uterus downwards, and the bladder follows after. Age is 
especially predisposing; cystocele is most common in the years from thirty 
to forty. Occupations which involve much standing, lifting, or currying 
heavy weights will render even nulliparous women liable to it. 
In comparison with those just mentioned, the other causes of vaginal 
cystocele occur but very rarely. It may happen with prolapsus uteri in 
women who have never borne children, in consequence of a fall, or of ex- 
cessive exertion, as Malgaigne has observed; or tumors of the vesico- 
vaginal septum itself may drag it down. It may occur as a vesical diver- 
ticulum, where the corresponding portion of the viscus is weighted with 
a. large calculus, which Ruysch has noticed.1 But in most such cases the 
process is reversed; there is first the cystocele, and only later the forma- 
tion of a calculus. This was so in Gendrow's case, where a woman sixty- 
five years old, and who had had seven children, had a cystocele out of 
which two stones were spontaneously evacuated. In this category belong 
also the cases of Eyster and Galabin. 
Anatomical Relations.-In slight degrees of this affection the lower 
part of the bladder is somewhat sunken; in more marked cases the viscus 
is hourglass-shaped (Figs. 21 and 23), being divided into an upper and a 
lower part by the horizontally placed urethra, in which we often find 
small hypertrophies of the mucous membrane. In the highest grades 
(comp. Fig. 24, after Schroder), where there is also complete uterine 
prolapse, the bladder may be so twisted that the orifice of the urethra will 
be above, and the canal itself extend downwards to the bladder, which is 
upside down. 
When the malady has existed for a long time we find also changes in 
the bladder walls; they become thicker and more succulent, not from 
stasis and oedema, but from hypertrophy. (Comp. Fig. 24.) The mucous 
membrane is sometimes in a condition of chronic hyperaemia and catarrh. 
The dragging upon the fundus vesicae may further cause dilatation of the 
ureters and hydronephrosis; Philips, Froriep, Virchow, Braun, etc., have 
seen this happen. It is of importance to note that the malposition causes 
the excavatio vesico-uterina to become deeper, and the peritoneum to 
descend to the vagina. If the prolapse is considerable, coils of the small 
intestine may descend into it. However, the vesico-uterine excavation is 
usually closed, and is found as a third cavity when cut into. (See v. 
Franque.) 
The symptoms of cystocele vaginalis are partly those of prolapse of 
vagina and uterus; we will naturally confine ourselves to those caused by 
the bladder and seen in that organ itself. Not infrequently there is at 
first only drawing sensations in the navel region, probable from tension of 
the superior vesical ligament; and also anomalies in the urinary secretion, 
' Compare Chap. VI.: Vesical Calculi. MALFORMATIONS OF THE FEMALE BLADDER 
85 
such as dysuria, frequent desire to micturate; they may even be unable 
to empty the bladder unless they replace the tumor beforehand. I have 
found, however, that these difficulties do not occur nearly so often as 
might be expected; that many women with considerable vesical dilata- 
tion do not have the least trouble with their urine. And I must confess 
that in G8 cases of cystocele I have never seen vesical catarrh, which Gold- 
ing Bird says is specially liable to occur in women who are in the climac- 
teric years. I admit that it will occur the more easily the greater the 
portion of the bladder is which protrudes from the vulva, the longer re- 
tention remains, and the more frequently the catheter is used. 
Fig. 24. - Complete Prolapse of the Antiflexed Uterus, with a Myoma in its Angle (6) 
The apex of the bladder is displaced down to a. The urethra is up at c. The intestine has descend- 
ed. (After K. Schroder.) 
Ramsbotham found that cystocele might be an obstacle to delivery, es- 
pecially when there is slight contraction of the pelvic outlet. McKee was 
once called to such a case, in which he could not succeed in catheterizing 
the prolapsed and over-distended bladder. He therefore punctured it 
with a lancet; delivery was rapid, and the woman got well. Ramsbotham 
says that Merriman tells of a case in which a physician mistook the pro- 
lapsed bladder in partu for a hydrocephalus, and punctured it. More 
recently Brennecke, Dick, More, and Spencer have published accounts of 
cases of this class. Brennecke believed that the occipito-anterior position 
of his case was caused by the cystocele, and found that after emptying 
the bladder with the catheter the violent pains ceased. The furious bear- 86 
THE FEMALE URETHRA AND BLADDER. 
ing-down pains, not coincident with actual delivery, and disappearing 
after the bladder was evacuated, were characteristic. 
But even granted that most vaginal cystoceles do not cause nearly all 
the symptoms that are generally ascribed to them, it must be admitted 
that so soon as a catarrhal condition of its inner surface and ammoniacal 
decomposition of the urine occurs, their results may be much more un- 
pleasant than when they do not occur in a prolapsed bladder; for the in- 
flamed bladder is subjected to abnormal pressure and tension, and its 
evacuation cannot be so perfect as when in the normal condition. If 
there occur stasis of urine, dilatation of the ureters, and hydronephrosis, 
uraemic symptoms will not be long wanting. From the tension upon the 
peritoneum there will occasionally occur subacute inflammatory processes 
in the neighborhood of the bladder; pericystitis, and long-standing pro- 
lapsus when neglected may eventually cause so many adhesions to neigh- 
boring organs that reposition may tinally become impossible. 
Diagnosis.-Most patients when they notice a tumor appear at their 
external genitals soon consult a physician for the greatly feared " falling 
of the womb." Recognition of their trouble is usually easy. In 74 cases 
of prolapsus vaginae Malgaigne found cystocele vaginalis 39 times. The 
patient is placed in the lithotomy position, is told to press down, and 
when the tumor attains its greatest size it is to be grasped with the left 
hand, and fluctuation will be detected. Then a vaginal examination is 
made to find how far the cervix has fallen. A metallic male catheter is 
now introduced into the tumor, with its concavity directed downwards; 
if you succeed, the instrument can easily be felt in the tumor, and the 
diagnosis is certain. Finally the urine drawn off must be examined for 
pus, albumen, and casts. After drawing the Urine the tumor seems 
smaller and its vaginal walls are wrinkled. After carefully considering 
the causes of the malposition, an attempt at replacement is to be made, to 
ascertain the mobility of the organ. 
If, with Jobert, we very carefully diagnosticate cystocele during life, 
and fail to find it post mortem, it does not prove that our diagnosis was at 
fault. Prolonged rest in the horizontal position tends to cause the tumor 
to disappear, and if it has not been of long standing there may be no 
demonstrable anatomical changes after death. 
The prognosis is in most cases good, since the malady causes but little 
trouble, and may be held in check by palliative measures. If neglected 
it tends continuously to increase and become more and more annoying. 
In old individuals especially, from the relaxation and thinness of their 
organs, it is difficult to devise suitable methods of retention. A radical 
cure of cystocele can, however, only be obtained in most cases by opera- 
tion. Though Scanzoni, in 1859, declared that he had never seen a per- 
manent result from the operative treatment of cystocele vaginalis, nowa- MALFORMATIONS OF THE FEMALE BLADDER. 
87 
days the reverse may be maintained, and unsuccessful operations are 
among the rare exceptions. 
Therapy.-Reposition and retention are the only indications for treat- 
ment. The first one is usually simple to fulfill; but the second often ex- 
ceedingly difficult. Reposition may be effected with the hand when the 
patient is in the dorsal position; it is hardly ever necessary to use the 
catheter for anything else than to completely empty the viscus. That 
accomplished, retention may be effected palliatively by pessaries and 
tampons, or radically by means of various operations. In the beginning 
and with the slighter grades of the affection, tampons with astringent 
salves may do good. 
But in later stages this mode of treatment will not accomplish much, 
though when a patient will not consent to an operation, and has acquired 
catarrh from a pessary, we may be compelled to have recourse to it. 
Since most patients will not submit at once to a bloody operation, we 
must as a general thing use at first at least the mechanical means of re- 
tention. Of the long list of these apparatuses we will mention those only 
that are especially applicable to cystocele. Among these we reckon stem, 
external, simple and winged pessaries. C. Mayer's simple round rings of 
rubber do good service in the slighter cases. But they are too yielding, 
and are at once squeezed out in more pronounced cases, and we may then 
use hard rings of round rubber well shellaced. These round pessaries 
are pushed over the levator ani and pelvic fascia, and by dilating the 
vaginal vault tend to keep the prolapsed vaginal wall in place. But 
even the largest of them will be expressed when the vulva is dilated and 
the pressure considerable, and then the Martin stem-pessary may be used. 
Besides these a few cases may require the Zwanck-Schilling hystero- 
phore. For I have found cases in which all other instruments could not 
be retained, but this one could. Its thin edges, however, may do harm 
by pressure, and may cause a vesico-vaginal fistula. 
Some patients may be improved by the use of stem pessaries fastened 
to an external belly-band, such as those of Roser and Scanzoni. I for- 
merly permitted patients to carry these for long periods of time, but do 
so no longer. Poor patients cannot well afford to get them, and all soon 
begin to complain of pain and burning, since the arm may easily cause 
ulceration in the urethral region. And if the pressure is great, the knob 
at once glides out, the arm falls, or the vaginal wall slides down beside or 
behind it. 
The Scotch hysterophores which Breslau 1 has especially recommended 
are better, but can only be used for the less severe cases. They dilate 
the vagina both antero-posteriorly and transversely; but they often cause 
irritation and may readily set up catarrhal trouble in unclean individuals. 
1 Scanzoni, Beitrage, IV., 275. 88 
THE FEMALE URETHRA AND BLADDER. 
For some patients a lightly-applied T-bandage is sufficient, and this, 
with the tamponade should at all events be tried in the less severe cases. 
For a radical cure of inversion and cystocele an operation is needed; 
an operation so simple and effective that, if the measures already described 
do not quickly succeed, it should be proposed-to the patient. 
The operation consists of the excision of an oval piece of the anterior 
vaginal wall, and is known as colporrhaphia anterior. The origin of the 
operation and its slow perfecting may be read in Marion Sims's clinic, p. 
228. Sims claims that until his time nothing had been done in an opera- 
tive way for cystocele, and that its success is due to the use of the silver 
suture; a view which is not correct. The length and breadth of the ex- 
cised piece depends upon the grade of the inversion and the cystocele. 
The more extensive this is, the longer and broader must the piece be, ex- 
tending in the worst cases from the tuberculam vaginae to the anterior lip 
of the uterus, and measuring 2| to 3 inches across. 
The woman is prepared by injections and by emptying the bladder, is 
placed in the dorsal position, and is anaesthetised. The anterior lip of 
the uterus is then strongly drawn downwards with a hook or a thread, so 
that it approaches the posterior commissure. The assistants hold the 
legs, draw the nymphae apart with sharp hooks, so as to expose the entire 
field of operation. The anterior vaginal wall is then thoroughly washed 
with a 3 to 5 per cent, carbolic acid solution, and an irrigator trickles 
some of the same fluid over the wound during the entire operation. 
The incision is begun below. The outlines of the piece to be excised, 
are lightly marked with the scalpel, then the deep incision is made, be- 
ginning at the left and going through the entire thickness of the vaginal 
wall. As soon as the loose connective tissue between vagina and bladder 
is reached, the handle of the scalpel only must be used to separate them. 
In the middle of the piece to be excised, are one or two larger vaginal 
arteries, arising from the uterine, as well as some veins. The arteries must 
be seized with the catch-forceps. The excision of the entire oval piece 
takes 5 to 6 minutes. The surface of the wound is then smooth; any 
islets of vaginal tissue that have been left are removed, the surface then 
freely washed again with the carbolic solution, and then the stitches ap- 
plied. The points of entrance and exit should be f inch from the edges 
of the wound. If the surface freshened is very large, the sutures, if 
passed behind the entire surface, would cause it to lay in folds; they 
should therefore be brought out at the middle of the wound, and the 
needle reintroduced half an inch further on and brought out at the op- 
posite side. In smaller excisions all the threads may go behind the entire 
denuded surface. 
Ligature of the divided arteries is unnecessary. The sutures pass be- 
hind them, and they are enclosed in the threads when they are tied. To 
overcome the greatest tension gradually, the sutures must be tied alter- MALFORMATIONS OF THE FEMALE BLADDER. 
89 
nately above and below towards the middle. I hardly ever apply super- 
ficial sutures, while K. Schroder, on the contrary, uses a few deep sutures 
and many superficial ones; a procedure which Werth has rightfully char- 
acterized as improper. As soon as all the sutures are closed, the neigh- 
borhood of the wound is carefully washed, and the whole wiped dry. When 
not a drop of blood longer exudes, the vagina can be replaced. It is not 
necessary to use protective or a cotton tampon. 
As a rule it is unnecessary to use the so-called sunken sutures which 
Dr. Werth (Kiel),1 has proposed; and they may hinder union. I prefer 
fil de Florence for the sutures. The whole time of operation is 20 to 25 
minutes. 
If the patient after the operation can pass her water voluntarily, as is 
most commonly the case, there is no need of catheterization. Ischuria, 
however, does occur, since the stitches are carried through the bladder 
wall. If vesical pain or catarrh follows the use of the catheter, the blad- 
der must be washed out with a 1 to 1000 solution of salycilic acid, or a 3 
per cent, solution of boracic acid. 
The stitches must remain in at least eight days; iffil de Florence is used 
they may remain in for weeks. Silk sutures must be removed in six to 
seven days. 
Defecation must be seen to after the fourth day, and on the twelfth to 
fourteenth the patient can get up. By this time the cicatrix is stout 
enough to withstand considerable pressure. If the patient belongs to the 
poorer classes she must for a time avoid heavy work. 
In very marked cases of inversion with cystocele, which usually occur 
in combination with descensus and prolapsus uteri, colporrhaphia anterior 
alone is insufficient, and must be combined with the similar posterior 
operation. 
It maybe necessary to remark that on account of their uncertainty and 
the liability to cause trouble in neighboring organs, we have entirely 
abandoned the use of strong caustics, as fuming sulphuric acid, chloride 
of zinc, or the actual cautery, for the purpose of diminishing the amount 
of tissue present. 
Supplement.-In Fig. 25 I have reproduced a drawing from Schatz, 
which may be described as showing retrofiexio vesicce urinaria. The pos- 
terior vesical displacement is caused by the fall of the womb. I have 
lately seen the same thing at the post-mortem examination of a non-preg- 
nant woman. The uterus lay horizontally in the true pelvis, and its 
fundus was adherent to the rectum. The portion of the bladder that 
was drawn backwards formed a diverticulum which contained a calculus, 
and the vesical neck was securely fastened to the rectum by adhesions 
which ran over the uterus. 
1 Centralblott f. Gynacol. 1879, No. 23, p. 561. 90 
THE FEMALE URETHRA AND BLADDER. 
II. Ectopia of the Unfissured Bladder, and Prolapse of the Bladder 
through the Urethra. 
Ectopia of the undivided bladder is the rarest malposition of the blad- 
der. and the only one in which the shape of the organ is not changed. 
So far as I know only three cases have been recorded; one by G. Vrolik, 
one by Stoll, and a third by Lichtenheim. In all three there was a vivid 
red, round tumor in front of the lower part of the abdominal walls, which 
in Lichtenheim's case could be replaced. After reposition there was ap- 
parent a sharp-edged aperture in the abdominal walls, of somewhat smaller 
dimensions than the tumor itself. The pubic bones were separated to 
the extent of two inches. With the finger in the rectum, the posterior 
bladder wall could be inverted into the tumor, and with the other hand 
Fig. 25.- Shape and Position of the Bladder in Retrofectio Uteri Puerperalis. (After 
Schatz.) 
the intruding finger could be recognized in the midst of the mass. Urine 
could be fully retained and was evacuated in a full stream. It was re- 
markable that the external surface of the bladder was apparently covered 
by a mucous membrane exactly similar to that clothing its internal sur- 
face. Microscopic examination demonstrated in this external mucous 
membrane the existence of convoluted glands lined with cylindrical epi- 
thelium. In G. Vrolik's case I am of opinion that there was no ectopia 
of the bladder at all, but rather a fissure of the abdominal walls, into 
which opened the dilated urachus. 
Fissure "of the bladder is wrongly called ectopia by many authors. The 
dislocation is merely secondary. The malposition we are considering is to 
be exactly designated as prolapsus resicce completus per fissuram tegumen- 
torum abdominus s. ectopia vesicoe totalis. 
Lichtenheim's patient suffered no inconvenience save from the scanty 
secretion from the surface of the tumor, and no operation was under- 
taken. MALFORMATIONS OF THE FEMALE BLADDER. 
91 
If the vesical displacement cause pain and disturbance in the urinary 
function, it may be necessary to take measures to close the defect in the 
abdominal walls. The simplest plan is probably to follow Billroth's pro- 
cedure for cases of eversio vesicre. One flap, or if the defect be large, one 
from each side, is to be loosened (page 74), then slid over the bladder, and 
sutured there. The resulting covering is thin but tough, and it may be 
supported by a padded bandage. 
Should the patient not decide to have an operation done, a suitable 
bandage may be employed to protect the bladder from excessive pressure. 
The bladder should be replaced, and the cavity filled with salycilated cot- 
ton, and the pad of a well-cushioned truss applied ovei' it, the spring of 
which encircles the pelvis. 
Another rare malposition, which at the same time changes the shape 
of the organ, is the prolapse of the bladder through the urethra; inversio 
vesica urinaria cum prolapsu, exocystis, cystoptosis. Leveille holds that 
not the entire thickness of the bladder-wall, but only its loosened mucous 
membrane appears in the urethra. But there has been found post-mortem 
in dilated bladders which were paralysed during life projections of the 
entire vesical wall into the lumen of the canal (Joubert, Rutty, Levret); 
and Meckel describes the appearance below the nymphae of a triangular 
body, which examination showed to consist of all the coats of a prolapsed 
bladder. Burns also has proven that in these cases the entire bladder 
thickness is present, and thinks that the whole bladder can be everted 
before the mucous membrane could be loosened and prolapse. Streubel 
collected a series of recorded cases in which the entire bladder wall pro- 
lapsed, but only one in which the mucous membrane alone protruded. 
The tumor is in the urethra and may project out of it. It is pigeon- 
to hen's-egg in size (Noel), rounded, of a reddish flesh color, and occasion- 
ally granular. Sometimes we notice at the posterior portion of the tumor 
two orifices into which the sound can be passed, and from which the urine 
trickles (Crosse). It can, as a rule, be replaced without particular trouble. 
The urethra is naturally more or less dilated in all these cases, so that 
the finger can be passed directly into the bladder. 
If we consider the normal figure of the empty bladder and its relations 
to the uterus (see Figs. 1 and 2), it is easily seen that the posterior vesi- 
cal wall, which lies above the orificium vesicale, may be forced into the 
urethra by a certain amount of pressure coming from above where there is 
some relaxation of the walls of the organ and some dilatation of the 
calibre of the urethra. These three conditions are as necessary for inver- 
sion of'the bladder per urethram, as they are for inversion of the uterus. 
The pressure from above may consist of an abnormal use of the abdomi- 
nal muscles, of an over-filled and sunken caecum, or of the uterus. In 
most cases the trouble begins gradually. It can only occur suddenly 
when for instance a pedunculated new growth suddenly prolapses through 92 
THE FEMALE URETHRA AND BLADDER. 
the urethra, dragging the bladder with it; or when, as in de Haen's case (see 
Streubel) the inverted bladder together with vagina and rectum prolapse 
in consequence of a sudden fall. It may occur at any time of life. 
Weinlechner saw it at 9 months, Oliver at 16 months, Crosse at 3 years. 
Streubel at 14 years, Thomson at 40 years, and Percy at 52 years. 
The first symptoms, which in isolated cases may be present months and 
years before any others, are frequent desire to urinate, sometimes reten- 
tion, and especially a sudden interruption in the stream. Then the 
patients notice, generally after an unusually persistent attempt to urinate, 
the appearance of a tumor. This tumor disappears at times, and then 
returns; and its return is accompanied with dragging pains in the hip and 
the back, and with fever. If the urine now collects in the bladder, and 
if the patient can withstand the tenesmus, as Percy saw, the tumor may 
gradually disappear, and the flow of urine begin. Sometimes, when the 
mucous membrane has become eroded, a few drops of blood may appear 
with the urine. As the tumor grows the troubles it causes increase, 
pain becomes severer, the appetite less, the kidneys irritable from the 
dragging upon and dilatation of the ureters. The patient becomes more 
and more emaciated, and dies of uraemia if her trouble is not relieved. It 
makes no difference in the symptoms whether the entire vesical wall, or 
only the mucous membrane, is prolapsed. 
The recognition of inversion of the bladder through the urethra is not 
always easy. We must take into consideration the surface of the tumors 
(also its microscopic characters), their consistency, pedicles, ease of reduc- 
tion, and finally the presence of the urethral openings. The finding 
of the latter of course render the diagnosis easy. If they cannot be found, 
the attempt should be made to replace the tumor with a catheter; and 
then from the vagina, or in young girls from the rectum, we can feel 
whether the vesical wall is thickened or not. If the vagina is large, and 
the inversion is chronic, we might attempt to replace the bladder from the 
vaginal vault, or to feel the depression. If we do not discover the nature 
of the tumor by these methods, we must endeavor to pass a finger into the 
bladder alongside the tumor, and try to find out whether we are dealing 
with a tumor springing from the inner surface of the bladder, or whether 
after reposition the prominence has disappeared. An overgrowth of the 
vesical mucous membrane, as Baillie has several times seen it, and consist- 
ing of mucosa, submucosa, and abundant fat has been observed by Patron 
in one case prolapsed through the urethra. Patron tied it successfully. 
Inversio vesicse per urethram differs from prolapse of the urethral mucous 
membrane, in that the position of the lumen of the urethra, which in 
the latter cases is either central or in the upper part of the tumor, in the 
former may be shown by the catheter to encircle it. Besides this, the 
prolapsed bladder wall has a thick pedicle, whereas with prolapse of the 
urethral mucous membrane one is hardly demonstrable. MALFORMATIONS OF THE FEMALE BLADDER. 
93 
Therapy.-To prevent vesical prolapse we can treat the symptoms of 
dysuria and tenesmus vesicae which usually precede it with warm baths, 
warm fomentations, inunctions with narcotic salves, (extr. opii gr. xxv.; 
vaseline 3 i.), liniments (ol. hyoscyam 3i., chloroform gtt. xv.); and in- 
ternally with almond milk, emulsions with exir. hyoscyami (gr. xxv. 
3 vi.), or with tra. thebaica. Or we may use per rectal injection 5, 10 to 
20 drops of laudanum, and suppositories containing extract belladonna 
gr. iii and ol. theobrom. 30 grs. once or twice a day. These measures 
are usually sufficient so long as the urine is clear and the vesical mucous 
membrane not notably affected. If this lattei' does occur, we must use 
weak solutions of nitrate of silver (1-2-5:500) as injection, or salycilic acid 
(1-1000), or mucilaginous drinks, linseed tea, etc. 
When vesical dislocation has occurred reposition must first be attempted. 
If the tumor be large, this may be attempted with the little or index fin- 
ger, since the urethra will be so dilated as to admit them. If it be smaller, 
we must use a moderately thick and well-oiled catheter, and first com- 
pressing and replacing as much as possible with the fingers, shove back 
tin; rest of the tumor with the catheter into the bladder. If the patient 
presses down on account of the pain you cause, and renders the opera- 
tion difficult, she should be anaesthetised. Any position will do; but one 
which renders the intra-abdominal pressure as small as possible is prefer- 
able. Hence the lithotomy position, or the knee-elbow position when no 
anaesthetic has been used, is the best. 
To prevent a return of the prolapse the catheter might be left in place 
for a time; but it causes a good deal of trouble to many patients. It has 
therefore been advised to cauterize the neck of the bladder and the orifi- 
cium vesicale urethrae, so as to cause increased contraction and vigorous 
resistance to further prolapse. But this is more uncertain and less pleas- 
ant than to effect contraction of the neck of the bladder, by the use of the 
colpeurynter, or cotton tampons, or Schatz's pessaries for incontinence 
of urine. If frequent relapses occur, astringent vesical injections should 
be used to overcome its relaxed condition. 
Weinlechner claims to have prevented the return of the prolapse by 
means of sticking plaster; his patient was nine months old. 
An operation is only to be thought of when the tumor is recognized as 
a polypus of the hypertrophied vesical mucous membrane. The method 
of extirpation will be described in Chapter IV. CHAPTER XIII. 
INJURIES TO THE FEMALE BLADDER. 
Urinary Fistula in the Female. 
~VT'rE owe a history of urinary fistula in the female to the critical indus- 
' ' try of AV. A. Freund; and we have one which is rare in medical 
history for its completeness. We have drawn largely upon his works. 
In the oldest medical writings we find no indications to show us that the 
physicians knew anything of urinary fistula. Impartial judges cannot 
admit the forced interpretation that would impute a reference to this 
malady to certain passages of Hippocrates. The Arabs wrote much upon 
incontinentia urime, but nothing in reference to fistula. Perhaps these 
lesions were rarer in ancient times, or went unrecognized, partly because 
delivery was easier, and partly because men were long debarred by custom 
from the practise of obstetrics and gynecology. Even much later men 
held the practise of obstetrics to be infra viri dignitatum. It was only at 
the end of the 16th and the beginning of the 17th century that we 
find urinary fistulas mentioned at about the same time by several physi- 
cians; so that it is hard to decide to whom its first recognition is to be 
ascribed. In any case, however, we must first mention the name of 
Ludovicus Mercatus, a renowned Spanish physician, who in his work: 
De. communibus mulierum affectionibus, 1605, devotes a long chapter to 
" fistulas of the uterus/' and not only describes the symptoms, but proposes 
a definite operation for their relief. Thus he says: Prima indicatio, 
quatenus ad affectum pertinent, docet callum prius conterere; nam cum 
ea quag disjuncta sunt, uniri minime possint, callo in medio existente, 
curandum primo est, eum exstirpare. Orificio satis patulo, callum uno 
e tribus modis exstirpare poteris: medicamentis nimirum acrioribus et cal- 
lum conterentibus, scissione ac avulsione calli et ultima partis inustione. 
Further, Felix Plater in his work which appeared at Basel in 1625: De 
mulierum partibus generationi dicatis, mentions two cases of tearing of 
the neck of the bladder in difficult labors, notices the erosions of the vulva 
which occur with it, and names the remedy to be employed. (Lactis 
cremor et mucilaginosa). In a Paris thesis of Severinus Pinseus of the 
year 1597, urinary fistube are also mentioned. In 1606 Fabricius Hilda- 
nus mentions several noteworthy cases of the affection, and especially 
described a case in which a large vesical calculus gave rise to such a fis- 
o o INJURIES TO THE FEMALE BLADDER. 
95 
tula. In 1664 Pietro di Marchetis strenuously urged the use of the actual 
and the potential cautery for these fistulse, and obtained a complete cure 
in this way. As early as 1663 Hendrik van Roonhuyzen of Amsterdam 
had advised stitching for the cure of the affection; but like Mercatus he 
seems to have left the execution to others. More exact data concerning 
the malady we are considering are found in J. Varandaeus (1619), Ch. 
Volter (1687), Musitanus- (1698), Mauriceau (1712), J. Fatio (1752), 
A. Levret (1753); and henceforward it is mentioned by almost all writers 
upon diseases of women and on surgery. But, as Freund says, there is a 
complete and surprising absence of any description of the malady in the 
larger pathologico-anatomical works of Morgagni and J. Lieutaud. In 
fact the pathology of urinary fistula was much neglected until very lately, 
partly no doubt because the patients were seldom the subject of post- 
mortem examination, and partly because all interest had long been centred 
upon the therapeutics of the disease. In this latter field the following 
names are to be noted: Desault, who at the beginning of this century 
again recommended cauterization, Dupuytren, who repeatedly used the 
red hot iron in 1820 with complete success; Dieffenbach and M. Chelius, 
Monteggia, Soupart, and Roubaix. 
But a new era in the history of the operative cure of this malady was 
inaugurated by Jobert de Lamballe in 1834. The success obtained by 
this operator by his method, cystoplastie par glissement or autoplastie 
vesico-vaginale par locomotion, a procedure first proposed by Velpeau in 
1834, attracted the attention of all Europe. From this time begins a rapid 
progress in the therapy of urinary fistula. One of the first to accept the 
method of the French surgeon, and to improve it, was Gustav Simon, 
then in Darmstadt, who had assisted Jobert in Paris at several of his 
operations. After him we may mention M. Sims and N. Bozeman as 
the two Americans who have carried the operative treatment of fistula to 
its highest perfection. 
Stolz in Strasburg in 1828 first described the vesico-uterine fistula, G. 
Simon in 1856 first mentions the uretero-vaginal fistula, and A. Berard 
in 1841 first mentions the uretero-uterine fistula. Finally, among 
the more recent and larger works upon this subject, are to be especially 
mentioned those of W. A. Freund (1862) and Ed. F. Bouque (1875). 
The latter has especially corrected the misapprehension that Marion Sims 
specially improved the method for the cure of urinary fistulas since he 
was the first to use the duckbill speculum to expose and operate on urin- 
ary fistulae. Bouque calls attention to the fact that Dr. Schuppertof New 
Orleans has proved that Sims's speculum is exactly like the speculum de- 
scribed by Metzger in 1846 in the Prager Vierteljahreschrift. For v. 
Metzger described a speculum as follows: A silver vaginal dilator, consist- 
ing of a guttered conical blade 5| inches wide, whose lower | is turned 
outwards; and an 8. inch long steel staff, fastened at a right angle to the 96 
THE FEMALE URETHRA AND BLADDER. 
lower third, and provided for 5 inches of its length with a large wooden 
handle. Probably v. Metzger's invention remained unnoticed so long 
because he made no drawing of it. At all events, since it has been in- 
troduced there has been an important advance in the treatment of urin- 
ary fistula, since it renders possible complete exposure of the defect, and 
probably no fistula is operated upon to-day without its help. Thus to a 
German and not to Americans belongs the credit of this advance. 
The Various Kinds of Urinary Fistula in Women. 
Beginning at the external urethral orifice, the following abnormal open- 
ings between the urinary passages and neighboring organs may occur: 
1. Urethro-vaginal fistula (Fig. 26), always situated at the lower end of 
the anterior vaginal wall, and opening into the urethral tubercle. Ex- 
amples have been recorded in the literature of the last seven years by 
Aveling, Engelmann, Frissell, Grune, Pean, Verneuil and Winckel. 
2. Vesico-vaginal fistula, which may occur at any point in the posterior 
vaginal wall from the sphincter vesicas to the fundus (Fig. 26.) If the 
upper border of such a fistula lies against the cervix, it is called a super- 
ficial vesico-vaginal uterine fistula; if it pass through the anterior lip of 
the os, it is called a deep vesico-vaginal uterine fistula, both these latter 
being first named by Jobert. 
If the bladder communicates with the vesical neck we have a vesico- 
uterine fistula. Ambrosio, Bozeman, Isenschmid, Lossen, Muller, and 
Winckel have within recent times published examples of this lesion. If 
the bladder has an abnormal communication with the rectum, it forms a 
vesico-rectal fistula (Heath); if there is an opening from the bladder into 
the small intestine, there is a vesico-intestinal fistula (cases of Krakowi- 
zer, Blanquique, and Valenta. Finally, if the urine exudes from an open- 
ing in the anterior bladder wall ami the abdominal parietes, there is 
either a fistula of the urachus (page 68), or a cleft bladder (See Chap. 
I.) or a simple external vesical fistula. 
3. The ureters themselves may be perforated, and may empty their secre- 
tions into neighboring organs. These urethral fistula do not indeed be- 
long strictly under diseases of the bladder, but deserve mention among 
their complications. A ureteral fistula may open either in the vault of 
the vagina, uretero-vaginal fistula, or it may open into the cervical cavity 
of the uterus, uretero-uterine fistula (cases of B. Credo and Zweifel), or 
into the intestine, uretero-intestinal fistula, or outwards, external ureteral 
fistula.1 
Here we have twelve different urinary fistula? occurring in females; and 
' See case of G. Simon, which occurred after ovariotomy, and was cured by 
nephrectomy. Cf. Muller, Arch. f. Gyn., XV., 264. INJURIES TO THE FEMALE BLADDER. 
97 
we may in addition have various combinations of them. Thus we may 
have urethral with vesico-vaginal fistula (cases d'Ormea, Torreo, Freund, 
Simon, Engelmann (see Fig. 26), or vesico-vaginal with vesico-uterine 
fistula; or vesico-vaginal uterine with uretero-vaginal fistula (case of the 
author). There are also vesical, vaginal, and ureteral fistulae where the 
Fig. 26.-Urethro-vaginal (w/) and vesico-vaginal fistula /), with atresia (a) of the urethra 
between the two fistulae. (After G. Simon.) 
vesico-vaginal wall is injured at the spot where the ureter lies between 
vagina and bladder (case of G. Simon.) 
Finally, double uretero-vaginal .fistula may occur, as W. A. Freund 
has first proved (1862). 
We will now turn to the causes and origin of urinary fistulae. As a 
rule their origin is quite clear. By far the greater part of them are due 
to malignant new growths of the genitals (see Introduction, page 25), 98 
THE FEMALE URETHRA AND BLADDER. 
and are not subjects for surgical treatment. Of those which do come 
under our care most are due to certain puerperal processes. The ori- 
gin, the seat, the whole process in the walls of the affected organs are en- 
tirely different in the other cases. So we may divide urinary fistulas into 
two great classes, puerperal and non-puerperal fistulas. Puerperal urinary 
fistulas are such as stand in causal relation to pregnancy, childbirth, or 
the puerperium. In these conditions the walls of vagina and bladdei' are 
swollen and vascular, their vessels are much dilated, and the veins are 
often ectatic; the union of bladdei' and vagina is more loose, and they 
are liable to be squeezed between any hard body and the margins of the 
pelvis. The causes which might work injury are also more active at this 
period, and affect larger areas of surface. Thus the puerperal fistulas 
are sometimes enormous in size; and the hyperasmic condition together 
with the irritation caused by the lochial discharge, tend to keep up the 
ulcerative process. Puerperal urinary fistulae may be urethro-, vesico-, 
uretero-vaginal and vesico-uterine fistulas. They may occur spontane- 
ously or in consequence of mechanical violence. 
The following causes have been noticed as originating spontaneous puer- 
peral fistulae; rupture of the cervix and the vesico-vaginal septum when 
the head advances and the parts are rigid and cicatricial; cases of Berdot, 
Kiwisch, Detroit and others. The literature of this branch of our sub- 
ject has been collected by F. L. Meissner and Duparcque-Nevermann. 
Further to be noted are pressure effects when there are exostoses of the 
pelvic wall, vesical calculi, and carcinomata of the cervix and vagina. 
Then the necrosis of gangrenous or diphtheritic parts, especially when 
there is a narrow pelvis, may occur. Simple necrosis during delivery of 
a woman with a narrow pelvis is common; in the other conditions it is 
rare, partly because the patients usually die before it can occur, and 
partly these processes most often affect the introitus vaginae and the pos- 
terior vaginal wall, and do not disturb the bladder. The extent, the 
seat, and the time of origin of these fistulae vary greatly in accordance with 
the structure of the tissue affected, the amount of blood it contains, its 
infiltration with serum, the length of time the pressure is continued, and 
its intensity, and the nature of the contusing body. So the contusions 
caused by the skull of the infant in a small pelvis appear as round and 
striped red patches, or as round, dry, colorless, gray, punched-out places. 
They are cast off by process of ulceration, and usually leave a circular loss 
of tissue behind. The seat of the injury varies in accordance with whether 
the contusion is at the entrance of the pelvis, or in the true pelvis. In the 
latter case it is usually close behind the urethra in the fundus vesica?; in 
the former it is high up in the vaginal portion. A resistant and large 
head predisposes to the accident, as does hydrocephalus (case of G. Simon, 
Rostock. Krankenhaus, No. 3; case of author, see below), and faulty 
position. A pendulous abdomen also predisposes, though not to the ex- INJURIES TO THE FEMALE BLADDER. 
99 
tent that Esmarch would have it. The mechanical hindrance which a nar- 
row pelvis presents, cannot be so easily overcome as can that caused by a 
pendulous abdomen; in fact the latter is usually in a relaxed condition due 
to the presence of the former. Schatz maintains that the expulsive force is 
exerted mainly by the abdominal walls, but it is not to be doubted that 
the uterine muscle does take part in the crushing of the soft parts. Face 
presentations often cause urinary fistula? (cases of Schupp, Danyau, cra- 
niotomy; Metzger, cases 26 and 33 of Simon, and cases 2 and 17 of the 
author); the sharp edges of the child's face being very apt to do damage, 
especially as the presentation usually occurs with contracted pelves. 
Hecker claims that unusual height of the pubic symphysis also predisposes 
to abnormal pressure. 
Several spontaneous fistulae may occur at the same time. In the author's 
case, N o. 7, there were 4 openings. Here the gangrene occurs from pres- 
sure successively or simultaneously applied to different portions of the 
soft parts, and even if only one part is implicated, the pressure may have 
been uneven, and bridges of living tissue be left, so as to give us several 
orifices. 
There was a time when the occurrence of vesico-vaginal fistula was sup- 
posed to be largely due to the execution of certain obstetric operations, 
and especially to those that involved the use of the forceps. In 1828 
W. S. Schmidt vigorously combatted this prejudice, and claimed that the 
accident would be of far less frequent occurrence if there was not such 
an ingrained fear of the use of the instrument. Even the teachings of 
the schools inculcated a reluctance to use the instrument which was a 
direct cause of the evil which it was sought to avoid; since in by far the 
greater number of cases it is the continued pressure of the impacted head 
which causes the fistula. We are not so much afraid of the forceps now. 
Ch. West (1858) and G. Simon and Baker Brown have recorded it as 
their opinion that in most cases it is the postponement of instrumental 
assistance in tedious labors which causes the lesion. Perhaps the truth 
of the matter lies between these two extremes. In Bouque's collection 
of 204 different fistula?, 118 occurred after labor; of these latter 65 or 55 
per cent., more than half, were instrumental confinements. I have myself 
operated upon a large number of fistulae in cases in which delivery had 
been effected by artificial means, and in almost every case it could be sat- 
isfactorily proven that the operation was the cause of the fistula. This 
can only be decided by a thorough consideration of the seat, size, shape, 
and edges of the loss of tissue. The presence of extensive scars or adhe- 
sions, or of stenoses or atresias of the vagina, will render probable the in- 
jury of the parts by the forceps themselves. In 28 cases of vesico-vaginal 
fistula upon which Spiegelberg operated (Landau, p. 343), 22 occurred 
after instrumental labors, 17 were in primipara?, 11 in multiparae, and 
half of all the cases had stenoses, cicatricial bands, and atresias. The fis- 100 
THE FEMALE URETHRA AND BLADDER. 
tula? occurring after normal delivery are mostly situated in the upper part 
of the vagina, and are either superficial or deep utero-vesico-vaginal fis- 
tulae, or utero-vesical fistula?. Thus in 15 cases of uterine fistula that 
Spiegelberg operated upon, 12 were after simple, and 3 after instrumen- 
tal deliveries, 12 were primiparous and 3 multiparous. As complicating 
causes we may mention premature rupture of the membranes, non-dilata- 
tion of the cervix in spite of long-continued pains, and in the deep utero- 
vesico-vaginal fistulae, tardy opening and canalization, especially in 
cervices ruptured at earlier births. Naturally the existence of these 
conditions cannot always be ascertained by observers who were not present 
at the delivery. 
Urinary fistula? due to violence may occur inter partum from instru- 
mental or manual interference. In Bouque's 65 confinements before 
mentioned, 37 were delivered with forceps, 7 with the lever, 12 bycephab 
otripsy, craniotomy or embryotomy, and 3 by the blunt hook; turning 
was employed 5 times. The forceps may cause a fistula directly or in- 
directly; directly, by cutting the vesico-vaginal wall with its sharp edges 
as it is drawn out, by their use before the os is sufficiently dilated, by too 
rapid change from one position to another, or by rotating them upon 
their longitudinal axis to alter the position of the head. If the instru- 
ment lie in the oblique diameter of the pelvis, the anterior blade may cut 
the vesico-vaginal septum; if it lies transversely, it may cut the sides of 
the vagina. Cuts in the vaginal walls made by the forceps are often found, 
even after easy operations. They appear as cleanly marked cuts 1 to 2 
inches in length, and mostly in the posterior wall, being caused by the 
hinder surface of the blades as the handles are being elevated. Less often 
we find them at the sides, just behind a point opposite the place of union 
of pubes and ischium. In these latter cases, as once happened to me in 
spite of the greatest care, and an easy and strictly lege artis extraction, 
the vesical wall is often injured. The case of childbirth recited in the 
appendix was in my presence ended with the forceps by my assistant, on 
account of danger to the child; yet a cut was made upon the right side. 
A single application of liquor ferri sesquichlorati to the small fistula sufficed 
to cure it. The fistula? caused by the forceps are, as we have said, usu- 
ally in the lower third of the vagina, and are often greatly complicated, 
since they are mostly due to pressure-necrosis. But direct cuts and tears 
are not of rare occurrence. Thus I operated upon two patients in both 
of whom one and the same surgeon had torn the vesico-vaginal septum 
upon the left side from the vault of the vagina to within half an inch or 
so of the orifice of the urethra. 
It has occasionally occurred that one blade of a forceps has pierced the 
vaginal vault; the same thing has also happened with the scissors-shaped 
perforator. The parturient parts have often been torn with the sharp 
hook, as also by the use of the cranioclast (see Saxtorph's case). Turning INJURIES TO THE FEMALE BLADDER. 
101 
may cause injury to the bladder by the hand being forcibly passed through 
the cervix before it is sufficiently dilated; as also when, as Spiegelberg, 
horribile dictu / proved in one case, the hand of the accoucheur is intro- 
duced into the urethra instead of into the vagina; and finally, when ver- 
sion is difficult, though the foot has been seized, the attempt to drag it 
down causes too great friction and pressure upon the anterior pelvic wall. 
After version is completed, extraction may cause vesico-vaginal fistula, 
either by tearing or by gangrenous destruction from pressure. The 
uretero-vaginal fistulas occurred in all cases so far known (Simon 2, 
Alquie, Pauas, Landau, and my own) after deliveries ended by operation; 
and Landau is certainly right when he ascribes them to the interference. 
I also observed a fistula of this kind, which had been caused by a pessary. 
An injury to the ureter near the fundus vaginae, appears to be only possi- 
ble when it has been fixed by precedent parametric inflammation, and 
suffers a direct injury from some instrument. 
A well-known German gynecologist lately told me that once, while 
operating upon a ruptured cervix with Greenhalgh's instrument, and 
without the blade being set very far out, he caused a uretero-uterine fis- 
tula, which, however, happily soon healed under tamponade of the cer- 
vical canal. According to Bandl, Bozeman wounded a ureter in two 
vesico-vaginal fistula operations by enclosing them in a suture, and thus 
causing fistula of the ureter. 
Forced catheterization during labor may perforate the bladder from 
within outwards, as occurred in Dieffenbach^s case. The bladder has been 
repeatedly incised in the operation of synchondrotomy during labor. 
The only remaining causes of fistulae are the ulcerative or so-called 
diphtheritic processes which occur in the vagina of puerperal women, 
and perforating ulcers of the bladder. Carcinoma, para- and perimetric 
processes, and ovarian abscesses not infrequently break through the vesi- 
cal wall. Fistula may occur, though rarely from these causes; thus in 
the case of Hamonic already cited, an ulcerative inflammation of the ure- 
thra caused a urethro-vaginal fistula. 
In my 14 cases the fistula occurred: without use of instruments, once 
(No. 10); without instrumental violence twice (Nos. 4 and 13); probably 
through the use of instruments 3 times (Nos. 1, 2, 14), and almost posi- 
tively through their employment 8 times (Nos. 3, 5, 6, 7, 8, 9, 11, 12.) 
The non-puerperal urinary fistulae may also be either due to violence, 
oi' they may occur spontaneously, from certain morbid processes. The 
first class may be caused by perforation with the sound, with the litho- 
triptor, or by other foreign bodies, especially hair-pins. A fall upon a 
sharp body, as upon the pointed stake of a fence, etc., may cause fistula; 
or puncture of the bladder in retention of urine, due, for instance, to 
retroflexio uteri gravidi, or an accidental wound in vaginal puncture of 
the ovary may cause it. It may follow lithotomy. Further, the bladder 102 
THE FEMALE URETHRA AND BLADDER. 
may be injured in amputatio calli uteri, in prolapsus uteri; also in ovari- 
otomy, and, as the cases of Dieffenbach and W. A. Freund teach us, in 
the attempt to open with the knife an imperforate vagina. 
Mittelhauser claims that the forcible passage of a finger into the urethra 
has caused incontinence. It is well known that fissures may be caused 
in this way; but that by the passage of one finger the entire urethra may 
be torn through to the bladder, and the bladder wall then also perforated 
in the same manner, seems almost impossible. For I have often made 
digital exploration of the inner surface of the bladder, when the urethra 
in spite of specular dilatation still offered great resistance, and have caused 
no tear. Still less likely is the occurrence of a fistula by concubitus vio- 
lentus, as Munnik has claimed. A blunt body like the male penis can 
hardly tear the walls of so dilatable a cavity as the bladder, either per 
vaginam or per urethram, even in the case of a rape committed upon a 
girl six years old, as in Pollak's case. 
On the other hand it is not infrequently observed that large and sharp- 
edged pessaries, or those left too long in situ, have caused perforation of 
the vesico-vaginal septum. The cases of Fabricius Hildanus, Breschet, 
Berard, Dupuytren, Dieffenbach, Lisfranc, Busch, and others prove this. 
Erosions occur in the most tensely stretched portion of the vaginal wall, 
then ulcerations, and finally the pessary breaks through into tlie bladder, 
and occasionally into the rectum at the same time. Zwanck's pessaries 
are especially dangerous in this respect; I have seen one and Pagenstecher. 
has seen two cases of vesico- and recto-vaginal fistula caused by them. 
Ulcerative malignant processes may cause fistula in carcinomatous dis- 
ease of the uterus and the vagina. Statistics show (see page 25) that half 
of these patients eventually suffer from perforation of the bladder; and 
most frequently the vesico-vaginal wall suffers. In hardly 20 per cent, of 
the cases does the new growth destroy the utero-vesical junction. 
It is doubted by many whether tubercular 01* syphilitic ulceration can 
cause urinary fistula. The pulmonary and intestinal complications pro- 
gress more rapidly than do those of the urinary organs, and we sometimes 
seem them causing hypertrophy of the vesical wall. A case of W. A. 
Freund teaches us that specific vaginal ulcerations may cause urethro- 
vaginal fistula, and one of Beckwith's shows us that they may cause vesico- 
vaginal fistula. 
Among the diseases of the bladder, which may cause spontaneous vesico- 
vaginal fistula, the most important is stone in the bladder. (See Chap. 
VI.) Others are: chronic ulcerative vesical catarrh with diverticulum- 
formation; and carcinomatous degeneration beginning in the vesical 
mucous membrane. 
Finally we must remember that disease in the neighborhood of the walls 
of the bladder occasionally causes fistula; pelvic abscesses may perforate 
both bladder and vagina; hannatocele may do the same, and so also may INJURIES TO TIIE FEMALE BLADDER. 
103 
ovarian abscesses, and those due to an extra-uterine pregnancy (see cases 
of Simpson and others). 
The Anatomical Relations of Urinary Fistula in the Female. 
We must now more minutely specify the exact seat, size, form, and 
edges, etc., of the abnormal openings which we have been considering. 
We will begin with the seat, upon which often depends the shape. The 
urethro-vaginal fistulae are usually placed in the middle of the lower wall, 
are round, from a hair to a bean in size, and are rather orifices than canals. 
Only very exceptionally are they cross rents, as in a case of Freund's, and 
in mine, No. 12. Freund has also given us an example of a perforation 
caused by syphilitic ulceration of the mtroitus vaginae. The vesico-vaginal 
fistulae are situated as a rule at one side of the lower third of the vagina 
when caused by operative procedures, and nearer the laquae vaginae when 
occurring spontaneously with contracted pelvis. It is not certain that 
they occur more often upon the left than upon the right side, though this 
is claimed by Simon, Neugebauer, Jarnatowski and Spiegelberg (Archiv. 
VII., 346). As in so many other cases, this assertion has been based upon 
the analysis of only a small number of cases. G. Simon found it so 10 
times in 17 cases, but adds " or at least they extended more to the left 
than to the right side/' 
Their shape is variable. The smaller are circular or oval; and oval 
especially when they are fixed to one or other rami of the pubis by cica- 
tricial bands. Busch found those situated near the sphincter vesicae, to 
be half-moon shaped, with the concavity directed forwards, on account of 
the action of the transverse muscular fibres. Others again are mere fis- 
sures; and these fissures may vary in size from a slit so small, or so im- 
bedded in a carcinomatous or other growth, as to be invisible, to openings 
large enough to pass several fingers through. But both size and shape 
vary with the time that has elapsed since they first appeared. As a rule, 
they are the larger the more recent they are; in the older ones cicatricial 
contraction of the fistula itself, together with vaginal stenosis, which may 
go on to the extent of complete atresia, (comp. Fig. 28) tend to diminish 
their calibre. 
Uretero-vaginal fistulae are situated at one side in the vaginal vault, or 
at its posterior portion; or they may be in front and above the left half of 
the posterior lip, the anterior having been destroyed, and the ureter being 
drawn to the right by cicatricial contraction. The size of the ureteral 
opening is of course small, though a sound can easily be introduced into 
it; its shape is round. In my case the mouth of the ureter formed a 
button-like prominence, from which the urine flowed in a thin stream as 
the speculum was moved about. Busch, 1. c. p. 77, mentions a case from 
B. S. Schultze's clinic, in which two small fistulae of the right ureter were 104 
THE FEMALE URETHRA AND BLADDER. 
attached to the right pelvic wall. W. A. Freund has observed a case in 
which both ureters were involved in the destructive process. The fistula 
was seated in the median line, was elliptical, being inches long, f 
inch wide, and distant from the uterus |th inch, and from the external 
meatus f th of an inch. The terminal portions of both ureters had been de- 
stroyed for £ of an inch; they projected as round prominent openings into 
the lumen of the fistula, and were visible in the vagina. (1. c. p. 61). 
The latter variety of uretero-vaginal fistula), which occui' in that por- 
tion of the bladder corresponding to the trigomon, and are always found 
in connection with a partial destruction of the vesical wall, should be 
designated as the lower variety; for they differ both therapeutically and 
prognostically from the kind described before as occurring in the fundus 
vagina, which may be called the upper variety. Simon found such a one 
on the left side, |th of an inch from the os and 21th inches from the 
external urethral orifice. The fistula was x |th inch in size, and the 
left ureter, which could be reached with the sound, was destroyed for its 
lower |th inch. 
The position of vesico-utero-vaginal fistulas (see Fig. 53, a and b) is de- 
scribed by the name. They occupy the vault of the vagina, are round, 
or quadrangular, and not large as a rule. The deeper ones, where the 
anterior lip of the cervix is destroyed, are not much larger, since the pos- 
terior lip is often also involved. As a rule, both are median, since with 
a contracted pelvis the chief pressure is upon the middle of the anterior 
pelvic wall. 
The utero-vesical fistula? are situated to j of an inch from the external 
cervical lip, either in the median line, or to one side. They are usually 
as large as a pea or bean. Only in rare cases are they found combined 
with deep utero-vesico-vaginal fistula?, being divided off from it by a thin, 
narrow bridge of tissue. The uretero-uterine fistula? are very rare, and 
are usually so small as to be hardly visible to the naked eye. The former 
are placed more in the middle of the anterior wall, while the latter are 
placed at the sides, and somewhat forwards. The three cases observed 
respectively by Berard, Puech, and Freund did not any of them come 
under post-mortem observation. 
The vesico-intestinal fistulae are situated as follows: the vesico-rectal, 
the vesico-intestinal, and the vesico-ventricular are of course situated on 
the sides, posterior wall, or vertex of the bladder. Long fistulous tracts 
may arise. A coil of the small intestine may adhere to the bladder, and 
perforation occur at the point of adhesion; or an inflammation of the 
pelvic cellular tissue may perforate both bladder and rectum. 
Finally, the urinary fistula? of the anterior abdominal wall, the external 
urinary fistula?, form longer or shorter channels or slits, as we have seen 
when considering version of the bladder. 
The edges of the fistula? are at first usually swollen, uneven, infiltrated, INJURIES TO THE FEMALE BLADDER. 
105 
tender, and bleed easily when touched. Gradually necrotic portions are 
cast off, secretion diminishes, the margins become firmer, and the vaginal 
pavement epithelium grows over the edges of the wound. A connective- 
tissue proliferation now takes place between the bladder and the vaginal 
wall, and the edges of the fistula become thinner, indurated and tense. 
Thus Freund proved in a carefully observed case, that the bladder was 
adherent to the vaginal wall for a concentric ring 2 to 3 lines in width. 
Microscopically, we see abundant connective-tissue proliferation between 
the adherent portions of the two organs; the muscular layer and the 
mucous membrane become thinner as you advance nearer to the edges 
of the fistula, the papillae are less marked, until at ^th inch from the 
edge of the orifice, the entire thickness consists of a hard, cartilaginous- 
like and poorly vascularized connective tissue, in which we can still recog- 
nize some remains of the degenerated mucous membrane. Of course the 
extent to which these processes advance depends largely upon the cause 
of the fistula. If there has been but little contusion, or perhaps only a 
simple cut, the vitality of the margins is better, the lips of the wound are 
thicker, the granulations are more vigorous, the scar is smaller, and the 
neighboring tissues are less implicated. I might refer to cases that I 
have myself seen, where the fistula was caused by a forceps blade, and 
where months later the edges were as described; or I might mention 
Bouque's case (1. c. 1875, p. 124-125), of which he says: "les bourgeons 
charnus sont tellement volumineux, qu'ils arrivent au contact en faisant 
pont au dessus de la trouee anormale, etc." 
On the other hand, there seem to be some special causes which tend to 
cause the thinning of the edges of the fistula above described. Thus 
tension of the edges caused by contracting cicatricial tissue, and especially 
fixation of the edges of the fistula to one or other of the bones of the an- 
terior pelvic wall, appeal- likely to do so. And if, as sometimes occurs, 
inflammatory processes in neighboring organs cause tension of different 
parts of the border in different directions, it is easily understood how 
thinning from tension may occur. 
In the non-puerperal fistulas, the condition of the edges is of much 
less importance, and indeed depends mostly upon the nature of the can- 
cer, perforating calculus or foreign body which cause them. 
After a urinary fistula has existed some time, there occur certain 
changes in neighboring organs, in the urinary organs, in the genitals, 
and even in more distant portions of the pelvis. The most important 
change in the urinary organs is the change in the urethra; the urine no 
longer passing through it, it becomes smaller and smaller, is gradually 
obliterated, and is said in some cases to have been difficult to find at all. (?) 
As examples of this we may cite the cases of W. A. Freund, Hoffmann, 
Lancerotte, and G. Simon (5 cases, 29, 30, 31, 32, 33=12 per cent, of 
all cases.) The bladder also diminishes in size, the walls come in contact 106 
THE FEMALE URETHRA AND BLADDER. 
with each other; as a rule the anterior wall covers the fistula, and may 
even prolapse through it to the extent of becoming visible in the external 
genitals. It is usually in a hypersemic and catarrhal condition, and some- 
times (as in W. A. Freund's case) has polypoid growths upon its surface. 
It may become adherent to the posterior vaginal wall (case 39, Simon). 
The vesical muscularis is generally hypertrophied, and the serosa is some- 
times injected; and pericystitis with perimetritis may cause varying ad- 
hesions between the two organs. 
The ureter is often involved in the changes of shape, position, and 
tension of the fistulfe. If it is torn across, the lower end will atrophy 
like the urethra; cicatrization will approximate it to the ureter of the 
other side. Its wall will usually be thickened on account of the inflam- 
mation of the subserous tissue; and the canal will be dilated above the 
thickened part. The kidneys are also very liable to suffer, especially in 
uretero-vaginal fistulas, since injurious matter can most easily reach the 
Fig. 27.-Atresia of the Vault of the Vagina. (After Hegar.) 
pelvis of the kidney from the vagina. The case of B. Credo is noteworthy 
in this respect, he finding the extirpated kidney belonging to the injured 
ureter in a high state of interstitial nephritis. Verneuil has very recently 
paid particular attention to this subject. 
The external genitals are continually moist, pale bluish red in color, 
eroded in places, and sometimes secreting pus. After the fistula has ex- 
isted for some time, we often find small flat tumors, hypertrophies of the 
papillary bodies, pointed condylomata and excrescences. (Cases of 
Hoffmann and G. Simon.) In recent cases the vagina is hypersemic, 
swollen, and dilated; when much scar tissue is formedit is often stenosed, 
and at times the seat of complete atresia (Fig. 27). Thus in one of 
Freund's cases the lower part of the vagina was much narrowed by cica- 
tricial tissue; then came a wider portion, containing the vesico-vaginal 
fistula, and then above this was another stenosed portion, from which 
urine also flowed. The vaginal contracture and irregularity may be so 
great as to render it difficult or even impossible to find the cervix and fix 
the position of the uterus. Erosions of the vaginal wall also occur. In INJURIES TO TIIE FEMALE BLADDER. 
107 
old large fistulae we not infrequently find the vagina relaxed and dilated, 
pale in color, and with its epithelium very like that of the epidermis. If 
the fistula is near the uterus, or involves that organ itself, the lips of the 
uterus are swollen, eroded, and covered with weak granulations. The 
lower part of the organ is chronically inflamed, partly from constant con- 
tact with urine, partly from the same influences that caused the fistula, 
and partly from the resulting cicatrization, which dislocates the cervix 
and causes disturbances of circulation and position. The subserous con- 
nective tissue and the serosa of the uterus often participate in these 
chronic or subacute inflammations, and abscesses around the cervix and 
perimetritis with fixation of the uterus are apt to occur. The anterior 
layer of the omentum may fall down into the neighborhood of the fistula 
and adhere, as G. Simon has first shown us.1 He lost such a case (No. 
4) 14 days after the operation from peritonitis, the fold of omentum being 
included in the sutures. 
It remains to note that with urinary fistulae stony concretions and even 
full-sized calculi may form in the bladder, in the vaginal pockets, in the 
uterus, and in the external genitals. (Petit, Wendt, Saxtorph, Bock.) 
Thus the ligatures of a partly healed operative case may become covered 
in a few days, and in rare cases the salts form a crust over the surface of the 
vaginal canal. Simon's experience is that calculi occur oftenest in fistulas 
when there is at the same time vaginal stenosis below its orifice; he never 
found one with a simple fistula, save when a foreign body was present. 
The urine stagnates in the diverticulum, and causes deposit of the lime 
salts, especially around their orifices; and from here it spreads over the 
interior of the vagina and bladder. Among 42 patients Simon could find 
only 1, number 38, where there was a large vesical calculus several years 
after the delivery which caused the fistula. 
The Symptoms of Urinary Fistulce.-Any opening of the kind under 
consideration will of course be at once followed by the outflow of urine 
through the vagina and vulva. This may even occur before delivery, if the 
slipping forceps incise the bladder. This outflow, however, is often not 
noticed either by physician or patient; the pain incidental to delivery and 
to the operation, and the flow of liquor amnii and blood, suffice to hide 
what has occurred. But after several days, when pain and hemorrhage 
has ceased, it is noticed that there is never much desire to urinate, and 
that very little is spontaneously voided, and that the lochia have a urin- 
ous odor. In the worst cases the signs of the vesical lesion are at first 
entirely covered by the general puerperal symptoms; for tiie patient is 
feverish, and does not always pay proper attention to the condition of the 
lochia. The case is different when the fistula is caused by pressure necro- 
sis. There is moderate pain in the vagina, difficulty or inability to pass 
1 Rost. Krankenhausbericht, p. 155. 108 
THE FEMALE URETHRA AND BLADDER. 
water, moderate fever and general unrest; a combination of symptoms 
not at all characteristic. But when a portion of crushed and necrotic 
tissue suddenly gives way before the urinary pressure, and a large amount 
of urine is voided through the vagina, the vesical distress suddenly ceas- 
ing, then the characteristic picture of urinary fistula is developed. But 
the symptoms depend largely upon the size and seat of the fistula, the 
length of time it has existed, the amount of reaction shown by neighbor- 
ing tissues, the complications, and the patient's constitution. Even the 
first and most important symptom, involuntary discharge of urine, is ex- 
tremely variable; for in urethro-vaginal fistula? it is not involuntary in 
regard to time, but in regard to direction, the stream being directed back- 
wards and downwards, and into the vagina. In vesico-vaginal fistula? it 
may flow by drops, or in a stream, continuously, or with longerand shorter 
interruptions. The flow is permanent if the orifice is large, unless there 
be stenosis of the vagina with calculus formation. When the orifice is in 
the vaginal vault the flow is often voluntary and involuntary; voluntary 
when the patient is in the erect position, the lower portion of the bladder 
being filled with urine, and the patient micturating at will; involuntary 
when she is recumbent, the water flowing out directly through the fistula. 
In utero-vesical fistula? the same is the case; and since the orifice of com- 
munication is usually small, the amount of urine voluntarily emitted is 
considerable. I operated upon one case with a large vesico-vaginal fistula 
(case 11), only a lentil-sized fistula being left at the orifice of the urethra; 
in twenty-four hours she spontaneously evacuated 41 ounces of urine, 
losing a small quantity at night drop by drop. 
If the uterus is moderately movable, the edges of a fistula in the vaginal 
vault may be dragged into approximation when the patient stands up, 
and the involuntary flow of urine greatly diminished. In the isolated 
uretero-vaginal fistula? but little urine escapes per vaginam, and that only 
occasionally; besides this, the patient can regularly evacuate what urine 
accumulates in the bladder. 
If the amount of the involuntary flow is considerable, the above-men- 
tioned changes in the neighborhood of the fistula occur, though in cleanly 
persons they may be warded off for a considerable time. The more marked 
they are, the greater the disturbance of the functions of the genital ap- 
paratus do they occasion. Menstruation may be absent, irregular, or 
painful; but it may also be quite normal. It is natural that there should 
be a certain distaste for cohabitation on the part of both husband and wife; 
the woman dreads the pain, and fears another conception. C. v. Braun 
claimed that a fistula caused sterility; but Simon, Schmidt, Freund, and 
others have disproved this. But Simon believes that when it does occur 
under these circumstances, an abortion or a premature delivery is the re- 
sult. A case of Schmidt, and one of the author's, show that this is not 
always so. In fact, my father had a case in which pressure at the same INJURIES TO THE FEMALE BLADDER. 
109 
spot of a child at term at the next confinement caused the fistula, due to 
the previous one, to heal. We must admit that conception is rarer among 
these patients than in healthy persons, for few patients with fistula be- 
come pregnant; but some do. I mention a patient in my Berichten unci 
Studien, (Vol. II. p. 129,) who had a very considerable vesico-vaginal fis- 
tula, and in whom after an unsuccessful attempt to. secure direct union 
transverse obliteration had been done. This was not entirely accom- 
plished; a small opening was left, and through this coitus was accom- 
plished during a short visit which she made to her home. She aborted at 
the 5th month. In the same volume on page 79 is recorded the confine- 
ment of patient No. 931 (1874) with an unviable and macerated girl; a ceph- 
alotripsy done 4 years ago had occasioned 4 fistulae, and there were a large 
number of cicatricial bands in the vaginal vault. Nevertheless she con- 
ceived again. Naturally, succeeding pregnancies may enlarge the fis- 
tulae, or delivery may be hindered by the cicatricial bands, etc. In the last- 
mentioned case air entered the gaping cervical vessels, and the patient 
died four hours after delivery. The puerperal period may be greatly in- 
fluenced by the recrudescence of subacute inflammatory processes in the 
neighborhood of the uterus. As a rule a new pregnancy means increased 
trouble and greater danger for the patient. 
On the other hand K. Schroder maintains that the power of conception 
is not much altered in women with urinary fistula?, and the ensuing preg- 
nancies and deliveries are normal. Kroner's thorough investigation of 
sixty cases of fistula in the Breslau Klinik do not confirm Schroder's state- 
ments. He found that menstrual disturbances frequently accompanied 
the affection. The periods often ceased entirely, or only began some time 
aftei- delivery, or they were irregular and painful. In only 23 per cent, 
were they normal. 6 cases only conceived; and in all the literature of 
the subject he only found 37 cases of fistula that did so, including these 
6. This small number alone, among the hundreds of cases of fistula 
which have been reported (Bouque alone cites 639 operated upon by su- 
ture) proves the rarity of conception in these cases. Among Kroner's 37 
cases 21 were pregnant once, 12 twice, 3 three times, and one had a series 
of children. 36 of them bore 54 children; 9 only went to full term, and 
23 suffered from abortion or premature labor. There was much varia- 
tion in the exact mode of birth; but the number of cases was too small to 
draw any definite conclusions about. Out of 9 cases in which the fistula 
was subsequently examined, 8 were unchanged, and one considerably 
enlarged. Finally, in 37 confinements, many of which were premature, 
there were 2 deaths, a high percentage. 
When the fistula is small, high up, and there is but little loss of urine, 
the general health maybe entirely unimpaired. I have seen patients who 
not only did not suffer in their nutrition from pretty large fistula?, but who 
could not make up their minds to undergo the operation necessary for 110 
THE FEMALE URETHRA AND BLADDER. 
their cure. But these are exceptions. The constant wetting, the urin- 
ous odor, the excoriation and pain around the genitals, the loss of appe- 
tite, the disturbed sleep, the frequent colds, eventually cause loss of 
strength, a gray anaemic appearance, and melancholia; the patients become 
a nuisance to themselves and their friends, and readily submit to repeated 
operations in the hope of cure. 
One symptom remains to be mentioned of which different explanations 
have been given; that is constipation. Jobert believes it to be due to a 
tonic contraction of the rectal muscular fibres from the irritation caused 
by the flow of urine. Freund believes that increased urinary secretion is 
caused by the ready outflow (as occurs in other secreting organs under like 
conditions), and hence the sluggishness of the bowels. Although Schafer 
(Giessen) has proved that there is such an increase, it is so small (2 to 5 
per cent.) that it can hardly be the cause. It is probably due to want of 
exercise, depressed spirits, the puerperal state, and the anaemia resulting 
from these various causes. 
Death rarely ensues in consequence of urinary fistula. These women 
live on miserably year after year until they are either cured by operative 
procedure or they die from some intercurrent disease. In one of my cases 
a pleuro-pneumonia with subsequent phthisis followed within three 
months of her confinement, and carried off the patient before any opera- 
tion was done (see Kohler's case, 7). 
Diagnosis of Urinary Fistula.-As soon as a women who has had a severe 
confinement, or has cancer, or has had some operation like removal of the 
portio vaginalis with ecraseur or galvano cautery, begins to complain of 
trouble in making water, a thorough examination of the entire genital 
system should at once be made. It might of course be possible to detect 
by touch a necrosed spot in the vesico-vaginal septum from the pain occa- 
sioned by pressure there, and thus the existence of a fistula be suspected; 
but as a rule the task of determining the exact seat, size and complications 
of the fistula is not an easy one. If it is half an inch or more in size, and 
if it is situated in the anterior vaginal wall, digital examination, and the 
passage of a catheter into the bladder and through the fistula into the 
vagina will suffice. But if the fistula is situated to one side, and is small, 
or perhaps is placed in the depths of a forceps-cut, the task is much more 
difficult. The finger does not recognize it, nor can the catheter be passed 
through it. The bladder must be emptied by the catheter, to find out if 
there is any urine in the organ, and if there is whether it is bloody or not. 
If none is found, the patient is to be forbidden to urinate voluntarily for 
one oi' two hours, and dry napkins laid under her. At the end of that 
time the catheter is again passed, and any urine obtained is to be quan- 
titatively and qualitatively examined. If there is still doubt, Simon's 
speculum and the duck-billed instrument for the posterior vaginal wall is 
to be employed, the mouth of the womb accurately and firmly closed with INJURIES TO THE FEMALE BLADDER. 
111 
a plug of white cotton, and 8 to 12 ounces of some dark-colored fluid 
poured gradually into the bladder with a Hegar's funnel through a clean 
catheter. Close observation of the anterior vaginal wall will inform us 
whether any fluid, passes or not. If such an exuding spot is found, it is 
to be immediately fixed with small hooks, and an attempt should be made 
with the sound to penetrate through the fistula into the bladder. Milk, 
or a solution of permanganate of potash are the best fluids to use for this 
purpose, and of course the anterior vaginal wall should be well dried 
beforehand, so that the smallest quantity of fluid may be recognized. 
If not a drop flows into the vagina, there cannot be a vesico-vaginal 
fistula; but there may be a vesico-uterine fistula.' The plug is now taken 
out of the cervix, and, if there is such a fistula, the white cotton will be 
found to be colored, and the dark fluid will exude from the os uteri. The 
cervical canal can then be rapidly dilated with metallic dilators or an ap- 
propriate speculum, or the commissure may be incised, so as to expose 
its inner surface to view. 
If the fluid pass through neither of these channels, and if it is certain 
that there is an involuntary loss of urine, a fluid containing urea flowing 
into a clean porcelain vessel when the urethra is closed by a solid bougie, 
there can only be a uretero-vaginal or a uretero-uterine fistula. In the 
first case there will be near or behind the vaginal portion a little orifice, 
or a button-shaped prominence with a hole in it; into this the sound can 
easily be passed foi* a certain distance upwards and backwards; and care- 
ful examination will reveal the fact that a clear fluid flows in varying 
quantity from the orifice. 
If, when the cervix is tightly plugged, the vagina remains quite dry, 
there can be no uretero-vaginal fistula. Is there a uretero-utero-cervical 
fistula ? There is, if the fluid issuing from the cervix is distinctly proven 
to be urine, and if the fluid is not colored by injection as above into the 
bladder. If, as is often the case, the vagina is so stenosed that the fin- 
gex- cannot be introduced, the colpeurynter or compressed sponge or inci- 
sion must be employed, to be followed by Simon's urethral specula, and 
the finger. 
Finally, there remains another method of diagnosis, the rapid dilatation 
of the urethra with specula, <md the subsequent palpation of the inner 
surface of the bladder. Simon has in this way (Publ. No. 10) several 
times determined the exact size and boundaries of vesical fistulas. But 
small fistulae can be felt but with difficulty or not at all, as I saw myself 
only lately in one which was situated far to the left side. 
In the same way we can examine whether any other organ, the ovary, 
the processus vermiformis, or the small intestine communicates with the 
bladder, our attention being directed to these points by finding pus, or hair, 
or remnants of food in the urine; to which points we will return later. 
It will also enable us to decide whether substances found in the urine 112 
THE FEMALE URETHRA AND BLADDER. 
come from neighboring organs, or whether they are portions of tumors 
of the inner surface of the bladder. When we cannot insert the finger 
into the orifice we feel, we may be able to pass an elastic catheter along- 
side it through the opening. We may thus obtain some of the secretion 
of the part and directly apply treatment to it. 
The fistula once found, and its seat exactly determined, the nature of 
its borders, their fixation, tension, and direction is to be considered, the 
condition of the uterus looked to, not forgetting to search for more than 
one fistula. In difficult cases repeated examinations will be necessary, 
and chloroform will have to be used in sensitive patients. We will use, 
according to circumstances, Simon's dorsal, Bozeman's knee-elbow, or the 
Sims-Emmett side position, selecting that one which renders the fistula 
most clearly visible. Only after a most thqrough inspection and palpa- 
tion will we be in a position to give a correct prognosis regarding its fis- 
tula, and to take proper means for its cure. 
Prognosis.-Urinary fistulas are always serious maladies, since they ex- 
ercise a deleterious influence upon the patients' health, and render their 
condition a most uncomfortable one. It is true that spontaneous cure 
may occur. Bouque (1. c. p. 8G to 87) has found GO such cases recorded, 
including even fistula into whose vaginal opening 1 or 2 to 4 (!) fingers 
could be passed.1 Some of these cases had existed for months and years. 
Thus a case of F. Hildanus had lasted 8 years, one of Duparcque's 4 
years, one of Zechmeister's 4 to 5 years, one of Ehrmann's 14 months, and 
one of Conradi's G| years. The author himself records two cases of small 
fistula in the appendix, which even both healed in 14 days; one spontane- 
ously, and the other after a single cauterization with liquor ferri sesqui- 
chlorati; and he can add two cases of spontaneous cure from the practice 
of his father. Leishman observed a case of vesico-uterine fistula, in which 
spontaneous cure occurred in consequence of inflammatory atresia of the 
cervical canal. But a spontaneous cure is very rare, and therefore every 
case of this kind is recorded. In cases where a calculus caused the fistula, 
the abnormal opening closed after the cause was removed. In the sixty 
cases mentioned above, stone was the cause in 6; pessaries in 2; confine- 
ment had preceded the malady in 28, and 17 of these confinements had 
been completed by artificial means; and once only did the fistula occur 
in consequence of a fall upon a pointed object. Most favorable of all will 
the prognosis be in those cases where the bladder has been wounded by a 
sharp, non-contusing instrument, as in lithotomy. The chances of 
spontaneous cure depend on the seat of the fistula, the direction of its 
long diameter, the tension of its edges, their thickness and vitality, as 
well as the presence of complications, such as inversion of the vesical 
mucous membrane. 
1 Cases of Fabr. Hildanus, Cederschjold, Guthrie, Sedillott, Feron, Habit, Dan- 
yau, Depaul, Monod, Denaux and Gaitskel. INJURIES TO THE FEMALE BLADDER. 
113 
As regards the prognosis of the different kinds of fistulae, we would ex- 
pect a priori that the lowest, being the most accessible, would bo those 
most easily curable. Such is by no means always the case. Simple 
urethro-vaginal fistulae have indeed sometimes been cured both quickly 
and easily. Pecchioli cured one by cauterization with nitrate of silver 
in 25 days; Da Costa, Duarte and Hobart did the same with cauterization 
and a single suture; the author cured 12 with stitching simply. But the 
injuries to the lower portion of the bladder, in which the urethra takes 
part, are much worse. For not only is the urethro-vaginal septum much 
thinner than the vesico-vaginal one, but it is difficult to spare sufficient 
tissue for the operation, since the thickness of the muscularis and the whole 
wall diminishes from above downwards, and the danger of incontinence 
increases as it gets thinner (Simon). On the other hand those fistulae 
which are situated below the vesical mouths of the ureters, and the 
uretero-vaginal fistulae, were held by many to be of the most unfavorable 
prognosis. As Simon has shown us, this is not always the case. Those 
of the first class are all curable, as are also many isolated uretero-vaginal 
fistulae. 
The most recent collection of statistics as to curability are those of 
Bouque. They are as follows: GO fistulae of various kinds healed sponta- 
neously; 109 ditto healed by cauterization; 25 out of 34 by immediate 
secondary union = 71.4^; and 463 out of G39 fistulse by suturing = 72.0^. 
Thus of all cases are incurable in the hands of the most skillful prac- 
titioner. Besides this, a large proportion of the patients cured had to 
undergo several operations. Many operations done by most skillful sur- 
geons fail; as has happened to Jobert, Bozeman, Simon, B. S. Schultz, 
Baker Brown, Schuppert, Courty, Spiegelberg, de Roubaix, Follin, An- 
drade, etc. Many fistulae are at once declared incurable, either on ac- 
count of the great loss of substance, or because of the destraction of the 
urethra. Even when the operation has been successful, complete con- 
tinence has not always been obtained, some patients being unable to retain 
their water when standing or walking. In addition to this the operation 
itself may be dangerous, especially when working in the neighborhood of 
the peritoneum; so that death has occurred in the most skillful hands.1 
So that we must be cautious in giving a favorable prognosis for certain 
fistulse; nor must we forget that whether we use cauterization, or the 
knife, whether we are tyros or practised operators, we may possibly make 
the patients condition much worse by increasing the size of the fistula. 
Thus Bozeman's case No. 2 was one previously operated upon by G. 
Simon (No. 10); and the lentil-sized fistula which Simon had left was large 
enough to accommodate a finger easily after Bozeman's operation. 
1 Simon 4.4 percent., and single cases by Roux, Wutzer, Herrgott, Jobert, 
Dieffenbach, Follin, Spiegelberg, Schuppert, Sims, Heppner, Kuchler, Courty, 
Wilms, and others. 114 
TILE FEMALE URETHRA AND BLADDER. 
Finally, many fistula? can only be closed by operations which render the 
patient sterile for the future, either by using the posterior lip of the cer- 
vix to fill the defect caused by the loss of tissue, or by obliterating the 
vagina transversely. Occasionally after this latter operation, as after 
marked stenoses of the vagina, a satisfactory cohabitation is no longer 
possible. 
Even after the operation is done the sufferings of the patient are by no 
means necessarily ended. Calculus formation, cystitis, and pyelitis (case 
2 of Simon) may still cause a fatal termination. 
The causes of death in non-operative cases are either of a local or of a 
general nature. Local inflammatory processes, peritonitis, ulceration, 
general exhaustion, or even tuberculosis, may occur. The cases that 
died after operation were either cases in which peritonitis followed injury 
to the peritoneum (Spiegelberg, Simon, Bozeman), or where death was 
caused by pyelitis or septicasmia following suppurative inflammation of 
the connective tissue between bladder, uterus, and rectum. 
On the other hand weak and emaciated patients sometimes recover so 
quickly after a successful operation as to be hardly recognizable. The ex- 
tensibility of the bladder, even when large defects have been present, 
increases continually. If conception now ensues, pregnancy, delivery and 
childbed may run a perfectly normal course, if there are no extensive 
stenoses. This was the case in Simon's cases G, 23, and 30. I have 
already mentioned my father's case, in which a new contusion at the same 
spot in the next delivery cured the fistula. In recent times the success- 
ful operations of the German surgeons have risen to 85 to 90 per cent.;1 
the mortality hardly reaching 2 to 3 per cent. It is true that Verneuil 
lost 5 of the 80 patients he operated upon = G.2 per cent; but they were 
done at a time at which antiseptic precautions were hardly used in France. 
Treatment oj Urinary Fistula}.-A repeated examination of the fistula 
will soon show us whether there is any hope of cure by operative proced- 
ure, or whether it is incurable, and the symptoms only .can be treated. 
In all recent cases, before thinking of operation, we would endeavor to 
obtain spontaneous cure by removing all hindrances and obstacles to the 
process. 
Various are the ways that have been proposed to obtain this end. 
Fabricius Hildanus used frictions of the edges, injections, balsams, and 
internal remedies. Desault placed a cylindrical pessary in the vagina; 
Monteggia, Barnes, Marjolin, Sedillot, Herrgott, Habit, Nelaton, Danyau, 
Follin, Conradi, Gaitskel employed the permanent catheter, either with 
or without vaginal injections; others tamponed the vagina in addition, 
so as to prevent the outflow of urine through it, as Cumming, Freund, 
Burkner, Aubinais, Danyau. Others again introduced a sponge. Elsasser 
1 Simon, Hegar, B. S. Schultze and Spiegelberg. INJURIES TO THE FEMALE BLADDER. 
115 
had one patient lie upon her abdomen for nine weeks, without using the 
catheter, and giving only low diet; he cured her in twelve weeks. Bur- 
chard (Breslau) cured four cases of vesico-vaginal fistula by the vaginal 
tampon alone. Some, like Duparcque and Dupuytren, used mild aperi- 
ents, secured extreme cleanliness, and saw the fistula heal without further 
local treatment. In this category belong the cases of spontaneous cure 
after the extraction of perforating calculi or incrusted pessaries. Reid 
cured a fistula by plugging it, so that no urine could pass, by means of a 
bottle-shaped bag of inflateable rubber. Raffaele (Florence) recommended 
the use in the vagina of an inflated bladder to 'cause pressure. Tomes 
de la Villanueva improved his patient, and secured continence of urine 
for several hours, by making his patient lie continuously on one side; she 
finally got entirely well. A like case of vesico-uterine fistula is related by 
Habit. Zechmeister had a patient who could only endure the catheter 
for forty-eight hours; so he had it used every half hour while walking and 
standing, and every 2 to 3 hours while lying down. 
Reybaud (Lyons) closed the fistula with an obturator, introduced a 
sponge into the vagina, and fixed the whole with a T-bandage. 
Feron (Paris) used a pig's bladder for a considerable time as a col- 
peurynter, and then a rubber pessary. The patient recovered, and had a 
child one year later without further injury. 
Maruejouls cured a case by using a Gariel pessary, and was able to 
discontinue it after a few months. 
Conradi cured a patient by using a golden button, the head being in 
the bladder, the neck in the fistula, and the plate in the vagina; in five 
years it fell out, and the patient was cured. Verneuil, Schup, F. 
Winckel, Depaul, Hildebrandt, Monod, Freund, and others saw the spon- 
taneous healing of fistulae without any local or general treatment at all. 
Not only small, but very considerable fistulse have closed in this way 
(Guthrie, Marjolin, Hildebrandt), and we should always first endeavor 
to obtain it. Thus Palfrey, who formerly operated as soon as possible, 
now holds that by procrastinating many patients can be spared the neces- 
sity of undergoing any operation at all. Two indications are to be ful- 
filled, to effect a ready outflow through the urethra, and to prevent an 
outflow through the vagina. The former indication is met by placing a 
metallic or elastic catheter in the bladder. Thus Fritsch (J. D. Von 
Heyne) passes a drainage tube 4 inches long and inch in diameter 
through the urethra in the bladder, and washes the viscus out through 
it. Every two days the tube is removed and cleaned. The carbolic in- 
jections also exercise a mild cauterizing effect upon the edges of the fis- 
tula. Two cases were cured in this way. If the catheter or drainage tube 
is not well borne, we must catheterize every 1 to 3 hours. The second 
indication is to be met by a careful tamponade of the vagina. The best 
material to use for this purpose is the ball of salicylated cotton covered 116 
THE FEMALE URETHRA AND BLADDER. 
with linen, which Esmarch has introduced into practice; for small portions 
of loose charpie and cotton can easily pass through the fistula into the 
bladder, and there form the nucleus for the formation of stone. The 
colpeurynter and sponges are not sufficiently antiseptic, nor do they fit 
well enough. If the amount that passes through the vagina is small, the 
tampon may remain in situ for several days; in other cases it must be 
renewed daily after evacuating the bladder with the catheter. 
The healing of the fistula may be favored by placing the patient in an 
appropriate position, either lying on the side opposite to the fistula, or 
lying upon the abdomen. (See Winn.) 
There are authorities who are opposed to the above method, and who 
claim that the catheter is not well borne by an irritable bladder, and that 
vesical spasm, abdominal pain, vomiting, and other symptoms are caused 
by it. Among them are Velpeau, West, Baker Brown and others. This 
is sometimes the case; and then we can only pass the catheter every few 
hours, or perhaps not at all. The tampon will cause no trouble, and it 
may be tried both in recent and in old cases. So long as the patient im- 
proves it is to be continued, for months if necessary. 
If the fistula becomes no smaller, and the patient is no better, is opera- 
tive interference indicated? and if so, of what nature should it be? 
The answer to the first part of this question depends upon the size, seat, 
nature, and complications of the fistula. It depends also upon the ex- 
perience of the surgeon: Simon has cured many a fistula which other sur- 
geons have failed to remedy. For it is undeniable that as in recent times 
the operation by freshening the edges and suturing is more and more fre- 
quently and successfully done, the more the other methods arc neglected 
and cast aside. To Ed. F. Bouquc belongs the credit of having reintro- 
duced among others the method of cauterization either alone or together 
with immediate union of the edges; for he rightly says that: " Les fis- 
tules vesico-vaginales dans leur grande variete ne repondent pas a une 
seule indication, a un seul de moyens therapeutiques connus; mais que 
tons sont appeles a rendre, dans un certain nombre de cas, des services a 
1'exclusion des autres et que tous par consequent meritent d'etre etudics 
a un egal degre. " 
Lotus now consider cauterization as a means for the cure of urinary 
fistula?. Its object is to cause the formation of a more or less deep eschar 
at the edges of the wound, or in its neighborhood, and to close the orifice 
by the granulation and cicatrization which occur when the slough is cast 
off. Various caustics maybe used; the red-hot iron, the galvano-cautery, 
nitrate of silver, acid nitrate of mercury (Ehrmann, Cousot), creosote 
(Emmert), sulphuric acid (Soupart, Du Moulin, van Wetter, Deneffe, de 
Lorge and others), chromic acid (Deneffe), the juice of euphorbia (Sou- 
part), caustic potash (Deneffe, van Wetter), chlorine water, Vienna paste 
and others. They may be applied either from the vagina to the genital INJURIES TO THE FEMALE BLADDER. 
117 
mucous membrane in the neighborhood of the fistula, or from the vesical 
surface, or finally to the fistulous tract itself. 
Cauterization of the neighborhood of the fistula from the vagina was 
first practised by Chelius in 1844. He cauterized with nitrate of silver in 
substance a broad tract of the vaginal mucous membrane around the 
fistula, and about half an inch from its edges. The method was espec- 
ially favored by Soupart, Du Moulin, van Wetter and Deneffe in Belgium; 
and Soupart modified it by converting the simple perifistular cauteriza- 
tion into a perifistular centripital cauterization, making each successive 
application nearer and nearer to the fistula, yet without touching its edges. 
He used sulphuric acid as well as the actual cautery and the galvano- 
cautery. A second cauterization is undertaken as soon as the eschar caused 
by the one is cast off and the wound is cicatrized. 
An older method was the so-called intermediary or intra-fistular one of 
Desault, which consisted of cauterizing the inner surface of the fistulous 
canal. The actual cautery, and lunar-caustic in holders from which it 
could be projected, were especially used. Dupuytren, Lallemand, G. 
Simon, Soupart, and others have cured cases in this way. Sometimes 
the vesical mucous membrane near the fistulous opening was cauterized 
at the same time. Dupuytren and Velpeau described instruments carry- 
ing a piece of lunar caustic bent to a right angle, which could be projected 
and used to cauterize the vesical mucous membrane for a certain distance 
from the orifice. 
This procedure has been improved upon by Soupart, Deneffe and 
Bouque, so that an intra-vesical cauterization may be conducted as fol- 
lows: in a hollow sound shaped like a uterine sound, but thicker, is a 
mandril, to which a small sponge soaked in chromic acid or a piece of lunar 
caustic may be attached. The fistula is then fixed by the left index fin- 
ger in the vagina, and the bladder being empty the sound is passed to 
the neighborhood of the fistula through the urethra, the caustic holder 
projected, and with the help of the finger in the vagina, is swept over a 
vesical surface surrounding the fistula and some | inch distant from it. 
The cauterizations per vaginam and per vesicam are not always concen- 
tric, and the uneven cicatrization leads to a more rapid reduction of the 
size of the fistula. 
These three methods of cauterization may be used singly or combined, 
on urethro-vaginal, vesico-vaginal, and vesico-uterine fistulse; it is appli- 
cable not only to small fistulae, but to those also which measure 2 to 3 
inches in diameter (Nelaton, Passamonti). 
It may be urged as an objection to the cauterization method that the 
cicatrices it causes in the neighborhood of the fistula diminish the chances 
of a subsequent cutting operation; but this has not been found to be the 
case. It must be conceded, however, that severe intra-fistular cauteriza- 
tion may occasionally cause enlargement of the fistula. 118 
THE FEMALE URETHRA AND BLADDER. 
Cauterization has been recommended for a number of fistulas in which a 
bloody operation is contra-indicated; namely those situated high up in the 
anterior vaginal vault, and those in which the peritoneum is liable to be 
wounded, though peritonitis from the latter cause is hardly to be feared 
now that we use systematic antiseptic precautions. It has also been 
recommended for vesico-uterine fistulas, so as to prevent union of the lips 
of the os and sterility, though the process itself is liable to cause atresia. 
It was not to be thought of for uretero-uterine and uretero-vaginal fistulas, 
on account of the danger of closing the ureter, with subsequent uraemia. 
As to the most suitable time and method for cauterization, there is con- 
siderable difference of opinion. Some authorities, as Nelaton, Verneuil, 
Trelat, West, Sims, Schuppert, would wait six to twelve months, to give 
time for as great as possible amount of cicatrization of the original wound; 
others, like Velthem, Baker Brown, and especially Nottingham, with 
Bozeman, Wright, Warner, etc., recommend cauterization as soon as pos- 
sible: Nottingham relates that he found only small fistulae in a woman 3 
months after confinement; but that 3 months later, probably in conse- 
quence of coitus, they were 3 times larger than before. The length of 
time required for cure by this method is in favor of early cauteriza- 
tion; according to Bouque, when done less than 1 month after the 
injury it was 41.1 days; 1 to 2 months after, 75. G days; later than 2 
months, 115.8 days, and the average. The average time for all cases 
cured by cauterization was 77.5 days. 
There is also no agreement of opinion concerning the length of time 
that should intervene between single cauterizations. If we wait for 
complete cicatrization we may have to wait for months, though my ex- 
perience confirms the opinions of Soupart and Bouque in that two to three 
weeks is usually enough. Only very considerable losses of substance and 
ureteral fistuhe contra-indicate cauterization. It may be employed in 
pregnant women; sulphuric acid has been freely used in such cases by 
Deneffe and Bouque without doing any harm to the patient. 
Cauterization has the advantage of not requiring any special prepara- 
tion of the patient; though the same remark applies to Simon's operation. 
Any position may be employed, and the fistula must of course be as 
thoroughly exposed as for any other operation. 
After-treatment is very unimportant. As a rule, narcosis is not ne- 
cessary. After using neutralizing or refrigerating applications to prevent 
any possible injurious effect of the caustic upon neighboring organs, the 
patient can get up and go about her usual business. It is unnecessary 
to use the catheter at all. rriie believers in cauterization declare tam- 
ponade of the vagina to be useless and harmful. If there is pain 
after the operations, sponges and cloths wrung out in cold or ice-water 
may be introduced into the vagina; or lukewarm sitz-baths, with injec- 
tions of belladonna and opium, may be employed. INJURIES TO THE FEMALE BLADDER. 
119 
In this connection we may mention a method first proposed by Naegele 
V. in 1812, and which consists of union of the edges of the wound by for- 
ceps, serrefines or even stitches, after cauterization. While the first 
instruments used were voluminous and heavy, those of Tellinucci, Mon- 
teros, Deneffe and van Wetter are not heavier than those used by Boze- 
man, Simpson, Atlee, Battey, and others. It is of course necessary that 
the edges of the fistula can be drawn together without any too great ten- 
sion; and granulation along the edges of the cut must be active before- 
hand. Bouque, who believes that this procedure deserves far more atten- 
tion than it has hitherto received, says: the larger the freshened surfaces, 
the greater the chances of healing. He found 35 published cases which 
had been treated in this way, 25 were cured, 4 improved, and 3 died. 
Bouque's list of 639 operations with the knife 1 give a percentage of suc- 
cesses of 72 per cent.: the above 25 cases give a percentage of successes 
of 74.4 per cent.; and he believes it may compare favorably with the 
more common mode of operation. I confess that I have been led to form 
an exactly opposite conclusion; I believe it takes longer time, gives 
much more pain and trouble, and has results which are not so good. 
Altogether I must remark that in spite of the many successful results 
of the method of cauterization, the ideas of the Belgian authors whom 
Bouque represents are opposed to those of the German school. Bouque 
says: For most practitioners the immediate union of the fistula will re- 
commend itself on account of its simplicity and ease of execution, ajid 
many other advantages; and there is no reason why we should not first 
try the value of the various cauterizing agents in any given case. But 
these attempts should be methodical, and should be persevered in for a 
sufficiently long time. We need not have recourse to a bloody operation 
until we have sufficiently proven the uselessness of caustics. The Ger- 
man authorities on the other hand believe that the cauterization of large 
fistula is entirely useless; that severe cauterizations, especially by the 
actual cautery, often do direct damage, enlarging the fistula and trans- 
forming its walls for a considerable distance into hard, unyielding cica- 
tricial tissue; further, that a successful result from cauterization can only 
be expected under certain well-defined conditions, those conditions being 
that the fistula is small and has broad, granulating edges, as recent fistulae 
in the puerperal period, or small fistulas left after other operations. If 
cauterization is not rapidly successful, it is soon abandoned in Germany, 
since by persevering in it we only spoil our chances of a future operation. 
(Hegar, 1. c. p. 351.) That they are not rapid is shown us by the above 
statistics; while hundreds of fistulae have been entirely cured in a few days 
by a bloody operation in the hands of skilled, and even unskilled surgeons. 
1 Cases of Jobert de Lamballe, Follin, Bozeman, Monteros, de Roubaix, Baker 
Brown, Simon, Schuppert and Courty. 120 
THE FEMALE URETHRA AND BLADDER. 
Indeed Professor D. G. Boddaert van Cutsem of Ghent lias personally as- 
sured me that he, as well as the majority of the Belgian surgeons, de- 
cidedly favor operative union, and only exceptionally employ cauterization. 
Since cauterization by no means always cures these fistulae, the very 
earliest authors have sought to devise measures to secure a direct artificial 
union. Roonhuysen proposed in 1G63 freshening of the edges with sub- 
sequent continuous suture. Fatio, a Switzer, is said to have cured the 
first case by suture in 1752. It was then forgotten until Naegele in 1812 
again recommended it. At once many various stitches were proposed by 
Naegele, Roux,Wutzer, Schreger, Ehrmann, Blasius,Colombat, Beaumont, 
Dieffenbach, Esmarch. They did no particular good, partly because the 
fistulae were imperfectly exposed, and partly because the freshening of 
the edges consisted either of a superficial scarification, or the removal of 
a band a line in width. 
Nor could better results be obtained by changing the materials used 
for suturing. Gilded, silver, steel, straight or curved needles, insect 
needles, or the use of silk, golden, iron or silver threads were of no avail. 
Three men have done more than all the others combined for the operative 
cure of urinary fistulae; these are Jobert de Lamballe in France, 1834, 
Gustav Simon of Darmstadt, and Marion Sims of New York. 
In 1853 Simon showed that the gist of the operation lay in an exact 
freshening and a careful suturing. He simplified the operation, and de- 
serves credit for taking it out of the hands of a few specialists, and 
placing it in those of a large number of surgeons and gynecologists. 
The operation may be done at all ages and at any time. G. Simon did 
it in I860 in a girl eight years old. (Case No. 9.) It has been done after 
sixty. It has been performed successfully during menstruation, and 
during pregnancy, though premature delivery has been seen to occur in 
consequence. (Schwartz.) Excepting carcinoma of the uterus or vagina, 
the only contra-indication is such excessive weakness as to render speedy 
death probable, as in a case suffering from a rapidly progressing cheesy 
pneumonia. In such cases no operation should be undertaken, since the 
pain, loss of blood, uncomfortable position, and the use of chloroform, 
might cause the patient to die upon the table. 
The best time for operation was formerly the subject of much discus- 
sion. Nelaton, Verneuil, Sims and West placed it at 6 to 9 months, 
Kiwisch, Baker Brown, Bozeman, Simon and Hegar at a few weeks after 
the occurrence of the fistula. Recent statistics show us that it is not wise 
to postpone the ope ration more than 6 to 8 Aveeks after delivery. I have 
repeatedly cured large fistula by freshening and suture, during the first 
G weeks post-partum ; and Hegar always obtained a good result by a first 
operation done G to 8 Aveeks after birth. Hegar rightly claims that the 
treatment of other co-existent maladies is much simplified by the operation. 
Most patients themselves desire to have it done as soon as possible. Even INJURIES TO THE FEMALE BLADDER. 
121 
if the edges of the wound are not yet entirely cicatrized, they can be 
thoroughly freshened; and besides, being unthinned and unfixed by cica- 
tricial tissue, they are more succulent and vascular than they will be later. 
Gravidity is not in itself a contra-indication. Pregnant women stand the 
operation well, and quickly recuperate when the continence of the bladder 
is re-established, as the cases of Cohnstein, Rogowicz, and Schlesinger 
prove. Kroner, however, cites 5 cases, in 4 of which premature delivery 
took place after the fistula operation. In the case of fistulas caused by 
calculi and pessaries, the croupous cystitis and colpitis must first be cured 
and the wound become clean, before any operation can be attempted. 
The exact time of operation will depend upon whether any preparation 
for the operation is necessary. In most cases it is not; especially if there 
are no extensive cicatrices, and no vaginal and vulvar ulcerations. And 
even if such measures should be necessary, it is better to combine them 
with the operation, rather than to draw them out for days beforehand, as 
some surgeons do. Thus Bozeman gradually dilates cicatricial bands by 
cutting, and subsequently by using rubber tampons. Thus the pus and 
urine was directly applied to the cuts, and cojpitis, cystitis, and if the 
pelvic connective tissue be opened, abscesses may occur, as also parame- 
tritis and pelveo-peritonitis, endangering the patient's life. This occurred 
twice to Simon and Bozeman. (Cases 3 and 4.) Simon himself admits 
that incision is difficult and requires considerable experience. Very re- 
cently Bandl, von Massari, and Pawlik have obtained very good results 
by Bozeman's method of preparatory treatment, in sufficiently operable 
fistulas. The vulva and vagina are first cleansed of urine by means of 
sitz-baths and lavements of hot water, and the sore spots are brushed over 
with a 10 per cent, solution of nitrate of silver. The incised cicatricial 
bands are also brushed over in the same way, and the dilating instruments 
introduced. In this manner Bandl, Massari, and Pawlik have always 
thus far been able to avoid kolpokleisis. 
As a rule, vaginal injections, a warm bath, as much nourishment as 
possible, and repeated and exact examinations of the patient, are all the 
preparatory treatment that is necessary. Repeated examinations are 
necessary to determine the size, seat, and complications of the fistula, to 
determine in which position the fistula can be best exposed, and to decide 
beforehand upon the method of operating. 
Now as to the patient's position. Dieffenbach, Jobert, Baker Brown 
and others prefer the simple dorsal or lithotomy position. Deep fistulae 
can be well exposed in it, anesthetization is easy and rapid. But fis- 
tulae seated high up cannot be well-exposed from the inclination of the 
pelvis. Simon has, therefore, introduced the dorsal position with the 
pelvis so elevated that it lies somewhat above the level of the abdomen 
and chest. The thighs are flexed upon the abdomen, and the legs are 
extended. Thus the field of operation is free, assistance can be rendered 122 
THE FEMALE URETHRA AND BLADDER. 
with certainty, the use of several specula and retractors at the same time, 
is possible, and narcosis is well applied. Nevertheless the patient's posi- 
tion, even when the head is supported by a cushion, is unpleasant and 
tiresome, and some patients feel sick for days after being in it. 
The lateral position is much more convenient for the patient, and the 
side corresponding to the fistula should be selected. Less assistants are 
needed, it is unconstrained, anesthetization can be easily affected, and 
the height of the buttocks can be varied for higher or lower fistulae. For 
those unused to it, the exposure of the fistulae and the use of instruments 
will present some difficulty in this position. Sims is its chief advocate. 
His pupil, N. Bozeman, has, however, selected the knee-elbow position, 
which Schreger, Wutzer, and Simpson had already employed. Bozeman 
uses a special speculum (see Fig. 28) consisting of two lateral blades 
united by a metallic bar, which bears the screw; when dilated to a cer- 
tain extent, the blade for the posterior vaginal wall can be inserted. 
Simon was convinced, by seeing one of Bozeman's operations, that with 
his position and speculum the fistula can be admirably exposed, and the 
result of every cut and every stitch can be seen during the entire opera- 
tion. But he believes that it is very difficult to handle the instruments, 
since Bozeman used the scissors in fistula which were easily exposable 
and took off considerable tissue, while Simon for various reasons prefers 
the knife, and spares the substance of the septum as much as he can. 
However that may be, the accompanying illustration from Neugebauer 
(Fig. 29) plainly shows that the knee-elbow position is the least convenient 
of all for the patient, is the worst for anesthetization, is the most com- 
plicated in the apparatus it requires, and is the most annoying for the 
operator, since the legs are here more in the way than in any other posi- 
tion. These are serious objections; and since Bozeman in the competitive 
operations attained no better result than did Simon with his position, 
Simon's or Sims's positions are always to be preferred. 
After the patient has been placed in one or other of these positions, she 
must be held in it by the assistants. Since patients often make vigorous 
movements while narcotized, I have repeatedly tried by means of broad 
padded leather pelvic girdles, to fasten the patient's pelvis to the table, 
and prevent motion. But the girdle always pressed upon the abdomen 
between the anterior superior iliac spines, and several unpleasant cases of 
asphyxia while under chloroform occurred; so that I had to give up the 
use of the girdle. 
Narcosis is not always necessary. After the patient has been placed in 
the proper position, we may proceed to expose the fistula. Jobert and 
Simon drag down the uterus, while Bozeman and Sims do not displace 
the fistula, but operate in situ. All operators first lift up the posterior 
vaginal wall with a blade or plate, and then draw asunder the two sides 
with retractors. (Fig, 31, a, b, c.) If the patient is in Simon's or the INJURIES TO THE FEMALE BLADDER. 
123 
lateral position, and the anterior vaginal wall falls down under the fistula, 
it must be elevated with one of Simon's vaginal retractors, or it may be 
lifted with a sharp hook. If the upper edge of the fistula is high up near 
Fig. 28.-Speculum for Fistula Operations. (After N. Bozeman). The plate a is introduced 
between the two side plates b and c. 
the uterus, it may be made more accessible by drawing down the os with 
a hook, or by passing a couple of strong silk threads though it, knotting 
Fig. 29-Knee-elbow Position. (After L. A. Neugebauer, of Warsaw.) 
them, and giving them to an assistant to hold. If the uterus is fixed by 
cicatricial bands, or if a precedent inflammation renders the existence of 
adhesions probable, the uterus is not to be dragged down. If the loss of 
tissue is not great, and the vesico-vaginal wall is movable, displacement 124 
THE FEMALE URETHRA AND BLADDER. 
of the uterus is entirely unncessary. It is of especial importance to ex- 
actly explore and expose every edge and corner of the fistula; for it has 
happened to the most practised operators, as to Simon in No. 4 of the 
competitive operations, not to fully close the fistula, but to forget to 
freshen and unite the edges of some hidden corner. Various means have 
Fig. 31.-G. Simon's Retractors, without a 
with 2 to 3 Points. 
Fig. 80. 
been recommended to prevent such errors. Chassaignac has constructed 
an instrument to be introduced from the vagina (Fig. 30), which contains 
six booklets to be projected by a piston, and, the hooks catching the edges 
of the fistula, to stretch it apart. Similar to this, but not so good, is the 
instrument that Roser has described (Fig. 32.) Antal (Budapest) uses 
a rubber ball to evert the edges of the fistula and render them tense. It INJURIES TO THE FEMALE BLADDER. 
125 
can be dilated to various sizes, is introduced closed into the fistula, and 
blown up through a rubber tube fastened with a stop-cock. To cut off 
the edges of the fistula we must accurately grasp each portion; for this 
purpose long-hooked forceps, like that of Simon and Matthieu (Fig. 
33, a and 5), or that of Simon and Roser (Fig. 34, a and 5), or sin- 
gle or double hooks (Fig. 34, c) are all that is necessary. They are to be 
preferred to more complicated apparatus. 
Probably for the same reasons the various complicated specuke intro- 
duced with the object of diminishing the number of assistants, have not 
Fig. 32. 
Fig. 33 a. 
Fig. 33 b. 
found general acceptance. Marion Sims's instrument is shown in Fig. 36; 
the American and that of Spencer Wells in Figs. 37 and 38; and the com- 
plicated apparatuses of Neugebauer, Ulrich, and Bozeman in Fig. 35. 
For we cannot vary the tension and position of the fistula with them as 
minutely as may be necessary during the operation. If cicatricial bands 
prevent the full stretching of the fistula, they must be incised, or divided. 
The edges of the fistula being fully exposed, we now proceed to fresh- 
en them up. Different instruments are used by various surgeons for 
this purpose. G. Simon and Sims employ only long-handled straight or 
elbow-bladed knives, with blunt or sharp points; while Bozeman only 126 
THE FEMALE URETHRA AND BLADDER 
Fig. 34. 
Fig. 35. 
Fig. 36. 
Fig. 35.-Three-bladed Dilator of Neugebauer. Applied in the knee-elbow position for a 
fistula-operation. 
Fig. 36.-Marion Sims's Fistula Speculum. INJURIES TO THE FEMALE BLADDER. 
127 
transfixes the edges of the fistula with his knife, and completes the abla- 
tion of the edges with the scissors. Simon made the objection to the 
scissors that it was liable to contuse the tissues and cause considerable 
loss of substance, and that in vesico-vaginal fistulas situated near the 
urethra it might easily endanger continence, although he admitted that 
the operation could more easily be done with the scissors than with the 
knife in the deeper cavities. But he says that when we come to the suc- 
cessive ablation of the edges, to be continued until we reach perfectly 
healthy tissue, the knife is far preferable to the scissors for the preserva- 
tion of tissue. We endeavor, of course, to obtain broad, smooth, vascular 
edges, free from cicatricial tissue; it has therefore been disputed whether 
it is preferable to freshen along the surface of the vagina, and spare the 
vesical mucous membrane as much as possible (the American method), 
Figs. 37 and 38.-Spencer Wells's Specula for Fistula Operations. 
or to freshen perpendicularly from vagina to bladder (G. Simon). The 
former method will probably enable us to avoid vesical hemorrhages with 
greater certainty. Hegar employs the flat funnel-shaped freshening when 
the edges still contain cicatricial tissue, claiming rather inconsequently 
that he thus sacrifices less tissue than he would if he freshened perpen- 
dicularly outside the area of scar-tissue. 
It is necessary before incising to mark out with the point of the scalpel 
the line of incision upon the vaginal mucous membrane; thus enabling 
us to keep at an even distance from the borders of the fistula. In doing 
this we must take into consideration the best direction to cut, so as to 
secure coaptation of the edges. The invaginated vesical mucous mem- 
brane which projects through the fistula must be replaced and held back 
before the cutting begins. This may be done by a sponge attached to a 
thread and passed into the bladder, or by an assistant holding back the 
tissue by means of a sponge attached to a sponge-holder. But the intro- 128 
THE FEMALE URETHRA AND BLADDER. 
duction of a good-sized catheter into the bladder will suffice to crowd the 
fistula from the vesical side against the instruments of the operator, and 
thus make the requisite tension. It will do so best, of course, with small 
fistulae. 
The lowest edge of the fistula is now transfixed about half an inch 
from the orifice, and the freshening of the edges is proceeded with evenly 
Fig. 41. 
Fig. 40. 
Fig. 39. 
Fig. 40.-Hegar's Fistula-knives. (Fig. 138 in Hegar-Kal tenbach.) 
Fig. 41.-Position of the Uterus. H H, Near the uterus. Blh, Vesical neck. (After Luschka.) 
along the line marked out. Meanwhile the assistants carefully sponge 
and irrigate the wound with a 3 to 5 per cent, carbolic acid solution. 
Spurting arteries must either be seized with an artery forceps, or twisted, 
or tied. There is most danger from the large arteria vesico-uterina, 
which runs along the side of the cervix uteri, and is sometimes as thick 
as a crow-quill. If it were cut, the threads of the ligature might be 
passed out through the wound, Simon having proven that this does not INJURIES TO THE FEMALE BLADDER. 
129 
necessarily disturb healing by first intention. The smaller arteries which 
may be cut will be included in the subsequent stitches. 
There is no doubt that the ureter may be cut through whilst freshen- 
ing the edges of such a fistula, especially if it be large and is laterally 
placed. It may be recognized by noticing the urine flow from a small 
orifice, into which a sound can easily be passed for a considerable distance 
upwards and backwards. We must then endeavor to bring the cut end 
into the bladder. It is to be fixed in the edges of the wound, slit up for 
a certain distance towards the bladder, and then a broad, flat surface 
Fig. 42. 
Fig. 43. 
Fig. 44. 
Fig. 45. 
Fig. 46. 
freshened for it to unite to. The openings of the ureters in the bladder 
according to Simon 1 correspond to a point in the vagina about f of an 
inch outside the outer edge of the os uteri, and about of an inch in 
front of it. Simon has operated upon quite a series of cases where the 
fistula was at this place or extended to it; but he never observed a symp- 
tom which he could with certainty refer to closure of the ureter. In all 
these cases the ureter was either not included, or if it was the thread cut 
through the ureter so quickly that no marked interference with the flow 
1 Compare Luschka, Fig. 41, and M. Hall. Contribution to the topography of 
the female ureter, Wiener Med. Wochenschr, XXXII. 45, 46, 1882. 130 
THE FEMALE URETHRA AND BLADDER. 
of urine ensued. If the ureter is seen to project into the fistula, it can be 
pushed away into the bladder. Pawlik in every fistula operation intro- 
duces an elastic catheter through the urethra into each ureter, only re- 
moving them after the operation is finished. If this precaution, however, 
has not been taken, and if after the operation there occur symptoms of 
interference with the flow of urine, colicky pains originating in the 
kidneys and radiating along the course of the ureters, with vomiting, etc., 
the sutures must be at once removed. Finally, before putting in the 
Figs 47 and 4S.-Needles and Needleholder. (After L. A. Neugebauer.) 
stitches we must be certain that the bleeding surface is everywhere smooth 
and clean; all projections, etc., may be snipped off with the scissors. 
The edges of the fistula being now fully prepared, we must decide upon 
the material to be used for the sutures. Each surgeon naturally advo- 
cates the kind he uses himself; Simon likes Chinese silk, whilst Sims, 
with Bozeman and Hegar, prefers silver wire. I have used silk, silver 
wire, and iron wire, and in one case where there was but very Tittle 
tension upon the elongated fistula, even catgut, and have had successful 
results. Simon objects to wire because he says it is very liable to become 
the nucleus of a calcareous deposit. But this happens just as often with INJURIES TO THE FEMALE BLADDER. 
131 
silk, (see Simon's 17th case,) and silk cannot remain as long in situ as 
can the wire. When there is much tension, when the loss of tissue is 
great, when the stitches have to remain in 8 or 10 or more clays, silver 
wire or iron wire is decidedly preferable. Only recently I removed some 
iron wire from the vesico-vaginal septum which had lain there for 10 
weeks without causing a trace of local irritation. Silkworm gut or Fil de 
Fig. 49.-Method of Operating when there is Atresia of the Urethra between two 
Fistula. (After Simon.) 
Florence is a very excellent material, and I have used it almost exclusively 
in fistula operations for the last 7 or 8 years. The best plan is to use 
the materials most suitable for each case, and sometimes to use more 
than one kind at an operation. Pippingskjeld uses alternate iron and 
copper or iron and silver threads at distances of j of an inch, and claims 
by this galvanic suture to have obtained union when he could not have 
done it in the ordinary way. 132 
THE FEMALE URETHRA AND BLADDER. 
The needles (Fig. 42), are either curved ones of various sizes used with 
a Simon (Fig. 43) or Bose (Fig. 44) needleholder, or they are long and 
hollow like those of Simpson (Fig. 45) or Salter (Fig. 4G) or Neuge- 
bauer (Figs. 47 and 48); Hagedorn's needleholder may also be used. It 
was formerly the custom to put the stitches at different distances from 
the margins of the wound; and Simon and Kuchler used the so-called 
double suture, the more distant (^ inch) threads being designated tension, 
and the nearer ones uniting sutures. Latterly Simon himself gave up 
these tension-sutures (compare Fig. 49) and passes all his sutures one or 
Fig. 50.-(After Hegar.) 
Fig. 51.-(After Hegar.) 
two lines from the edge of the wound. When the edge of the freshened 
surface is considerable it is not necessary to transfix the vesical mucus 
membrane; Simon usually did so, but not always (comp. Fig. 49), whilst 
Sims and others avoid it. About lines should be left between adja- 
cent sutures. But before the surfaces are united the entire surface of 
the wound must be wiped, and washed with cold water to remove coagula 
and other foreign bodies from between the surfaces to be united. When 
the stitches are tied, union may occur transversely, or longitudinally or 
obliquely. The first is the best, causing the least tension. Simon rightly 
always united the edges in the direction of the longest diameter of the 
fistula. Triangular fistulie, whose base is at the urethra whilst their apex INJURIES TO THE FEMALE BLADDER. 
133 
is at the os uteri, and large square openings he even closed thus T and 
thus and cured them. He regards it as a disadvantage of Bozeman's 
method that from the lateral tension upon the vagina the fistula had 
always to be united transversely. (Comp. Figs. 49, 50, 51.) 
In deep-seated fistulas, and such as cannot easily be dragged down, it is 
not easy to tie the knot of a silken suture, and the thread is very liable 
to break in the operation. This cannot occur with wire. Bozeman lays 
a leaden plate upon the wound before twisting the sutures, and presses 
this plate against its edges by the wires. He then passes the wire through 
split shot. The whole proceeding is too complicated to find general ac- 
ceptance, nor does it ensure any better results than a simple knot in silk 
sutures, or twisting wire sutures directly over the wound. Bozeman 
uses very thick wire, and places his sutures f of an inch apart. 
Fig. 52.-The Scars of the two Fistula with Atresia of the Urethra. 134 
THE FEMALE URETHRA AND BLADDER. 
After all the sutures are tied, and their ends cut off short, the bladder 
should be emptied with the catheter and washed out with a weak solution 
of salicylic acid. This enables us to decide if our union is perfect, or if 
any fluid still exudes. A neglect of this precaution has necessitated 
Simon himself repeating the operation more than once. 
The after-treatment has been greatly simplified by Simon. The 
patients are allowed to urinate at will, and can get up at once if they feel 
strong enough to do so. On the fourth or fifth day, if silk sutures have 
been used, otherwise later, the stitches are to be removed. The catheter 
is only employed when the patients cannot micturate spontaneously. 
Bozeman on the other hand leaves an elastic catheter permanently in the 
bladder, washes it out several times daily, and gives large doses of opium. 
My own experience is decidedly in favor of Simon's simpler plan. 
Fig. 53 A and B.-Superficial and Deep Vesico-utero-vaginal Fistuue. (After Hegar.) 
Vaginal injections are only necessary if there is any foul-smelling secre- 
tion. Easily digestible food and regular daily evacuation of the bowels 
are necessary. 
The removal of the sutures is to be done, as we have said, on the fourth 
to the sixth day in the case of silk, after the eighth day in the case of 
wire. Sore spots are to be cauterized with the solid stick. 
Any little openings which may be left can be closed by means of caustic 
applications; if this does not suffice, it will be necessary to operate again 
in 2 to 4 weeks time. 
This is the mode of procedure in urethro-vagirial and vesico-vaginal 
fistula. Some special additional precautions are, however, necessary for 
vesico-uterine and uretero-vaginal fistula. 
In the superficial vesico-utero-vaginal fistula the anterior lip of the os 
uteri is freshened and is united to the lower edge of the fistula, which is 
formed by the vesical or possibly the urethro-vaginal wall (Fig. 53 a); 
whilst in the deep vesico-utero-vaginal the posterior lip of the os is to be INJURIES TO THE FEMALE BLADDER 
135 
united in the wound, thus making the woman sterile (Fig. 53 6). Re- 
cently, however, Hegar has several times succeeded in curing longitudinal 
fistula with the help of very small remains of the anterior cervical wall. 
As A. Martin and K. Schroder remark, vesico-uterine fistulae show a 
great tendency to spontaneous cure, though operative interference may 
be necessary when they have existed for a long time. 
In vesico-uterine fistulae, when we cannot, after dilating the cervix, 
close the vesical opening by energetic cauterization (see successful cases 
of Hildebrandt and of Kaltenbach), we must split the cervix bilaterally, 
and bring the fistula into eyesight by dragging down the anterior lip of 
the womb. The edges of the fistula are then to be excised, and the cut 
surfaces united by suture. R. Wilms has told me himself that he did 
this operation successfully long ago a number of times. A. Martin, 
Lossen, Muller (Oldenburg) and many others, have done it; and I have 
cured five of my patients in this manner, (see below). In two of my 
cases closure was not complete immediately after removing the sutures;- 
but it soon ensued. In my first case I used silk, and I was unable to 
remove all the sutures, which had sunken deep into the uterine tissue. 
Several months later four of them encrusted with calcareous salts were 
evacuated by the urethra. If direct union fails, nothing remains but to 
freshen both lips of the womb and unite them together, performing 
hysterokleisis, first performed by Jobert. 
L. Landau has recently proposed in cases of uretero-vaginal fistulae to 
pass a long elastic catheter from the vagina into the upper end of the 
urethra, and then to pass the lower end out through bladder and urethra. 
Then the patient is to be placed in the knee-elbow position, and then the 
uncovered portion of the catheter to be covered with the vaginal mucous 
membrane and the lower ureteral wall. The catheter is to remain in situ 
for some time. If this does not succeed a long oval piece is to be 
excised from the vesical and vaginal wall, and the direct uretero vaginal 
fistula be thus changed into an ordinary vesico-vaginal fistula, into the 
uppermost point of which the ureter opens. Then the vesico-vaginal 
fistula is to be closed by deep sutures which pass through the vesical 
mucous membrane. 
Simon, however, was led by his want of success in his early attempts 
to secure direct and indirect healing of uretero-vaginal fistulae to teach 
in later years as follows: the vesical wall is to be pierced at the place of 
the fistula; a sound is to be passed from the bladder into the ureteral 
opening; and the uretero-vesical wall is then to be slit from the vesical 
surface for a distance of f to f of an inch. The edges of the cut are to 
be daily separated with a large sound until cicatrization has set in. The 
vaginal fistula now lies at a distance from the new ureteral opening, and 
its edges can be freshened and united. A small portion of the adjacent 
vaginal vault could be denuded, and used to help the closure of the 136 
THE FEMALE URETHRA AND BLADDER. 
fistula. Simon regarded this proceeding as more certain than that of 
Landau. 
Very recently L. Bandl operates as follows on uretero-vaginal fistulas. 
He passes a catheter into the bladder and then through an artificial fistula 
and into the ureter. Then he secures union over the catheter, which 
remains in place. Thus like G. Simon he entirely neglects the lower end 
of the urethra; nevertheless he completely cured two patients in this way 
after many unsuccessful attempts. (See Fig. 54.) Schede thinks un- 
favorably of Bandl's method on account of the subsequent cicatricial con- 
traction and striction of the ureter. He first therefore surrounds the 
Fig. 54.-Schematic Representation of the Field of Operation forUretero-vaginal-fistulje 
in the Knee-chest Position. (After Handl.) S 8, Vaginal surface. B, Bladder. U, Vaginal por- 
tion. H, Right, and H', Left Ureter, opening at a in the vagina, b b, Artificial opening into the 
bladder. 
artificial vesico-vaginal fistula with vesical mucous membrane to prevent 
future contraction; and he so arranges it that the ureteral mouth forms 
the outer, posterior end of the artificial fistula. The double fistula is then 
so freshened that there remains immediately surrounding the fistula a 
strip of vaginal mucous membrane 1 to 2 lines in breadth. In this way 
the margins of the fistula are covered with mucous membrane; this pro- 
truded into the bladder forms the half of a deep tube entirely clothed 
with mucous membrane, into whose extreme end the ureter opens. Schede 
cured one patient in this way. 
Finally, B. Crede and Zweifel cured uretero-uterine fistulas by ex- 
tirpating the kidney of the side involved. 
In case the opening of the vesico-vaginal fistula is very considerable, INJURIES TO THE FEMALE BLADDER. 
137 
Courty gradually closes it by successive incomplete operations done at 
intervals of 1 to 2 months. If the defect in vesico-utero-vaginal fistula is 
exceedingly large, Jobert first taught us to loosen the urethra under the 
pubic arch by the so-called vestibular-incision, so that the urethra could 
more easily be drawn upwards. Later, however, he abandoned the pro- 
cedure. G. Simon used it in case No. 2, which had been unsuccessfully 
operated upon by Bozeman in Heidelberg; at the same time he divided 
the commissures of the os uteri to the depth of half an inch in order to 
render the anterior lip mobile. He succeeded in closing the large fistula; 
but the patient could only completely control her water when lying upon 
her back; when she stood or walked it began to dribble after | or an 
hour. Future cases must inform us whether this faulty result was due 
to the short urethra (4 an inch), or whether the loosening caused it; and 
if the vestibular incision can be successfully used at all to re-establish 
continence. 
There occur cases, however, in which the loss of tissue is too great to 
be closed in the manner described; and cases in which the edges of the 
fistula have become attached to bone, so that there are not sufficient soft 
parts to be freshened up; cases where the abnormal opening is situated 
so high up that there is danger of wounding the peritoneum; cases in 
which repeated unsuccessful attempts at closing have been made, leaving 
the fistula larger than it was before. In all these instances there remains 
but one hope for the patient. That consists of closure of the vagina 
below the fistula, the transverse obliteration of the vagina, or Simon's 
kolpokleisis. (Fig. 55). 
Vidal, and after him Wutzer, Berard, and Dieffenbach, had proposed 
in the severest cases to close the vaginal opening; but they none of them 
succeeded in the operation, small clefts or fistulous tracts being always 
left. Schuppert of New Orleans is said to have been the first to secure 
complete closure by means of the so-called episiostenosis, without, how- 
ever, entirely curing the incontinence. It is very evident that this 
proceeding, which prevents cohabitation as well as conception, is only to 
be employed in the most desperate cases, and is always to be done, if at 
all, as high up as possible. Recently Bozeman, Bouque and others have 
claimed that transverse vaginal obliteration has been done oftener than 
is really necessary. Simon has cured such cases in the ordinary way 
after dividing the cicatrix. The indications for the operation are to be 
accepted with great hesitation. 
Kolpokleisis is done by selecting portions of the anterior and posterior 
vaginal wall in the neighborhood of the fistula which will fit to one 
another, and then marking with the point of the scalpel the limits of the 
area of tissue to be freshened. (Figs. 55 and 56.) One assistant then 
with forceps or hooks puts tension upon the part, whilst another pushes 
it out by means of a catheter lying in the bladder. After smoothing the 138 
THE FEMALE URETHRA AND BLADDER. 
edges of the wound and stopping the hemorrhage, two needles threaded 
upon one thread are used to pass the suture through the entire thickness 
of the denuded surface. The sutures pass from above downwards through 
the lower, and from below upwards through the upper border. The 
union should be especially exact at the corners. It is not necessary that 
the sutures should pierce the vesical or the rectal wall; but there is no 
harm done if this does occur. They should be p:y5sed at distances of 
about one line from each other. 
After the operation is finished the new closed reservoir must be tested 
Fig. 55.-Diagram. (After Heyar-Kaltenbach.) 
by means of injections through the urethra. Everything else is to be 
carried out exactly as in vesico-vaginal fistula?. If union is incomplete, 
pregnancy may ensue even though the opening be very small. As a rule 
the product of conception is not carried to term; it may make its way 
into the bladder, or, by enlarging the orifice, pass out by the vagina. 
(Cases of de Roubaix, R. Lane, and the author, No. 6.) If there be 
extensive cicatricial stenosis of the vagina, the operation should be done 
below the scars. In a case in which there was a cherry-sized fistula in 
the right vaginal vault, Simon obliterated the vagina obliquely, so that 
the vagina retained its full length, and only half its vault was closed off 
(see Fig. 57). In another case of kolpokleisis at the level of the urethra INJURIES TO THE FEMALE BLADDER. 
139 
the same operator later loosened the posterior vaginal wall from the wall 
of the rectum, and, covering the latter with a flap, lengthened the vagina 
4 an inch. Both operations are by no means devoid of danger. In the 
first one Douglas's pouch may be opened; and in the second injury to the 
rectum and re-establishment of the incontinence may easily occur. And 
the result to be attained is but a small one. 
Fig. 56.-Transverse Obliteration of the Vagina. (After Hegar-Kaltenbach.) 
We have already mentioned the fact (pages 107, 112) that calculus forma- 
tion is not infrequently seen after transverse obliteration. Tuefferd has 
recently recorded a very interesting case of this kind. The patient had 
formerly been delivered by Caesarian section. Kolpokleisis was done for 
vesico-vaginal fistula. For a time she menstruated through the lower 
edge of the scar, thus having a vesico-vaginal and an external vesical 
fistula. Then she fell sick of cystitis, and several large vesical calculi 
were detected. Tuefferd opened the vagina and extracted a stone 3 140 
THE FEMALE URETHRA AND BLADDER. 
inches in length and weighing 694 grains. The patient died neverthe- 
less. 
We are not yet in a position to fully decide upon the merits of the 
method of transverse obliteration. And although very recently Breisky 
(1879) and also Schede, have successfully performed it in cases of uretero- 
vaginal fistula not suitable for direct union, its applicability is restricted 
to extreme cases only. 
We may mention here that in the worst cases of vesico-vaginal fistula, 
when recovery was impossible, it has been proposed to transplant the 
Fig. 57.-Oblique Closure of the Right Vaginal Vault. (After Simon.) The anterior wall 
of the vagina is removed up to the line of union. The dotted line around v is the vaginal part, and 
the dotted circle around /is the fistula. 
ureters into the rectum. This lias been done, as we have before men- 
tioned, in cases of eversion of the bladder by Jules Simon; but the 
attempt is fraught with danger, and it is not to be recommended. Much 
less dangerous is the plan of first making a good sized recto-vaginal fistula 
surrounded with mucous membrane, and then closing urethra and vagina, 
or the entire vulva. This has been done successfully by Antal, Bozeman, 
Brose, Kaltenbach, and v. Pippingskjbld. The urine flows into the INJUKIES TO THE FEMALE BLADDER. 
141 
rectum, and can be voluntarily voided from time to time. For instance 
Antal's patient passed urine at intervals of £ to 4 an hour; the menses 
passed per rectum; and the organ itself was in no way injured. 
Untoward sequelae of a fistula operation consist mainly of violent vesical 
spasms, of severe secondary hemorrhage per vaginam or into the bladder, 
of vesical calculus, peritonitis, etc. Spasmodic contractions of the blad- 
der may persist for 3 to 4 days, are sometimes very severe, and can as a 
rule only be relieved by opium or by morphine injections in the vesical 
region. I have several times seen profuse secondary vesical hemorrhage, 
so that the patient became anaemic, and dilatation of the urethra was 
necessary to empty the bladder of coagula. The hemorrhage stopped on 
the injection of cold salicylic acid solutions (1:600) into the bladder. An 
ice-bag laid upon the abdomen sometimes effects the same end. Hem- 
orrhage into the vagina requires analogous measures, and possibly in the 
worst case ligature or acupressure applied to the bleeding vessels. 
If the urine remains turbid, and pain or hemorrhage persist in a blad- 
der which has been closed, the urethra must be dilated to ascertain by the 
touch if there are any solid concretions in the viscus; if there are, they 
must be extracted with the forceps and lavement of the bladder under- 
taken. 
Peritonitis may occur from opening the subserous tissue, cutting the 
peritoneum or including it in the stitches; but the experience of the ovari- 
otomists has shown us that there must be other additional moments before 
peritonitis follows such lesions. If it did occur, opium internally and an 
ice bag to the abdomen would be proper treatment. 
If incontinence, partial or total, still persists after a successful opera- 
tion, Hildebrandt uses cold vaginal douches, and the tampons charged 
with salicylic acid, or finally applies the pessary recommended by Schatz 
for this purpose. An instrument of this kind certainly did good to our 
patient No. 12. In especially bad cases, we can take into consideration 
the advisability of following Rutenberg's advice (cf. page 207), and, after 
making a supra-pubic vesical fistula, obliterate the urethra. In one case 
of this kind I obtained complete continence by narrowing the urethra 
through the excision of a portion of the urethro-vaginal septum. 
C. Pawlik has sought to procure vesical continence by causing lateral 
stretching and bending of the urethra in the region of the arcus pubis. 
With a sharp hook he first dragged the urethra to one side, and denuded 
the space between. This being done on both sides, it was so arranged 
that the orificium urethrae was dragged up towards the clitoris. Carbolized 
silk was used; and the operation was done first on one side, and then a 
week later upon the other. 
Patients who will not submit to the operation, or patients upon whom 
it has either been unsuccessfully done or successfully done without achiev- 
ing perfect continence, may wear a urinal (see case 1), though its use is 142 
THE FEMALE URETHRA AND BLADDER. 
sometimes very unpleasant and troublesome. Occasionally the fistula, 
when not too large, may be closed by the insertion of a hard rubber 
cylinder. 
Finally it is to be noted in connection with page 32, that very lately 
Lawson Tait1 made an artificial urethra with a trocar in the left vaginal 
wall in a case suffering from a large urethro-vesical fistula. Then he 
completely restored the old' urethra by means of side flaps, and closed the 
new one after having first restored the vesico-vaginal wall. 
No. 1. Large vesico-utero-vaginal-dstula after 11-face position with 
contracted pelvis; easy forceps case. In spite of fistula patient had 3 pre- 
mature childbirths in 3f years. 
Mrs. K., 28 years old, has had 3 living children born unassisted. At 
4th birth (Aug. 1859) waters flowed off one hour after pains began. She 
now complained of desire to urinate, and the midwife repeatedly tried in 
vain to introduce a silver catheter. I was called, but could not introduce 
an elastic instrument, the child being firmly wedged in the second face 
position in the contracted pelvis. There was considerable swelling of the 
face, and the heart sounds were inaudible; so I applied the forceps and 
delivered the head after 1 or 2 attempts at traction. The child had just 
died. In 3 to 4 days the woman sent me word that she could no longer 
retain her water, and when I saw her, on the 5th day, I detected in the 
anterior vaginal vault a vesico-vaginal fistula half an inch in size, and 
with uneven, ragged, and tender borders. The patient first wore a sponge, 
then later a urinal; but this latter gave her so much trouble that she soon 
discarded it. In August, 1850, hardly a year later, the patient had her 
fifth confinement, and my father was obliged to use the forceps again. 
In 1862 she was confined with a small immature child (footling), and 
in April, 1863, she had her seventh and last delivery, which passed off 
fairly well. The child was small, and died at the age of one month. 
The patient's pelvis was highly contracted; the distance between the 
spinre was 9.6 inches, between the cristae 10.8 inches, the external conju- 
gate was 6.9 inches, the diagonal 3.8, and the true conjugate therefore 
was 3.2 inches, the left oblique diameter was 8 inches, the right 8.2 
inches. 
In the summer of 1864 I had the patient come to Rostock, so that my 
colleague Simon might operate upon her. We now found a superficial 
vesico-utero-vaginal fistula, f of an inch long and 1.4 inch broad. Evi- 
dently the fistula had largely increased in size in the three latter deliveries. 
Simon healed the posterior lip in the cleft and obtained good union. Since 
then the patient menstruates through the bladder, and soon fully recov- 
ered her strength. 
1 Obst. Journ. of Great Britain and Ireland, Aug., 1876. INJURIES TO THE FEMALE BLADDER. 
143 
No. 2. Rachitic contraction of the pelvis. 3rd pregnancy. Perfora- 
tion, cephalotripsy, gangrene of the vesico-vaginal wall. A vesico-vaginal 
fistula appeared on the 1th day. 
Patient 26 years old, 3 children; abortion at 24 years, prolonged labor 
and still birth at 25 years old. At 3rd delivery the liqnor amnii was lost 
prematurely, and the dolores praeparentes were very painful; dilatation 
of os very slow. The head was high and the patient exhausted; an ac- 
coucheur who was called tried to turn; he did bring a foot down into the 
vagina, but could not turn the child. When I arrived the patient was 
greatly excited, the abdomen very painful; there was high fever and 
nausea. 
The heart sounds were not audible. I perforated through the great 
fontanelle, at the left, injected the skull several times with water, applied 
the cephalotryptor a few times, and compressed the skull on all sides. 
In spite of this extraction was very difficult. It needed long-continued 
and great traction in the first position, and I found several times that the 
anterior edges of the pelvis were too greatly pressed upon by the blades oj 
the instrument. Finally a large boy was extracted. In the first few days 
after delivery, patient was fairly well, save for ischuria and pain upon 
catheterization; but the discharge smelled very badly. On the 1th day 
a portion of vagina the size of a dollar suddenly came away, accompanied 
by a horrible stench; immediately there followed involuntary flow of urine. 
The fistula was high up in the anterior vaginal vault. In spite of this the 
patient gradually recovered, and since a large part of the posterior vesical 
wall was left, she could retain her urine for a time. She was very cleanly, 
so that there were no excoriations or ulcers. In fact her general condition 
was so good, six months after confinement, that although there was a IioIq 
in her bladder-wall large enough to pass a finger through, I could not 
persuade her to undergo an operation. 
No. 3. In May, 1870, I examined this case, which was one of vesico-va- 
ginal fistula due to violence, with retroversia uteri and atresia orificii ex- 
tern! 
Patient a primipara, 23 years old, had pains five weeks before the ex- 
pected time, followed speedily by rupture of the membranes. Six hours 
latei' the midwife arrived, and found prolapse of the cord, the head being 
still high up. She sent for the physician, who is said to have effected ex- 
ternal turning of the head, and to have applied the forceps without success 
three times during the ensuing night. Then he allowed the patient to re- 
main as she was till next noon; then he again applied the forceps, finally 
extracting a dead child with the aid of the hook. After the second op- 
eration there was continuous and involuntary flow of urine. Whenever 
the patient stood up the water dripped. The pelvis was normal, spinse 
10.8, cristae 11.6. Conjug. ext. 8.6, obliquae, 10.6 inches. 144 
THE FEMALE URETHRA AND BLADDER. 
We found the urethra patent, and in the left side of the fundus vesicae 
an oval fistula f X f inch in size, from which a cicatricial band extended 
to the left commissure of the entirely obliterated os uteri. The uterus 
itself was left retro verted. She had not yet menstruated again. I heard 
nothing further of her. 
In this case very probably the premature application of the forceps caused 
rupture of the left commissure, and the left blade cut through the vesico- 
vaginal septum; since there was no mechanical obstacle to delivery. 
No. 4. (1871.) Superficial vesico-utero-vaginal fistula on the 9th day 
after confinement. Cure in one sitting. 
Mrs. N., 34 years old, 5 children. First 3 confinements normal; an 
abortion between 3rd and 4th. Fifth pregnancy normal; confinement 
lasted twenty-four hours. At nightfall forceps were applied effectually. 
For 8 days she did well, but on the 9th she noticed an involuntary fiow 
of urine. 4 years later she was normally confined of her 5th child, which 
is yet living. In the anterior vaginal vault 2 lines from the anterior lip 
is a hole ^th inch in size. Under chloroform I denuded the anterior lip 
to the extent of |th inch, and put in 11 silk sutures. (Nov. 28, 1871.) 
The 3rd stitch to the left ulcerated out, but the spot soon closed under 
superficial cauterization. The rest of the wound healed by first intention, 
and on December 12th the patient was discharged from the Rostock 
clinic as cured. 
In this case the location and shape of the fistula, and the history of the 
confinement show us that the forceps had nothing to do with its occur- 
rence; the soft parts were contused by the child's head. 
* No. 5. Urethro- and vesico-vagina.l fistula; pneumonia. Death 6 months 
after confinement. (1874.) No. 109. Mrs. A. Kohler, VII p., 31 years 
old. 
After 6 easy and normal deliveries she was confined of her 7th child 3 
months ago. Breech presentation, hydrocephalus, forceps to after-com- 
ing head. Slight hemorrhage. 8 days later dripping of urine. Since 
then is bedridden. Examination shows rupture of the anterior cervical 
lip, with two urethro-vaginal fistula. The patient was much emaciated, 
and died of pneumonia before any operation could be undertaken. The 
specimen is in the museum of the Royal Maternity Institution. There 
is a wedge-shaped loss of tissue in the anterior os, the scar of which is con- 
tinuous with a fistula inch long by fth inch broad, situated in the 
middle of the vesico-vaginal wall. The right ureter is 2 lines, the left 3 
lines from the opening. The edge of these fistulas is in places double. 
Only f of an inch of urethra is left; towards the neck of the bladder there 
is a hiatus an inch long by f inch broad, which is united to the left 
margin of the upper fistula by a scar. The peritoneum is drawn down INJURIES TO THE FEMALE BLADDER. 
145 
almost to the level of the anterior lip of the os uteri; the bladder is very- 
small, and its walls are hypertrophic. There are no traces of perimetritis. 
The anterior pelvic diameter is 4 inches, the oblique 4f inches, and the 
transverse diameter of the brim is 5| inches; no great contraction. 
The central location and the enormous size of the opening render it 
probable that the forceps was at all events a partial cause of the lesion. 
No. 6. Large left-sided vesico-vaginal fistula, attached to the left ramus 
of the pubis. After an unsuccessful attempt to secure direct closure, 
transverse obliteration repeatedly done. 
Mrs. B., 26 years old, a small, stout, strongly built brunette, was con- 
fined April 27th, 1874, after a normal pregnancy and a 4 days' labor, and 
gave birth to a small full-term dead child. The midwife is said to have 
ruptured the membranes as soon as she arrived, and to have sent for the 
physician only several hours later. The latter attempted for 2 days, at 
first alone and then with a colleague, to deliver with the forceps. Finally, 
perforation was successfully resorted to. Since then the patient has 
passed urine involuntarily. We found a vesico-vaginal fistula 1 inch in 
size, the left angle of which was attached by a cicatrical band to the left 
ramus of the pubis. 
April 30th she was operated upon, 15 sutures being passed. When 
they were removed upon the 6th day, it was found that the angle of the 
wound in the left vaginal vault was not united. Most of the urine passed 
by the vagina. On July 20th a ring of vaginal tissue £ inch in breadth 
was denuded about inches from the vaginal entrance, and the wound 
united with 14 silk sutures. On the 7th day, on removing the sutures, 
the right and middle portion had healed per primam, the left not at all. 
Patient dismissed at request. She re entered May 8th, 1876. May 27th 
V. abortion. 4 months' foetus; great pain. 
The pelvis is generally contracted; spinge 9.4, cristae 10.4, conjugata 
externa 7. Obliquae 8.8 inches. July 4th, 1886, 3rd operation. Fresh- 
ening of posterior vaginal wall for inches. Then from the left lower 
corner of the fistula the vesico-vaginal wall was split; and after ligature 
and torsion had been applied to several arteries, and the actual cautery 
used for the parenchymatous hemorrhage, the vesico-vaginal wall was 
united to the denuded portion of the recto-vaginal wall by 18 silver wire 
sutures. July 11th, 8th day, 14 sutures removed. Union complete. 
Not a drop of urine passes. On the 13th, the 10th day, removal of last 
4 sutures. Urine flows from the left corner, though no opening is to 
be seen. Later, all her urine passed per vaginam. August 3rd, patient 
temporarily discharged. October, 1875, transverse obliteration repeated; 
it was successful in a part, a pea-sized opening remaining to be closed. 
No. 7. Rupture of entire vesico-vaginal wall by forceps in a pelvis con- 146 
THE FEMALE URETHRA AND BLADDER. 
traded to the first degree. Cure, save for a lentil-sized opening seated near 
the anterior lip of the os uteri, which resisted cauterization for months. 
No. 453. May 17, 1876. S., 26 years old; chorea when a child. July 
13th, 1875, delivered by forceps after being 4 days in labor. That same 
day urine passed by vagina. In the anterior vaginal wall, somewhat left 
of the median line, is a tear 1| inch long and | an inch broad, through 
which urine escapes. The vesical mucous membrane projects through it 
into the vagina. May 20th, denudation begun at lower border of fistula, 
and made about $ an inch broad. The end of the freshened area lies 
about yV of an inch from the urethral opening. The projecting vesical 
mucous membrane was cut off. 18 wire sutures were used. May 27th, 
the 8th day, 16 sutures removed. Union appears to be perfect. June 
2d, small fistula found at the upper angle, and cauterized. 2 sutures 
removed. June 13th, vesico-vaginal fistula entirely cured save for a 
lentil-sized fistula in front of the os uteri. Ferrum candens used. June 
27th, repeated. July 11th cauterization with acid. sulf, concentr. July 
14th; only very seldom while standing or walking does a drop of urine 
escape; noneat all passes while lying down. Discharged. Spin. 9.9, Cr. 10, 
D. obi. sin. 8, dext. 8.6, Conj. ext. 7, diagon. 3.7. In October, Novem- 
ber, and December, 1876, the actual cautery was used 9 times, partly peri- 
fistularly centripetal, partly intrafistularly; but without curing the little 
fistula. 
No. 8. Rupture of entire vesico-vaginal wall, with the stump of the left 
ureter opening near the anterior lip upon the left side. 
Union of vesico-vaginal wall with 10 catgut sutures; a bean-sized fis- 
tula being left, into which the left ureter opens. 
No. 241. 1st confinement January 24th, 1875, 5 to 6 weeks too early; 
premature rupture of membranes; forceps delivery by two physicians; 
immediate involuntary micturition. Longitudinal tear of vesico-vaginal 
septum, inversion of vesical mucosa. Opening extends from left margin 
of os uteri almost to tubercul. vag. Cicatricial band from left border of 
orifice goes to ascending ramus of pubis. Also a left uretero-utero- 
vaginal fistula. Operation March 4th, 1876. Freshening of edges of 
wound -j^inch; same to posterior lip of os. 19catgutand 1 silk ligature, 
and 2 tension sutures. Ligatures removed March 18th; save at posterior 
upper angle, where the ureter is, all is healed. May 30th, the fistula is | an 
inch in front and to left of the left commissure of the os. Funnel shaped 
portion excised; much hemorrhage; 5 silk ligatures. R. and L. walls of 
funnel united by 4 wire and 1 silk suture. At night a considerable hemor- 
rhage from the bladder. June 6th ligatures removed; non-union. July 
12th, sent home for 6 weeks. September, and October, 1876, peripheral 
cauterization of vaginal mucosa around fistula; it became much smaller, 
and is now bean-sized. INJURIES TO THE FEMALE BLADDER. 
147 
No. 9. Parturient woman with 4 vesico-vaginal fistula; death from 
entrance of air into the uterine sinuses. 
1874. No. 931. M. 28f years old: 3d pregnancy. Rachitis in child- 
hood. 1st birth easy, 2d a cephalotripsy, and since then involuntary 
urination. 3d confinement in the institution; high fever post partum; 
gases of decomposition from vagina. After expulsion of child, dreadfully 
stinking gases. Death 4| hours p. p. Necropsy: Pelvis 10.4 spinae 11. 
Conjug. ext. 7.2, oblique 8. Conjugata vera 3.1 inches. Thus pelvic 
contraction to II or III degree. Absence of greater portion of vesico- 
vaginal wall. A bridge of tissue .6 inch wide is present, dividing on each 
side into two arms; hence 4 openings, the lowest and largest being twice 
the size of a dollar. Edges smooth, in places cicatricial. Vesical wall 
now ulcerated; anterior vaginal wall below fistula moderately prolapsed. 
No. 10. Small vesico-vaginal fistula in left vaginal vault; spontaneous, 
from pressure ; cure without treatment. 
1874. No. 854. Primipara 28 years, 1st confinement 32| hours, 2d 
28 hours. Child asphyxiated, 20.8 inches long, weighs 90 ounces, and 
has numerous pressure marks upon head. On 8th day stillicidium of 
urine from ulceration in left vaginal vault. Closure during puerperium. 
Small depressed scar on left side of os on dismissal. May 7, 1876, No. 
388, second delivery, normal. Conjugata vera 3.9 inches. 
No. 11. Forceps delivery; thin vesico-vaginal fistula cut by R. blade; 
cure by one cauterization zoith liq. fern sesquichlor. 
1876. No. 265. Kurt I. primipara, 28 years old. Child died inter par- 
tum. Forceps. Dribbling of urine from 2d day. On anterior vaginal wall 
high up near cervix a small fissure. Catheter showed bladder containing 
only a little blood. Cauterization with strong liq. ferri sesquichlor. In- 
voluntary micturition decreased day by day; on 16th day discharged cured. 
Pelvis was normal, and it was only the long duration of the second delivery 
and the danger to the child from double coiling of the cord around its body, 
that formed the indication for forceps. 
No. 12. Urethro-vaginal fistula, united by 8 sutures without full resto- 
ration of continence; application of a Schatz pessary. 
II., 26 years old, brunette, was rachitic in childhood. Had a dead child 
at full term May 6th, 1875; turning and forceps to after-coming head. 
Since then cannot completely control urine. Pelvis: conjug. ext. 7.6, 
spinse 8.0, cristse 9.2, circumference 33.2 inches, a small pelvis. Numer- 
ous scars in lower part of vagina; a transverse urethral fistula .9 inch be- 
hind orif. ut. ext. There was a small opening drawn high up under the 
symphysis and going to the bladder; freshened, 8 silver sutures; incision of 148 
THE FEMALE URETHRA AND BLADDER. 
the lateral cicatricial bands. Complete union; but incomplete power of 
retaining urine whilst walking and lying. Improved partially by the use 
of one of Schatz's pessaries. 
My father had a very extensive obstetric practice in a district where os- 
teomalacia and rickets are very common, at Gummersbach, in the district 
of Cologne. In 700 artificial and in part very difficult confinements he 
only observed the two following cases of vesico-vaginal fistula. In many 
cases he was only called after labor had been long in progress; and the 
very small number of cases observed serves to confirm me in the opinion 
that it is not so much protracted labors and contracted pelves as unskillful 
and premature use of instruments, that causes the accident. 
No. 13. Mrs. M., 24 years old, very small in stature, pelvis rickety 
and contracted. Conjug. vera circa 4 inches. Pregnancy normal pains 
began November 29th, 1848. Face presentation. Labor tedious; loud 
vagitus uterinus; dead child finally extracted with forceps. Pinhead- 
sized vesico-vaginal fistula. January 1st, 1850, 13 months later, delivered 
by forceps of a small living child. The small fistula could be distinctly 
seen during labor, as the anterior vaginal wall was driven downwards by 
the advancing head. Thereupon the fistula closed completely without 
artificial aid, as was proven repeatedly years later. 
No. 14. Mrs. D., primipara, 28 years, considerable rachitic narrowing 
of pelvis. November 16th, 1874, confinement; prolapse of funis and hand 
along side, the head; perforation; attempted extraction of child with for- 
ceps and hook by physician. My father then tried the cranioclast in vain, 
and finally succeeded with the cephalotriptor. Puerperium normal. On 
arising at the Sth day, urine suddenly flowed off, and examination showed 
a small gangrenous spot at the vesical neck. Rest upon the side was 
ordered at once, a catheter introduced, and the edges of fistula touched, 
with lapis infernalis. The fistula was entirely closed in 8 days. 
Five Cases of Vesico-Uterine Fistula. 
No. 15. Case 1. Mrs. Bertha R., 27 years old; second child delivered 
by version and extraction on account of pelvic contraction; child died 
during the operation. A few days latei' involuntary urination. On the 
left side .6 of an inch from the external os is a pea-sized vesico-cervical 
fistula. The left commissure is ruptured. The right commissure was 
then splits and the fistula freshened, and its margins united by 7 silk 
sutures. Primo intentio. After removing several stitches it was found 
that the rest were so imbedded in the tissues, that, as their ends had been 
cut off short, they could not be removed. 6 months later the four that 
were left came out through the bladder. The patient remained cured. INJURIES TO THE FEMALE BLADDER. 
149 
No. 1G. Case 2. Mrs. M., 29 years old, farmer's wife, received October 
3d, 1879. Six confinements; 1st, 1870, forceps, 2 to 5 normal, 6th March, 
1879, 2 physicians, labor of 2 days. Forceps, turning, and extraction 
attempted. Child dead. Bedridden 14 days. On 31st day post partum 
sudden involuntary flow of urine, spontaneous evacuation thereafter im- 
possible. Improved, so that while recumbent could retain and pass water 
naturally. Stools normal. 
Vigorous brunette. Uterus movable, not enlarged, anteflected. Por- 
tio split in 4 parts by antero-posterior as well as lateral divisions. Ante- 
rior lip most deeply cleft; in it is a cicatricial furrow .4 inches distant from 
the lower border of the anterior lip. A lentil-sized depression in this 
furrow feels like a fistula. By means of milk injections, the real opening 
of the fistula was found, in front and to the left of the first opening, which 
turns out to be the os uteri internum. The fistula is left of the internal 
and .4 inch from the anterior cervical wall. Pelvis flat, not rachitic. 
Spinse 10.6. Cr. 15.2 Conj. ext. 7.2, Conj. diag. 4.4, left oblique 8.8, 
right 8.8. 
Operation October 7. Two strong silk threads introduced into the 
anterior and posterior lip; the entire portio drawn down, and so spread as 
to fully expose the fistulous opening. Circumcision of fistula by means 
of two oval cuts. Breadth .2, length .6 to .8, thickness .4 inch. Bridge 
of tissue .1 inch left, between interior os and wound. Direction of cut 
from below inwards to above outwards; 7 Fil de Florence sutures used. 
Two sutures were used at the angles of the wound to relieve tension, 3 
for deep and 2 for superficial union. The two first were at once tied; the 
others only after all the sutures had been passed. October 8 to 10, thin 
bloody vaginal discharge. Regular catheterization. October 11, 1st 
stool, clysma. October 13th removal of sutures. Complete linear union. 
Complete continence; bladder spontaneously emptied every 3 to 4 hours. 
October 17th discharged cured. 
No. 17. Case 3. Mrs. A. W., 42 years old, received March 5th, 1883. 
Menses regular, moderate, no pain, 4 to 5 days, began at 13^ years. 
Last menstruation, end of April 1882. 11 confinements; 1865, 1867, 
1868, 1869, 1870, 1872, 1873, 1875, 1877, 1879. Last on February 19th, 
1883. First 10 normal; last forceps, dead child, tedious labor, face pres- 
entation, according to physician. Puerperium natural. 1874, abortion 
at 3rd month. Immediately after last confinement, difficulty and pain in 
passing water. February 27th or 28th patient suddenly noticed that her 
urine was passing involuntarily. Costive. 
Status.-Medium sized, fairly strong, dark blonde. Chest normal. 
Coughing forces intestinal coils through the navel ring. Uterus enlarged, 
2 to 3 finger breadths above symphysis; anteflexed. Vulva livid. Portio 
soft, turned backwards, several deep fissures; one on right side of poste- 150 
THE FEMALE URETHRA AND BLADDER. 
rior lip extends to os internum. In the anterior vaginal wall, just in front 
of the anterior lip, is a fistula leading to bladder. Fistula well seen with 
speculum; urine streams from it freely. Little cicatrization around ori- 
fice; ovaries normal. Pelvis: Sp. 10.8, Cr. 11.6, Conj. ext. 8.2, both Ob- 
lique 9.4, periphery 35.2 inches. 
March 20th, narcotized. Fistula brought well into view by loops of thread 
and hooks. Thorough carbolized injection. Sound passed perurethram 
into fistula. Above the vaginal opening is found the formerly unseen 
opening of the cervix. There was thus a vesico-cervico-vagin'al fistula. 
The rupture originally affected the entire anterior lip; but the lateral 
margin of the cleft had grown together, and there is left a delicate but 
perfectly palpable cicatrix passing from the fistula over the anterior lip. 
Thus a bridge was formed which covered the continuation of the fistula 
into the cervical canal. A broad piece was dissected off all around it, 
and the margin of the wound united by 11 sutures of finest Listerian silk. 
Rather more loss of blood than usual. Violent bronchitis soon after 
operation. Catheterization during first few days; urine ammoniacal. 
The urethral opening had been drawn in consequence of the operation 
well into the vagina. March 22d, spontaneous urination; afternoon of 
same day, involuntary flow again. March 24 to 27, fever; some meteor- 
ism and abdominal tenderness (ether, ice-bag). April 2d, removal of 
most of the sutures; non-union. Complete incontinence. Eczema of 
nates. April 4th, patient got up; April 19th, last suture removed. 
Ordered daily introduction of tampons soaked in 2 per cent, carbolic acid. 
April 24th. Second operation.-Freshening done through the thick- 
ness of the vesico-vaginal cervical wall. Union in longitudinal direction 
of vagina by 7 sutures of Fil de Florence. Operation lasted 33 minutes. 
Catheterized at first; from April 2Gth, spontaneous evacuation of urine. 
Since April 30th, partial incontinence again. May 1st, removal of sutures. 
The upper posterior angle of the fistula is ununited. May 7th and 10th, 
the small fistula was cauterized with a small iron. May 26th discharged; 
complete continence and cure. 
No. 18. Case 4. Cresc. E., 31 years old, servant, Munich; admitted 
May 19th, 1884. Walked at 2 years, menstruated at 15 years. Menses 
thin, regular, last 3 to 4 days; considerable abdominal pain. March 16th, 
1884, first confinement. Spontaneous vertex; stillborn boy, very large 
and well developed. Liquor ainnii flowed off 5 days ante partum. Delivery 
lasted 46$ hours; small loss of blood. Got up on 9th day. Puerperium 
good. Suddenly noticed on getting up involuntary flow of urine, pre- 
ceded for several days by burning pains. Can retain some urine, and 
evacuate it spontaneously when recumbent. 
Status.-Moderately small blonde; fairly well nourished, but weakly. 
Vulva not reddened, vagina smooth; bathed with urine. Uterus dis- INJURIES TO THE FEMALE BLADDER. 
151 
placed somewhat backwards, well involuted, and not enlarged. Os half- 
way between anterior pelvic wall and the spine of the ischium. Anterior 
lip deeply cleft; the catheter in the bladder can be seen to enter the cer- 
vical canal. Posterior lip smooth, and fissured in its middle. Bladder 
contains a small quantity of dark muddy urine; sediment contains some 
blood cells and some epithelium; no albumen. In the posterior vesical 
wall, towards the middle, is a pea-sized opening communicating with the 
cervix. 
Pelvis: 
Spin. ant. sup. . . . . . . 8.2 inches 
Crist, oss. il. . . . . . . . 9.9 " 
R. oblique diameter, . . . . . . 8.08 " 
L. " 8. 
Conjugat. ext. . . . . . . . 6.8 " 
Breadth of R. ilium, . . . . . . 5.8 " 
" " L. " 5.8 " 
Height of R. ilium, . . . . . . 7.8 " 
" " 7 2** 
Conj. diagonal, . . . . . . . 3.6 " 
" vera, . . . . . . 2.80 to 2.88 " 
Distance from Tub. isch. sin. to spin. post, dextr. 7.4 " 
" il " il dextr. " " sin. . 7.4 " 
" " spin. post. sup. to R. spin. ant. supr. 8. " 
" " " " " L. " " . 7.8 " 
Circumference of pelvis, . . . . . 30. " 
Diagnosis.-Spontaneous vesico-cervical fistula, with generally con- 
tracted pelvis. May 21st, passed 34 ounces of urine in 4 hours. It is muddy, 
dark red, contains some albumen and a few red blood cells. May 23d, 
in 11 hours obtained 14| . of urine. May 26th, in 5 hours obtained 
85.0! urine, light gray in color, non-albuminous; contains pus cells, 
pavement epithelium cells, and crystals of phosphate of ammonia. 
Operation. May 27.-Narcosis; lithotomy position; guttered speculum 
used for posterior vaginal wall; cervix fixed with 2 hooks. Edges fresh- 
ened for .4 inch, then smoothed. 8 sutures of Fil de Florence passed 
deeply. Insignificant hemorrhage. No ligatures necessary. Fluid in- 
jected into bladder completely retained. From May 28th to June 1st, 
spontaneous micturition; urine slightly tinged with blood. June 2, first 
stool; clyster. June 5, menses. June 7th, removal of Fil de Florence 
sutures. Complete union. June 8, menses still present; constipation; 
ol. ricin. Urine completely retained and spontaneously evacuated. June 
9th, well; 2 stools; arose. June 12th, discharged, well; no urine passes 
pei- vaginam; complete ability to retain. 152 
THE FEMALE URETHRA AND BLADDER. 
No. 19. Case 5. B. W., 31 years, workingwoman, Munich, 8 confine- 
ments. Married since 1879; admitted November 4, 1884, 2 years ago, 
after confinement, peritonitis. Menstruated at 1G years, courses regular, 
last 3 to 4 days, painless. No menses since last confinement, August, 
1884, 8 deliveries, G spontaneous, 2 operative. Last in August, 1884, 
protracted, forceps. When getting up, 14 days post partum, patient says 
she noticed for the first time involuntary urination per vaginam. Liquor 
amnii flowed 3 days before confinement; latter normal. 
Status.-Medium sized dark blonde; wTell developed. Uterus retro- 
verted; anterior lip shortened. Sound can be passed from the urethra 
through the bladder into the cervical canal, and so out into the vagina. 
Diagnosis.-Vesico-cervical fistula in upper third of cervix. 
Operation.-November 8, 1884. Narcosis; posterior lip of os dragged 
down, and fistula thus exposed; it is situated very high up. The fresh- 
ening includes nearly the entire breadth of the anterior lip 9 sutures 
(Fil de Florence) passed deeply, and the edges of the wound united. 
November 9th, frequent desire to pass water; moderate pain in the vesical 
region. No hoematuria. November 10th, mucous vomiting in the morn- 
ing. Vesical pains cease; less urinary difficulty. November 11, persist- 
ent desire to urinate., with voidance of small quantity every % hour. 
Orange yellow color; no blood. Abdomen slightly sensitive. (Foment, 
humid, tepid-vesica glacial, ad caput-Pilul. glacial.) November 12th, 
urinary difficulty continues; patient passes water every f hour. No 
strangury. Clothes quite dry. Urine contains some blood. (Menses?). 
November 14th, complete euphoria. Menstruating moderately. Novem- 
ber 15th, sat up 2 hours in bed; dribbling of urine all night and in the 
morning. No incontinence; voluntary emission. November IGth, 
sutures removed; several small gangrenous spots; through them the urine 
percolates. November 17th, increased dribbling; spontaneous motion of 
bowels; at her own urgent request is given leave of absence. Returned 
in 4 weeks; no trace of fistula; the small openings had closed spontane- 
ously. Complete cure. 
Communications between the Bladder and the other Abdominal Organs. 
There exist a series of other injuries to the bladder, as a result of which 
openings between and cavities other than that of the genital canal may 
occur. These other abnormal openings are usually due to disease of 
neighboring organs, and in far are largely to be regarded as Nature's 
mode of curing these maladies. Very frequently they cause no trouble 
until they have effected a perforation of the bladder; so that vesical symp- 
toms may be the first signs of diseases of other parts, and may indeed 
continue to the end to be the chief cause of trouble. Thus the bladder 
may be abnormally attached to an ovary, or it may communicate with the INJURIES TO THE FEMALE BLADDER. 
153 
cavity of an ovum that has undergone extra-uterine development, or with 
the rectum, the large or small intestine, or even with the stomach or the 
gall-bladder. 
Fig. 58, A. - Dermoid Cyst of Left Ovary k, united to the Posterior Bladder Wall, e, 
Right ovary, d, Uterus, i, Left ureter, h, Left, f, right tube. 
Perforations of the bladder by ovarian cysts are not very uncommon. 
If only fluid contents pass from cyst to viscus, pus, serum, or colloidal 
fluid, the urine will only be abnormal so long as the communication 
Fig. 58, B.-Bladder Opened, a and b, Sounds in the ureters, g, Opening of cystoma ovarii 
sinistri into the bladder. 
exists. If the pressure in tlie cyst be but small, it will close up again 
after a time, after having caused at most a temporary dysuria and a cer- 
tain amount of vesical catarrh. This occurred in Bennet's case. It is 154 
THE FEMALE URETHRA AND BLADDER. 
otherwise if solid matters pass from cyst to bladder, as has occurred with 
hair, lumps of fat, and teeth. Obrien (1834), Civiale (1860), Robert 
Lee (1860), Humphrey (1864), and Blackmann (1869), have removed con- 
cretions of considerable size from the bladder, the nucleus of which was 
formed by a tooth. The best recorded case is that of Sentin (Brussels, 
1838.) 
Lithotripsy had been tried upon a woman 58 years old, in whose blad- 
der several calculi had been recognized. Later, lithotomy had been done 
and two stones extracted, the larger and harder of which was adherent to 
the upper and inner wall of the bladder. The stone was broken during 
removal, and contained a true tooth for its core. After the patient's 
death the inner surface of the hypertrophied bladder was found incrusted 
with urinary salts. The left ovary was hypertrophied, and had a cavity 
one inch in diameter in its centre. In this cavity was found a lock of 
hair and a bony mass. As it passed towards the bladder, the ovarian 
cavity narrowed into a canal 1 inch long, and 2 to 2.8 inches broad, which 
opened into the bladder. In this canal lay the hollow crown of a rootless 
tooth; and both crown and hair and bony mass were incrusted with urin- 
ary salts, showing that the excretion reached the ovarian cavity. The left 
tube was turned backwards over the left ovarian ligament. 
Besides these cases Delpech, Marshall, Larrey, Hamelin, Philipps, 
Delariviere and Huge, have found hair that undoubtedly originated from 
dermoid cysts in the female bladder. In all but Huge's case bone was 
found as well, and in many instances fat and other things. L. Mayer 
and Ulrich have observed the evacuation of large quantities of fluid fat 
from ovarian cystomata into the bladder. In some cases the elimination 
of hairs, bones, teeth, and fat has lasted for years. Since 1877 more 
cases of perforation of the bladder by dermoid cysts have been recorded, 
and have been collected by Pincus and Willie. The case that Willie de- 
scribes is pictured in my atlas from the preparation itself, which I owe to 
the kindness of Dr. Kuhn of St. Galle. The patient was 29 years old, the 
mother of two children, and was last confined in 1878. Since 1874 she 
had suffered from haematuria, and later had shown symptoms of vesical 
calculus. Dr. Kuhn, dilating the urethra, felt at the left of the posterior 
bladder wall, a bony substance, extracted it, and recognized a molar tooth. 
The vesical wall and the peritoneum was injured during the extraction of 
another tooth, and the patient died of peritonitis. 
Extra-uterine foetal sacs may penetrate the bladder, and set up inflam- 
matory and suppurative processes in its neighborhood. The foetal parts 
possibly pass out through the bladder, but they are more apt to be evacu- 
ated per rectum. Giessler in 1856 could only collect 6 cases of so-called 
secondary vesical pregnancies. The first case was observed in 1714 by 
Ebersbach. By far the most important and interesting case is that of 
Josephi of Rostock. INJURIES TO THE FEMALE BLADDER. 
155 
Josephi's patient became pregnant for the second time at the end of 
February, 1788. She felt no life after the 37th week; from Easter, 1789, 
she gradually began to menstruate again, and remained fairly well until 
1797, save for the occasional pressure upon the bladder of a hard tumor 
situated in the right lower abdominal region. In 1797 she had chill, 
colic, pain in the back, and regular bearing-down pains; then an inter- 
mitting fever with 3 exacerbations a day, which lasted for 3 months. 
From this time dated a dysuria which was excessively painful. She had 
to pass water every minute, and either urinated upon her knees or with 
her body well bent forwards. At each attempt she passed but very little, 
and what she did pass consisted of pus and pieces of a thick jelly-like sub- 
stance. At Easter, 1800, she first noticed a hard body in her urethra, and 
later in that year she passed her first greyish-white, bean-sized calculus 
with her urine. Thereupon followed a bone 3.2 inches long, the child's 
femur; then a calculus; then the petrous bone covered with phosphate of 
lime; and then 94 millet-seed to bean-sized calculi, one aftei' the other; 
then some bones of the lower extremities, one of the bones of the ear, six 
teeth, etc. In 1801 a physician incised the urethra, and successfully re- 
moved the lower jaw. At times there was complete retention of urine; 
the labia were somewhat swollen, and were red and excoriated from the 
constant trickling of urine. Through the dilated urethra a catheter 
could be passed into the neck of the bladder, where it at once encoun- 
tered a large, hard, and immovable body. On account of her sufferings, 
the patient spent her entire time in a crouching position or upon her 
knees. The appetite was good, though the bowels were sluggish. When 
ischuria occurred, as it often did, the urine evacuated with the catheter 
stunk horribly. Attempts to dilate the urethra with waxen bougies and 
extract the foreign body failed on account of its size. Therefore Josephi 
opened the abdominal wall and then the bladder to the extent of 2 in- 
ches, and extracted 112 pieces of bone. Three large calculi lay in the 
vesical neck which could not possibly have passed per urethram. In the 
fundus vesicas, where the head had been lodged, was an opening. The 
patient died upon the third day, and J. now found two openings in the 
bladder wall; one in the fundus and to the left, the size of a cent, with 
hard calloused edges, and one high up on the right side, .8 inch in diame- 
ter, from which he had with difficulty drawn out the child's head during 
the operation, and which undoubtedly was connected with the extra- 
uterine sac. 
In Giessler's case (1856) the woman began to pass pus and the bones of 
a 7th month foetus per rectum one year after the beginning of her second 
gravidity. 
Urinary difficulties then arose. By means of the catheter bones were 
detected in the bladder, and were removed per urethram. Defecation 
was accomplished at times through the bladder, and at times through the 156 
THE FEMALE URETHRA AND BLADDER. 
rectum. The patient died of exhaustion 3 weeks after the vesical perfo- 
ration. Examination showed fistulous openings from the sac into bladder 
and rectum. 
Thompson had a patient who believed herself pregnant 7 years. By in- 
cising the urethra, he removed from the bladder various foetal parts. 
Then from a communicating cavity lying to the left of the viscus, he first 
drew the foetal extremities, pelvis, and skull into the bladder, and thus 
removed them. Save for a moderate incontinence of urine, the patient 
recovered completely. 
B. S. Schultze's case was a similar one. Here a tubo-uterine pregnancy 
had led to perforation of rectum, uterus, bladder, and abdominal wall. 
A rib and a vertebra passed first per urethram, and then a large number 
of small bones. The abdominal fistula was dilated, and the bones ex- 
tracted. The foetal sac was then washed out through the bladder, and 
finally the patient was cured, although the abdominal and vesical open- 
ings were patent. There were repeated uraemic symptoms in this patient, 
which Schultze explained as due to a catarrhal nephritis, caused by exten- 
sion of inflammation from the mucous membrane of the bladder. In 
Edgar's case the patient died before the parts of the tubal foetus could 
reach the perforated bladder. 
Abnormal communications between the bladder and the rectum are ex- 
tremely rare in women. They most often arise in consequence of abscesses 
in the true pelvis, or in its neighborhood, which may break into the rec- 
tum as they more commonly do into the bladder. Occasionally the posi- 
tion of the fistulous tract is such that while urine may pass into the rec- 
tum, faeces cannot get into the bladder, thus giving us a true vesico-rectal 
fistula. Thus Eble observed a case in a girl of twenty years, who was 
suffering from suppurating psoitis. 4 to 6 weeks after the beginning of 
the sickness she began to void pus, blood, and urine per rectum. No 
urine flowed per vias naturales, until the rectal flow stopped. Then it 
was restored. 
If, as in Giessler's case (page 155) the orifice between bladder and rec- 
tum is large, excrement will of course pass into the former viscus, and 
may lead to the formation of stone. Similar, though caused in a different 
way, was the vesico-rectal fistula which George Glen has described. 
Soon after an arduous labor his patient had symptoms of inflammatory 
abdominal processes •with marked vesical involvement. She got well for 
a time; but 14 months later she began to have very painful passages of 
faeces and intestinal gases per urethram, and died a year later. The walls 
of the bladder were thin, and at the fundus was an opening which com- 
municated with the bladder. Here an abscess had arisen after the con- 
finement, which had perforated rectum and bladder, and had led to a 
recto-vesical fistula. 
Adhesions between the bladder and the ileum or jejunum can more INJURIES TO THE FEMALE BLADDER. 
157 
readily occur, and from the thin walls of the organ involved, fistulae may 
be easily produced. Thus van Geuns has described a fistula colica-vesi- 
calis; a quill of moderate size could be passed through the funnel-shaped 
opening, which communicated with the bladder 1 inch above the rectum. 
The patient had had cholera 5 years before, and had never entirely recov- 
ered. L. Mayer's case is most instructive. 
The patient was 28 years old, and had had 2 normal deliveries. Since 
her second confinement the year before, she had suffered from profuse 
diarrhoea with meteorism, pains and a tender tumor in the right iliac 
region. Six months later there set in vesical trouble. The patient again 
became pregnant, and felt one day, almost painlessly, intestinal gases issue 
from the urethra. Soon she noticed that her urine was at times greenish 
or gray in color, very thick, and containing flocculi and bodies that looked 
like undigested aliment, pieces of potato, muscular fibre, chocolate, etc., 
which were voided 3 to 4 hours after taking them comparatively un- 
changed. Blueberries colored the urine blue. The vesical troubles now 
remitted; the pregnancy ended normally, though the presentation was 
transverse, and turning had to be employed. Puerperium natural. But 
the menses did not return, and the diarrhoea became more troublesome, 
especially at night, when the abdominal pains and tenesmus would awaken 
her 6 to 9 times. Stools thin, grayish green in color, and contained un- 
digested aliment; they resembled the evacuations from the bladder, but 
had a more feculent odor. The tumor was in the false pelvis, but pro- 
jected into the true one and filled its right anterior upper part. 
The urethra was dilated, but the fistulous opening could not be reached 
with the catheter. Rapid urethral dilatation and palpation of the sur- 
face of the bladder had hardly been done at that time. The patient says 
that when the intestinal contents enter the bladder, she feels as if a burn- 
ing fluid had been injected, and at once wants to urinate. When she does 
so the vesical pains become spasmodic, extend into the urethra, and are 
especially bad when pieces of fecal matter pass. L. Mayer considered 
that carcinoma of the intestine was the cause of the perforation, and that 
the lowest portion of the small intestine was involved. The patient rallied 
under sustaining and slightly astringent medication, and the diagnosis 
was not confirmed by autopsy. There might just as well have been an 
opening between the caecum or the vermiform process and the bladder, 
caused by a perityphilitis. And vesico-intestinal fistulae, whether caused 
by tuberculosis or carcinoma, would hardly last 18 months, not to speak 
of the tumor originating 5 years before. 
Very recently Valenta (Laibach) has published a very interesting case 
of this kind. 
Patient was admitted in dying condition, and with the catheter there 
was removed a small amount of urine distinctly mixed with feces. In 
subsequent attempts the catheter struck against an impassable but soft 158 
THE FEMALE URETHRA AND BLADDER. 
obstacle. There was constant dribbling of urine. The autopsy showed 
the bladder to be enormously dilated, its mucous membrane in toto necro- 
tic and covered with urinary sediment. The anterior vesical was so thin 
and so firmly united to the anterior abdominal wall, that it tore in the 
attempt at separation. 16 inches of small intestine was adherent to the 
top of the bladder. There were two openings between the viscera, form- 
ing a perfect anus praeternaturalis. The urethra had disappeared. 
Douglas's cul-de-sac was completely filled by the non-adherent uterus, 
which contained a foetus of 5 months. 
Finally, my former pupil, Dr. Heim-Vogtlin, has had a case of vesico- 
dnod anal fistula. 2| hours after breakfast there appeared in the urine 
fragments of egg-yolk, $ an hour later swollen bread crumbs; foul-smell- 
ing gases also passed sometimes. She cured the fistula in short order by 
means of energetic cauterization with nitrate of silver. 
I know of no recorded case of direct union of stomach and bladder in 
the female. It is possible of course that with an enormously dilated 
bladder and pericystitis, that union might occur with stomach or gall 
bladder, and be followed by perforation. Gall-stones have been found in 
the bladder, as have the contents of the stomach; but it has been brought 
about by adhesion of the right kidney with the stomach or gall-bladder, 
and thus forming a bridge down to the bladder. Thus Melion has pub- 
lished the case of a man fifty-six years old, who suffered from nephritis 
calculosa, and who evacuated caraway seeds and vermicelli with his water. 
In the posterior wall of his stomach was an opening communicating with 
the right kidney, the pelvis of which contained two stones. The right 
ureter was dilated, and the bladder contained a hard, hen's-egg sized 
calculus. The like might of course occur in a woman. 
The symptoms as well as the etiology of these various forms of vesical 
calculi, are sufficiently emphasized by the foregoing examples. Diagno- 
sis is not difficult if we carefully examine the urine both chemically and 
with the microscope in every case of urinary difficulty. Vegetable and 
animal cells, remnants of food, will be seen. But to ascertain the seat 
and size of these vesico-intestinal fistula? it is necessary to dilate the ure- 
thra. As a rule, it can then be well exposed by means of the catheter and 
sharp hooks. 
The prognosis of vesico-intestinal fistula is generally unfavorable. As 
a rule, though they may be relieved, the patients eventually die of their 
malady. The case of Heim-Vogtlein (see above) shows, however, that 
in some cases much may be done by direct therapy. Spontaneous cure 
also may occur, as in Ed. Martin's case, in which the treatment was 
dietetic; but this only seems to occur in those cases in which a contracting 
exudation presses upon the edges of the fistula. In vesico-ovarian and 
vesico-fsecal fistula?, the prospects are upon the whole better; they are INJUKIES TO THE FEMALE BLADDER. 
159 
more ready to close as soon as all foreign bodies have been removed. In 
these cases Czerny's operation (see below) may be thought of. 
Treatment was formerly helpless. Except when the fistula affected the 
upper part of the rectum or the sigmoid flexure, when Amussat's colotomy 
could be done and the faeces diverted from the bladder, we could do hardly 
anything. Now we are able to reach the vesical end of the channel, and 
cauterize with solid nitrate of silver or chromic acid. Ferrum candens 
should not be used, on account of the proximity of the peritoneum. 
If this does not succeed, Simon and others have recently again recom- 
mended the vesico-vaginal incision (see ante, page 13), so that the 
bladder can be inverted and the fistula thoroughly cauterized or even 
closed by denudation and catgut sutures. The vaginal incision may be 
operated upon after the fistula is closed. 
If the bladder communicate with foetal sac or dermoid cyst, it will 
depend partly upon the size of the vesical concrements, bones or calculi, 
and partly upon the size of the tumor and its liability to rupture whether 
urethral dilatation, extraction of the foreign body and cauterization of 
the cavity will be sufficient, or whether it will be necessary to divide the 
abdominal and the vesical walls and perhaps remove the ovarian tumor. 
In the case which Pincus has published, where Czerny operated, the der- 
moid cyst was removed by laparotomy, and the ensuing vesical deficiency 
closed with silk sutures. Three drainage tubes were placed in the lower 
border of the wound. The patient made a good recovery, although there 
occurred a large abscess of the abdominal wall. 
In any case it is well to irrigate the bladder as frequently as possible 
with a lukewarm solution of salycilic acid (1 to 1000) using Hegar's funnel. 
Mild diuretics are indicated. If the contents of the intestine pass into 
the bladder it will be proper to use opiates in moderation with a view of 
lessening peristalsis, as also to exhibit astringents such as decoct, quiniae, 
decoct. Colombo, rhatany, etc. Suture of the gut has latterly made so 
good a record that laparotomy with separation and closure of intestine 
and bladder may well be as feasible as the operation of Czerny above 
described; though the operation for ileo-vesical fistula will in any case 
be more difficult and more dangerous than is ovariotomy with suture of 
a vesical wound. 
Rupture of Female Bladder. 
Etiology.-This can as a rule only occur when the viscus is subjected 
to direct violence when in a more or less filled condition. The greater 
the violence, the less fluid need the bladder contain to cause rupture. A 
blow, a push, a fall upon the abdomen, a fall from a considerable height 
upon the feet, may, as Wernher has proved, cause even the empty blad- 
der to rupture. The common causes of the accident, such as scuffling, 160 
THE FEMALE URETHRA AND BLADDER. 
occur much more rarely in the female. In 8G cases Graw found only 11 
in women. In a woman who had received a blow upon the abdomen. 
Hawkins found two ruptures, one. 6 inches long opening into the abdominal 
cavity, and another opening into the pelvic connective tissue. Possibly 
also the greater motility of the female bladder and the non -resistance of 
the pelvic outlet, protects the female, whilst the male organ is more 
exposed to injury. On the other hand ruptura vesicae has occurred 
in consequence of hyper-distension in connection with that diseased state 
of the bladder wall so often found in cases of retroversia and retroflexio 
uteri. The most important cases of this class which have been subjected 
to jnst-moriem verification are those of Gualth. van Doeveren (1765) and 
Lynn (1767). In other cases, like those of Keinick, William Hunter, and 
Wall, usually cited in this connection, there was really marked retention 
of urine with faulty position of a pregnant uterus. In a case that I pub- 
lished myself (l.c. p. 76), when a dying pregnant woman was admitted 
into the Dresden maternity hospital, the bladder had been dilated until 
it equalled the size of a child's head; its walls were in some parts thin, in 
others thickened, and it was filled with muddy, sour-smelling urine. Its 
vessels were markedly injected, and at the fundus was a space the size of 
a hand, showing several larger and smaller losses of substance, which were 
covered with a thick, gelatinous substance of an ammoniacal odor. And 
all this was after the bladder had been emptied with the catheter shortly 
before death. It is easy to understand how, with this over-distended blad- 
der, any pressure caused by an access of bearing-down pains, or by an 
attempt to empty the rectum, these thinned-out places might give way, 
and rupture of the bladder occur. Krukenberg has demonstrated that 
with long-continued urinary retention, the termination in rupture is the 
commoner. In addition to the above-mentioned cases of van Doeveren 
and Lynn, he has collected one of Hunter (1771), Naumburg (1796), Sax- 
torph (1803), Moreau (1838), and Southey (1871), of actual vesical rupture. 
Since the publication of the first edition of this work, we note in addi- 
tion a case by E. Schwartz,1 and one by Krukenberg (1882). 
Vesical rupture during labor has been mentioned, but I know of no 
case of the kind. They may possibly occur, but as a rule they are con- 
tusions and tears rather than ruptures. 
Anatomy.-In Doeveren's case the urinary bladder was found ruptured 
and the entire abdominal cavity filled with urine. Lynn found 9 to 10 
pints of urine in the abdomen; the bladder, torn at the fundus, hung re- 
laxed in the belly; the edges of the wound were gangrenous. Naumburg 
found an abscess with a fistulous internal opening in the anterior bladder 
wall, and a small round perforation in the posterior wall. Saxtorph 
found the posterior vesical wall torn. In Moreau's case the bladder was 
11880, Centralblatt fur Gynakologie, No. 6. INJURIES TO THE FEMALE BLADDER. 
161 
attached to the omentum, and showed a gangrenous spot and perforation. 
Southey found two gangrenous holes in the bladder, the lower one open- 
ing into the vagina, near the vesical neck, while the upper one led to a 
cavity between bladder and uterus, which was formed by extensive adhe- 
sions between uterus, caecum, small intestine, and sigmoid flexure. E. 
Schwartz's patient had 10 pints of brownish-red fluid in the abdominal 
cavity; there was a rupture 1.2 inch long in the posterior bladder wall. A 
similar condition of things was found in Hunter's case. Finally Kru- 
kenberg saw the space between the abdominal wall and the anterior 
surface of the bladder filled with a tissue infiltrated with pus. The pel- 
vic entrance was occupied by the lower coils of the jejunum and the upper 
ones of the ilium; and two of these coils were adherent, with mesentery, 
to the edges of a defect in the bladder wall as large as the palm of one's 
hand, which they closed. In this case it is to be remarked that 11 days 
after the reposition of the displaced pregnant uterus, a gangrenous mem- 
brane 1 line thick and weighing 1771 grains was cast off, which distinctly 
showed an inner and a peritoneal surface. On the mucous surface were 
amorphous masses of urates and ammonio-magnesic phosphates. 
Even the anterior wall of the bladder may suffer rupture; and adhe- 
sions to neighboring organs not infrequently encapsulate the effused 
urine. But the posterior median portion is the thinnest part of the vis- 
cus, and hence is the most prone to give way. The direction of the rup- 
ture may be oblique or transverse, and the opening in the serosa is larger 
than in the muscularis and the mucosa. The peritoneal border is sharp, 
the muscular coat ecchymosed, the mucous layer contains a narrow red 
ridge from effusion into the submucosa. 
In one case, when there was effusion of urine from rupture of the 
anterior wall, the tissues up to the navel were infiltrated, and only then 
did the fluid break through the omentum. In 61 cases of rupture of the 
bladder in both sexes, according to Smith, 50 times it was through the 
peritoneum, 9 times through the anterior non-peritoneum covered wall, 
and 2 times through the neck of the bladder. Peritonitis set in in 54 cases. 
Symptoms.--Rupture of the bladder with effusion of urine into sur- 
rounding parts may cause almost immediately the very severest symptoms 
of collapse. There is intense pain in the hypogastric region, a tearing feel- 
ing, incessant desire to urinate without success, terror, abdominal disten- 
sion, nausea and vomiting. Whether the urine is effused or not into the 
peritoneal cavity, there may be peritonitis, clammy sweat, urinous odor of 
the skin, and a small and very frequent pulse. The urine may be evacu- 
ated spontaneously or the catheter may be needed; it is usually bloody, 
but may be clear. If the rupture affects the anterior wall, there occurs 
infiltration of urine into the tissues of the abdominal wall. Smith found 
a fracture of the pelvis in a woman sixty years old who had been run over; 
her urine was bloody, and there was a painful tumor in the right iliac 162 
THE FEMALE URETHRA AND BLADDER. 
fossa, from which air, pus, and urine issued on puncture. Infiltration 
of urine may lead to abscess formation and so to spontaneous cure in these 
cases, without there being any peritonitis at all. As a rule, however, 
the pains increase and death speedily occurs. 
If peritonitis has been already present, or if other injuries have been 
caused at the time of the rupture of the bladder, the diagnosis of the lat- 
ter condition may be very difficult. The excessive desire to urinate will 
of course lead us to introduce a catheter; and the bloody urine, if pres- 
ent, will lead us to think of a vesical injury. An exact examination, es- 
pecially of the internal genitals, will, however, guide us aright. An evil- 
smelling urine points to disease of the bladder wall. If the urine were in 
the abdominal cavity, we might get no flow through the catheter until its 
head had been passed through the rent; or it might come now in full 
stream, and now in dribbling manner. The general picture will be that 
of a " perforation peritonitis''; and we will not always be able to tell before 
the necropsy which organ has ruptured. 
It is a question whether it is better, when we suspect a rupture of the 
bladder in an acute case, uncomplicated by retro-flexion of the gravid 
uterus, to search for the rent with the catheter, or to dilate the urethra 
and use the touch. There are as many arguments for the one as for the 
other course. One or other proceeding is necessary to inaugurate a rational 
treatment. It is objected that thereby the rupture is reopened, the peri- 
tonitis increased by renewed effusion of urine, that without narcosis the 
patient may quickly sink into collapse during dilatation, and more quickly 
sink if chloroform is used, and finally that we cannot obtain a complete 
reflux of urine through the rent. On the other hand the greater part at 
all events of the hurtful fluid can be removed by the catheter. A drainage 
tube passed through the rent into the abdominal cavity not only permits 
the escape of all fluids therefrom, but promotes the flow of urine out 
from the bladder; and all modern experience teaches us how easily 
and well such drainage tubes are borne, either with or without washing 
of the abdominal cavity with solutions of salicylic acid. Puncture of the 
abdominal wall would enable us to empty the peritoneal cavity of the 
greater part of the urine then present; but it could not be completely 
done, and would give but poor facilities for drainage. My opinion is that 
in cases where in women we suspect rupture of the bladder, we should 
dilate the urethra without narcosis, and thoroughly palpate the internal 
surface of the bladder. 
The prognosis, which is very bad, is the factor that determines me in 
giving the above advice. It is true that 6 cases of ruptured bladder out 
of 97 have recovered; but 50 per cent, of all cases died within 5 days, 30 
per cent, in 5 to 10 days, and the rest in 10 to 20 days. In infiltration 
of urine the prospects are of course better. Happily these cases occur 
but rarely. We must endeavor to bring to their aid all the resources of INJURIES TO THE FEMALE BLADDER. 
163 
abdominal surgery which ovariotomy has brought us. In the cases of 
rupture of the bladder in women mentioned above, death only occurred 
between the fourteenth and the fifty-first days. 
Therapy.-If a patient with the symptoms which we have above des- 
cribed, has fluctuating tumors in her abdominal walls, we would at once, 
after catheterizing the bladder, incise the spots, and empty them of their 
contents. If these contents contained urinary salts it would fix the diag- 
nosis. 
If there occur a sudden peritonitis from pouring of urine into the ab- 
dominal cavity, we should empty the bladder, use ice locally and opiates 
internally, and await developments. If the threatening symptoms are not 
much lessened in 1 to 2 days, the time has arrived when we must decide 
upon the question of exploration of the bladder. In cases where we suspect 
deep-seated disease of the vesical walls, as in those due to pressure of the 
pregnant uterus, it is not to be thought of. Krukenberg has demonstrated 
that even the most cautious manipulations may cause rupture, especially 
if attempts at reposition be made immediately after the expulsion of mem- 
branes clothed with peritoneum. So that vesical exploration from within 
is only indicated in the rare acute cases of direct rupture. If a perforation 
was found, and percussion showed the presence of a considerable body of 
fluid in the abdomen, we would imitate the procedure so successfully 
carried out in cases of rupture of the uterus, and pass an elastic catheter 
cautiously through the rent. If large quantities of fluid passed out, we 
would pass a drainage tube on a stylet through urethra, bladder, and 
rent into the peritoneal sac, and either leave it there until the symptoms 
got better, or, if they did not, gradually exchange it for a smaller and 
smaller tube. As soon as the opening was so small that a tube could only 
be passed with very great difficulty, it should be discontinued, and the 
edges of the wound cauterized with the solid stick. 
Puncture into Douglas's pouch would only be necessary when there was 
fluid encapsulated in it, which threatened to suppurate. Otherwise we 
can only attempt to disinfect it by means of injections made through the 
drainage tube. 
It is needless to say that free movement of the bowels should 
be attained and the position of the uterus be attended to. As long 
as there is collapse, frequent hypodermic injections of 30 minims of 
ether (every £ to 1 hour) should be persisted in; it not only stimulates 
the patient, but it renders the bladder less sensitive under the necessary 
manipulations. 
As in cases of acute " perforation-peritonitis," in acute cases of not 
too extensive rupture of the bladder, the patient's life may be saved by 
laparotomy with subsequent suture of the bladder walls. 164 
THE FEMALE URETHRA AND BLADDER. 
Pathological Anatomy.-The following new growths have been observed 
as affecting the walls of the female bladder: Polypi and polypoid hyper- 
trophies of the mucous membrane, cysts of tne mucous membrane, papil- 
lary tumors, fibroid tumors, fibromyomata, sarcomata, and carcinomata. 
In 119 cases of primary vesical tumor in both sexes, Sperling found 41 
fungoid growths, fibromata and papillomata, 19 medullary carcinomata 
(24 cancers altogether), 6 scirrhi, 10 mucoid polypi, G myomata, 7 sarco- 
mata, and 6 fibro-sarcomata. Of the fibromata f occurred in males and 
| in females; and carcinoma was 4 times as frequent in men as in women. 
Rauschenbusch (J. 1). Halle, 1882), found 10 females affected in 22 cases 
of papilloma of the bladder. 
a. Mucoid Polypi and Polypoid Hypertrophy of the Mucous Membrane. 
-The mucosa is spongy, thickened and soft, either diffusely or over 
limited areas. It bleeds easily and is often encrusted with salts. Its 
tissue is infiltrated with a serous or jelly-like matter, its capillaries are 
enlarged, and on its surface there is abundant cell-proliferation. Mus- 
cularis and serosa are usually thickened and hypertrophic. Some polypi 
are congenital; thus I found in 1875 two pediculated polypi of the posterior 
bladder wall in a new-born infant. 
No. 426. (1875.) A secundipara had been under treatment for some 
time for Bright's disease, and gave birth, on May 12th, 1875, at 3 o'clock 
a.m., to a girl at 8 months, 15 inches long and weighing 43 ounces. The 
child died in 32 hours. The necropsy showed the subcutaneous tissue to 
be generally oedematous. Lungs atelectatic in places. Abdomen con- 
tained some free fluid. Bladder contracted; mucosa hypereemic. At the 
fundus vesicje was a pea-sized round, soft and vascular mucoid polypus, 
attached by a pedicle; in the lower part of the bladder was another similar 
and somewhat smaller one. The walls of the bladder were comparatively 
thick, and the pelvic and retro-peritoneal connective tissue very oedema- 
tous. Single polypi may attain the size of a hen's egg (Hutchinson's 
cases), and are occasionally found in conjunction with uterine polypi. 
They consist of a connective tissue of varying density covered by a hyper- 
plastic and fringed mucous membrane (cases of Warner, Guersant, Spie- 
gelberg.) Kaltenbach has noticed a walnut-sized pedunculated papillary 
adenoma growing from the mucous follicles of the bladder. 
b. Cysts of the bladder wall occur in the mucosa and in the ureters. 
Fuentasays that Paget (Surg. Path. IL, p. 84) mentions a case of dermoid 
cyst of the bladder. Not having access to the original article, I cannot 
tell whether the cyst originated from the walls of the bladder or whether, 
as is not uncommon, a dermoid cyst of the ovary had penetrated the 
bladder. (Page 153.) Campa has described a case in which a serous cyst 
almost entirely filled the bladder; it contained 8 to 10 pints of a serous, 
New Growths in the Walls of the Female Bladder. INJURIES TO THE FEMALE BLADDER. 
165 
non-albuminous, lactic-acid containing fluid. We have already men- 
tioned (page 80) the occasional communication of l^rge urachus-cysts 
with the bladder cavity. Finally we may refer to a case of Wagstaff e's, 
where there was found in the fundus vesica? a cavity 2 inches in diame- 
ter lined with pavement epithelium, and communicating with the tuba 
and the rectum. It was supposed to be a constricted portion of the 
vagina (?). The bladder was tremendously dilated. 
c. Papillomata vesica? occur as smaller or larger pedunculated or flat 
tumors with granular raspberry-like surfaces. They are most frequently 
located at the posterior bladder-wall in the neighborhood of the trigonum 
lieutaudii. They consist of papillary excrescences containing well-de- 
veloped blood-yessels and a fine, loose, connective-tissue net-work, covered 
upon the surface with layers of hypertrophic epithelium. Birkett found 
them covered with layers (?) of cylindrical epithelium and some ciliated 
cells (?). Klebs is of opinion that from the small amount of stroma pres- 
ent, we must conclude that the blood-vessels form the basis of the new 
growth. The rest of the mucous membrane is usually ti~abecularly hyper- 
tophied, in consequence of interference with the emptying of the bladder 
by the growth. Klebs also mentions a kind of fibro-adenoma which he 
has found in the region of the vesical neck and the trigonum lieutaudii. 
Dr. Heim-Vbgtlin has successfully operated per urethram upon 2 cases 
of vesical papilloma occurring in women of fifty-four and sixty-four years 
of age respectively. 
d. Fibroid tumors and fibromyomata are extremely rare in the bladder. 
Faye has recorded the only case of fibromyoma in a woman, situated 
between the anterior bladder-wall and the fascia transversa, and so closely 
connected with the wall of the organ that it may well have originated 
there. It was the size of a man's head, had existed for many years, was 
situated on the right side over the true pelvis, and sent a prolongation 
the size of an egg along the urethra. It had a tough fibrous capsule and 
contained muscular elements. Not long ago a myoma of the bladder was 
successfully removed in Billroth's clinic from a twelve-year-old boy;1 
and R. Volkmann2 recently extirpated by epicystotomy a lemon-sized 
polypoid myoma from the bladder of a man. Myoma of the vesical walls 
thus occurs. Schatz removed a fi bro-myxoma telangiectases from the pos- 
terior bladder-wall, and Brennecke observed the spontaneous expulsion of 
a tumor at least as large as a child's liver by a pregnant woman, with 
bearing-down pains, which microscopic examination proved to be a fibro- 
myxoma. The patient made a good recovery, and in spite of the size of 
the tumor, did not suffer from any incontinence. In the first case, de- 
scribed by Ed. Muller (see next page, carcinoma of the bladder), a fibro- 
myoma was present also. 
1 Gussenbauer: Langenbeck's Archiv., Bd. XVIII., p. 411. 
2 Langenbeck's Archiv., XIX., p. 682. 166 
THE FEMALE URETHRA AND BLADDER. 
e. Senfleben has published the only case of sarcoma of the female blad- 
der that was known up to 1877. The growth was crumbly, was torn in 
the effort at extraction, and had to be removed piecemeal. 4 days later 
the patient died of purulent peritonitis, and the necropsy revealed a per- 
foration of the bladder-wall on the right side of the fundus vesicae, below 
the opening of the ureter. Since that time there have been several cases 
of primary and secondary vesical carcinoma. Thus, we may refer to the 
case from the clinic of Pernice at Griefswald, described by Siewart. The 
girl was three years old, and a spindle and round-celled sarcoma started 
from the anterior bladder-wall; it was driven by contractions of the blad- 
der into the urethra, and dilated it to such an extent that even the mouth 
of the womb was distended. Thereupon followed necrosis of portions of 
the tumor, purulent cystitis, atresia of the left ureter with hydronephro- 
sis, pylonephritis dextra, and purulent peritonitis. Inside of three weeks 
there were three times removed portions of the tumor as large as the 
palm of one's hand; but it always grew again quickly. Another case of 
primary vesical carcinoma has been described by Dr. Heim-V ogtlin; she 
operated upon the patient, who was only fifty-six years old, and who died 
a year afterwards. Secondary sarcomata from the vagina are not very 
uncommon; they have been described by Ahlfeld,1 Baiardi, 1880, Battini 
1880, Stinger (Archiv. XVI. 58), Soltmann.2 
f. Carcinoma is the commonest of all the new growths of the female 
bladder. It occurs sometimes as a diffuse schirrhus infiltration of the 
bladder throughout its entire extent, sometimes in circumscribed nodules, 
and sometimes as fungating cancer. The latter is the commonest of the 
secondary forms. It is most frequently situated between the mouths of 
the ureters and the urethra. It appears as very soft and spongy excre- 
scences and prolongations from the mucous surface, with a wide capillary 
net-work, and an epithelial covering. (Fig. 59.) It is liable therefore 
to be mistaken for polypoid fibroma of the bladder. In seven primary 
cancers of the bladder, Heilborn found fungating carcinoma three times, 
myocarcinoma once, cauliflower-cancroid once, and cancroid once. For- 
ster has published a couple of cases in which papilloma vesicas was compli- 
cated with fungating carcinoma. 
In two-thirds of the cases of vesical cancer there are adhesions between 
the bladder and neighboring organs, especially the uterus and intestine. 
There are often thromboses of the larger veins, of the femoralis, renalis, 
cava, and a. pulmonalis. Purulent thrombi of the vesical neck may 
cause embolism and metastatic abscesses. Peritonitis is not uncommon. 
Finally the cancerous cachexia sometimes causes amyloid degeneration 
of the kidneys, spleen, liver and intestine. (Heilborn.) A most inter- 
esting specimen of this kind in the Kiel collection, has been described by 
1 Arch. f. Gynak., XVI., 135. 
2 Jahrb. f. Kinderheilkunde. Leip., 1880-81, XVI., 418-421. INJURIES TO THE FEMALE BLADDER. 
167 
E. Muller. (See ante.} The lumen of the bladder was entirely filled 
by a fist-sized, round, pedicled tumor, which was attached to the upper 
inner vesical wall. Its color was grayish-yellow, its surface smooth though 
cleft in places. Its pedicle was an inch in breadth, .4 of an inch in thick- 
ness, and .6 of an inch long. The bladder wall was |th of an inch thick, 
and the muscle bundles were greatly hypertrophied. The tumor con- 
sisted chiefly of a sparse connective tissue with spindle cells, and contain- 
ing large bundles of smooth muscle. In many softer places were collec- 
tions of epithelial cell-nests, diffuse cell infiltrations being present only to 
a small extent. Uterus, tubes and ovaries were normal. Of the history 
of the case we know nothing. 
The cases of primary carcinoma which I have observed have been de- 
Fig. 59.-Fungating Carcinoma of Bladder. (Demme.) 
scribed by Dr. Bode. (See ante.} The only case upon which I had to 
operate occurred in a woman fifty-six years old; and after a partial removal 
of the tumor, it grew very rapidly and extended into the urethra. The 
patient died seven weeks after the operation. The necropsy showed an 
apple-sized spongy tumor, which included all the layers of the bladder. 
The urethra also was infiltrated. Another, still rarer, case is one of secon- 
dary vesical carcinoma, after primary urethral cancer, I have shown in 
Fig. 15 of this book. 
Addendum.-Hair on the walls of the female bladder. Trichiasis, 
pilmictio vesicae, have so far been observed only in consequence of the 
perforation into that organ by an ovarian dermoid cyst. Blich-Winge's 
case (page 168), though no tumor was demonstrated during life, was found 
after death to be due to this same cause. 
In all these new growths the symptoms are of gradual appearance, and 168 
THE FEMALE URETHRA AND BLADDER. 
are in general alike. First there is felt oppression in the vesical region, 
then urinary troubles, sometimes simple dysuria, or strangury, or even 
early ischuria; in Schatz's case there was dribbling of urine. The pains 
are situated partly in the hypogastric region, and partly in the back, 
loins, and legs; in some cases, as in ours, they may run along the urethra. 
After the pains have lasted for some time, there is usually haematuria. 
This occurs with all the new growths, and is sometimes great enough to 
lead to exhaustion, even with benign tumors. The urine is now often 
decomposed; it smells ammoniacal and foul. There may occur a sudden 
stoppage in the flow of urine, while micturating, from the presence of 
the tumor, or of coagula at the internal opening of the urethra. In the 
cases of Hutchinson, Plieninger, Clarke, Birkett, and in my own, frag- 
ments of the papilloma temporarily plugged the urethra. These loose 
portions of the tumor are very liable to become encrusted in decomposing 
urine, and calculous formations are common. This occurred in my cases, 
and in those of Coulson and Watson. The pain and hemorrhage due to 
the catarrhal condition of the bladder, together with the dilatation of the 
ureters and the secondary kidney affections, cause cachexia even in those 
suffering from benign forms of new growth, and cause death by anaemia, 
peritonitis, or even uraemia. The malady may last for many years. In 
our case it had existed 13 years, in one of Hutchinson's it lasted 6 years, 
and in Blich-Winge's 19 years. Appetite and digestion often remain 
unimpaired. In some patients there is an exacerbation in the symptoms 
at each menstrual epoch; and the pains are usually worst when the patient 
is in the recumbent position. Blich-Winge's patient had a cystitis in 
1850, due to perforation of the bladder by a dermoid cyst; the tumor was 
intimately connected with the bladder, into whose cavity it projected as 
a walnut-sized tumor, and was united to the ovary only by a narrow band. 
Nevertheless the patient only died in 1859. 
In cancer of the bladder the secondary nodules appear in kidneys, lungs, 
stomach, and liver. 
The diagnosis of vesical tumors is not always easy. We should never 
neglect to dilate the urethra in cases of obstinate haematuria in women. 
An exact urinary analysis should of course be made in all cases. Frag- 
ments of matter may be found in the sediment which can be recognized 
microscopically, as being papillomatous, or carcinomatous. Catheterization 
is as a rule excessively painful, and does not enlighten us much as to the 
condition of the vesical wall. It will inform us, however, if they bleed 
easily, whether they are very soft or not, and whether they are crumbly. 
Necrotic tissue speaks for cancer; and so does, according to Sperling, the 
finding of haematoidin crystals imbedded in the fragments. Small tumors 
cannot be exactly recognized from the vagina; and evqn with larger ones 
their sensitiveness, and sometimes their lateral and inaccessible situation, 
prevents our ascertaining whether the tumor springs from the bladder- INJURIES TO THE FEMALE BLADDER. 
169 
wall or originates between the bladder and the uterus, or perhaps from 
the uterus or ovary itself. The presence of teeth, hair, and bones in the 
bladder show beyond doubt that tumors springing from these last-named 
organs can perforate the urinary receptacle. We are thus relegated to 
Simon's specula or Rutenberg's illuminating apparatus, for information 
as to the seat, size, consistency, moveability, and possibility of operative 
interference. The illuminating apparatus is especially necessary when we 
desire to examine new growths, situated upon the anterior vesical wall. 
We can positively say that many a patient who has perished miserably 
from hemorrhage, etc., caused by a benign neoplasm of the vesical wall, 
might have been saved had we known Simon's method before. If after 
palpation and inspection the histological diagnosis is still not clear, we 
may scrape off portions of the tumor with the sharp spoon, and examine 
them microscopically. On the other hand, in no one of these cases is 
catheterization of the ureters allowable; for as we have just remarked, it 
is exactly around the ureters that the neoplasmata are most frequently 
seated. It would not only be difficult to find the displaced ureter, but it 
would be quite possible to bore through the softened tissues with the 
instrument. Nor can hydronephrosis, from extension of the growth, be 
prevented thereby, as Plieninger's case shows. The examination per rectum 
may be important when the vagina will not permit it in very young girls. 
But even in these cases the urethra may be dilated to the extent of ad- 
mitting the little finger, as we shall see when considering the question of 
the extraction of calculi. 
Etiology.-We know but little of the causes of vascular new growths. 
Carcinoma is generally secondary, and is more common in women than 
in men. Heilborn found it 37 times in 4778 necropses, in 33 women and 
4 men; it being primary in 4 women and 3 men. And since of these 4778 
subjects 3043 were malesand 1734 females, carcinoma of the bladder is 
15 times as common in men as it is in women. In the Dresden hospital 
it was found more frequently. Among 2505 women it was found 73 
times, almost 30 per cent, as against 20 per cent, in Berlin. 
As the cause for other neoplasmata is mentioned irritation by foreign 
bodies, especially fragments of calculi (Hutchinson, Civiale, Birkett), 
although decomposition of the urine and deposition of calcareous matter 
occurs in consequence of and secondary to the existence of many vesical 
tumors. 
It is probable that various lesions, contusions, permanent displace- 
ments, etc., may be of influence in causing local irritation and determin- 
ing the formation of tumors in the female bladder; but they appear too 
rarely for us to admit either these or the puerperal processes as especially 
active agents in their formation. The number of recorded non-carcino- 
matous vesical tumors in females increases from day to day, as dilatation 
of the urethra is more frequently practised. Sutton once extirpated a 170 
THE FEMALE URETHRA AND BLADDER. 
papilloma of the anterior vesical wall, which was inverted through a vesico- 
vaginal fistula caused by confinement. 
Hutchinson's case is of interest. A woman twenty-three years old 
over-exerted herself in lifting, and thereupon began at once to suffer from 
Fig. 60.-Sharp Spoon for Curetting 
Vascular Growths. 
Fig. 61.-Forceps for the Removal of 
Vesical Growths. 
pain in the back, retention of urine, until she finally had all the symptoms 
of papilloma vesicoe. And in my own case the patient fell with her entire 
weight against a projecting corner and struck the right side of the abdo- 
men; and a year later only she began to notice little clumps of pus and 
blood in her urine. A hemorrhage of the walls of the bladder was prob- 
ably the starting-point of the tumors in these cases. INJURIES TO THE FEMALE BLADDER. 
171 
New growths of the bladder occur at every age. We have already men- 
tioned two that were congenital. Plieninger's patient was 2J years old; 
Pernice's 3 years, Birkett's 5 years,Hewett's 9 years, Hutchinson's 39 years, 
ours the same age, Albers' 44 years, Heim-Vogtlin's 54 and 64, Clarke's 
and Coulson's 63 and 64 years. 
Prognosis.-This maybe called good, nowadays, for benignant circum- 
scribed neoplasmata of the bladder. They can be removed and the patient 
cured, always with certaipty, and often with ease. The necessary opera- 
tive procedure is not severe; and even when the tumor is large, a perma- 
nent incontinence need not be feared. Warner's patient was cured after 
three years, Hutchinson's after one year; G. Simon has one who has 
remained well for five and a half years, though in some of his cases there 
were relapses within a few months. In my case (see below) there was no 
return in eight years. One of Braxton-Hicks relapsed in six months. 
Carcinoma vesicas rarely lasts over one year. The secondary form leads 
to vesico-vaginal fistula in 50 per cent, of the cases, and thus hastens the 
end. Some few authorities, as Lambl, have held that cancer is less in- 
fectious in the bladder than it is in other localities. Probably they con- 
founded it with benign vesical growths; for Heilborn's investigations prove 
the contrary. Metastases do rarely occur but this maybe due to its rapid 
course, or to its occasional development from a non-malignant papilloma. 
The prognosis in every respect is very bad. Death does not usually occur 
from hemorrhage, but from uraemia secondary to hydronephrosis, or sep- 
ticaemia with peri- or pylonephritis, or septic peritonitis after perforation 
of the bladder, or numerous metastases. 
Therapy.-Warner was first to recognize a neoplasm of the bladder, 
and at once inaugurated a rational mode of treatment. He removed it as 
soon as possible, splitting the anterior half of the urethra upon the right 
side. He then drew out the egg-sized tumor and tied its pedicle. It fell 
off on the sixth day, and the cure was complete. (1747.) Civiale fol- 
lowed, who used a lithotriptor to crush vascular growths. Hutchinson 
in 1857 in one case dilated the urethra with Weiss's dilators, in another 
incised the left side of the urethra, and then tied the tumors. He cured 
the second patient. The rest, like Clarke, Plieninger, Blich-Winge, con- 
fined themselves for the most part to internal treatment, recommending 
creosote internally for the hemorrhages, morphine hypodermically and 
by the mouth, and lukewarm baths. 
When we have recognized the existence of a new growth upon the 
bladder-wall, and the possibility of removing it, the patient should be 
deeply narcotized and put in the lithotomy position. The left index fin- 
ger is then passed into the bladder to fix the tumor, and Simon's forceps 
(Fig. 61) passed in. It is then to be seized and twisted off. If too great 
hemorrhage is feared, the loop of a wire ecraseur (Braxton-Hicks's case) 
or a galvanocaustic wire may be passed over the forceps to the base of the 172 
THE FEMALE URETHRA AND BLADDER. 
tumor. If the tumor is too large for this, it may be divided into smaller 
portions by Simon's forceps or sharp spoons, and extirpated piecemeal, 
or portions may be removed through the speculum. 
Schatz in his case incised the right side of the urethra, and, after pass- 
ing several threads from vagina through bladder and urethra, inverted 
through the urethra that part of the bladder containing the base of the 
tumor. He then removed it in two parts, and united the edges of the 
wound with ten silk sutures. Then the patient was dismissed. These 
sutures, slightly encrusted with salts, were still in situ. 
In flat diffuse growths, especially in carcinomata, where radical extir- 
pation is out of the question, scraping must be done with one of Simon's 
spoons, and all loose portions of tissue removed. If there is much bleed- 
ing, cold lavements, or ice water, or direct application of liquor ferri ses- 
quichlorati (Braxton-Hicks) may be tried. The bladder should be re- 
peatedly washed out; and if the bleeding persists the vagina should be 
tamponed with cotton and an ice-bag laid upon the vesical region. We 
can then certainly control the hemorrhage. 
Finally, in those cases where the tumors and excrescences are situated 
so high up upon the walls of the bladder, or are so large that they cannot 
be well extracted even through the dilated urethra, a T-shaped vagino- 
vesical incision may be made, as Simon has proposed. (Comp, page 15.) 
The bladder can then be inverted, and scissors, knife and actual cautery 
be used. Then the vesico-vaginal incision is to be treated as a fistula. 
Simon removed the above-mentioned papilloma from the vertex of the 
bladder with the scissors, returned the bladder after cicatrization had 
occurred, and then performed the regular fistula operation. Kaltenbach 
made a single incision upon a catheter in the bladder, drew out the 
growth, tied its base in several places, removed it with knife, scissors 
and paquelin, and closed the fistula with eight wire sutures. After four- 
teen days a filbert-sized portion of tissue with the silk threads passed by 
the urethra.। The fistula healed by first intention. 
When operative help is out of the question, we can use narcotic irrigations 
(hyoscyamus), or astringent and styptic ones (liq. ferri sesquichlorati, 
lec. quercus) or antiseptic ones (Sol. ac. salicyl. 1:500) with Hegar's 
funnel. Thus we can relieve pain, prevent odor, lessen hemorrhage, and, 
with warmth externally, and narcotics inwardly, render the dreadful lot 
of these sufferers more bearable. 
Large Papilloma of the Posterior Vesical Wall.-Rapid Dilatation of the 
Urethra with the Finger, and Extirpation o f the New-growth,-Cure. 
-8 Years later, Cancer of the Bladder. 
Mrs. M. S., 39 ye.rs old, from New York, had a very itchy eruption 
in childhood, probably urticaria. At 4 years eat a quantity of unripe INJURIES TO THE FEMALE BLADDER. 
173 
plums, in consequence of which she had dysuria; relieved by medicine. 
At 15 there began regularly returning monthly febrile attacks. Men- 
struated first at beginning of 16th year, and has had courses regularly 
every 26 days. Cholera in 1866. 1868 married. Shortly before this she 
had fallen with the whole weight of her body upon her abdomen against 
a sharp corner. She feared that she had sustained an internal injury. 
But the pain, severe at first, gradually disappeared. May 10th, 1869, 7 
months after marriage, bore a living girl naturally, after 11 hours of labor. 
Since then abdomen large. In 1869, child having died, she first felt a 
paralyzing kind of weakness in the left side of her abdomen, low down. 
While it lasted she could neither walk nor speak. These attacks began 
to come frequently, and soon were accompanied by general convulsions. 
A few weeks later she first found pinhead-sized little masses of pus and 
blood in her urine. A year later the least motion caused neuralgic and 
violent urethral pains. The abdomen swelled and became painful, espec- 
ially in vesical and urethral regions. Appetite enormous; sleep deep. 
In the beginning of 1872 first noticed movable masses which attempted 
to flow out of the bladder with the stream of urine. Sometimes they 
suddenly and completely plugged the passage, and when this happened, 
there occurred a sudden spasmodic contraction of the muscles, which pre- 
vented her from emptying her bladder until she had taken abundant 
draughts of hot water, and had made local applications of a sponge dipped 
in hot camomile tea. Soon there appeared a new trouble. Every 
morning, when the bowels began to act, and wind to pass out, instead of 
going the natural way, the flatus passed from the right side above into 
the bladder, feeling, as she says, like a stream of molten lava. Amid the 
most terrible pain she felt it pass like the smoke from a locomotive among 
the trees; she felt the presence of a branched growth, but was only 
laughed at when she told of it. About this time she discovered at the 
entrance of the urethra a small inflamed tumor, which she touched with 
nitrate of silver. 3 or 4 weeks later, after passing much blood and pus, 
there passed from the urethra, with great pains, the 3 first bean-sized 
growths. A few more followed next day. For a while she felt better; 
but in a month the pains returned. On October 23d, 1872, Dr. de Moor 
of New York, after an exact examination declared her trouble to be due 
to an outgrowth from the right ovary, which had entirely penetrated the 
bladder. She was painted with tincture of iodine, and in a month the 
matutinal troubles disappeared, and have not since returned. 
The patient's condition remained unaltered until the summer of 1873, 
when I first saw her. She was a woman of medium size, with grayish 
hair, and features white and seamed by suffering. She was fairly fat, and 
her abdomen was tense; hence it wras difficult to detect a tumor. Touch- 
ing the urethra or the vagina was so very painful that she begged for 
chloroform, which was given her. I could then feel at the right pelvic 174 
THE FEMALE URETHRA AND BLADDER. 
entrance and near the uterus a projecting, tense, elastic, non-movable 
tumor, which appeared to spring from the right ovary. Urine was clear 
and contained no foreign bodies. The patient showed me a mass of nearly 
hazel-nut-sized warty bodies, sufficient to fill a medium-sized goblet, which 
she said had in the course of time passed through her urethra. My diag- 
nosis, therefore, agreed with that of Dr. de Moor; a papillary cystoma of 
the ovary had pierced the bladder, and the bunches were being cast off in 
this way. No tumor was perceptible to the catheter in the bladder, and 
there was nothing in the urine; therefore there were no indications for 
operative interference. 
In the next eight months there again began to be fragments passed 
from the bladder, on one occasion enough to fill a three-ounce vial. 
There was hemorrhage and pain, and the patient decided to undergo any 
operation to obtain relief. In order to keep her under close observation, 
I had her admitted into my clinic June 10th, 1874. There was no fever, 
appetite was good; costiveness was remedied by injections. Nights were 
bad, and were helped by small doses of tinctura thebaica. Drinking 
abundant hot drink, the patient passed June 11th 32 ounces, June 12th 
34 ounces, and June 13th 50 ounces of urine with some pus and blood, 
but no solid masses. 
On July 17th she was chloroformed, the urine evacuated with a cathe- 
ter, and the left finger introduced cautiously into the dilated urethra, into 
which it passed freely without violence after 2 to 3 minutes. I could 
then feel on the posterior bladder-wall, at about the place where the right 
ureter opens, a large, movable, fringed, soft tumor. This I tore into 
fragments with the finger, and then injected with the syringe about eight 
ounces of warm water. I then introduced into the bladder a Carus's 
dilator uteri, and the detached masses passed out in large quantities. I 
then attempted to remove the rest of the tumor in the same way; but 
the pedicle eluded my finger, nor could I grasp it with a small pair of 
forceps, which I introduced along the digit. After three or four at- 
tempts, all the prominent parts that I could feel were detached, and were 
removed in the way described. There was but little hemorrhage; the 
sphincter closed after withdrawal of the finger, so that no fluid escaped, 
and after the operation was done, there was only a small fissure in the 
upper part of the urethral mucous membrane. 
The patient finally vomited once while narcotized, and this happened 
again several times during the next forty-eight hours. But that was the 
sole reaction that she showed. Pulse remained 72 to 80, there was no 
fever, and hardly any burning when she passed water. The urine at first 
contained blood and clots, but gradually cleared. Warm baths were very 
refreshing to her. 
The uterus I found entirely healthy, normal in size, position, and 
movability. I found no trace of the former tumor upon the right side. INJURIES TO THE FEMALE BLADDER. 
175 
The masses we removed were similar in nature to those the patient for- 
merly passed. They are papillary tumors, each being about the size of a 
grain of corn. Their surface is covered with hypertrophous pavement 
epithelium; their mass is composed of a delicate connective-tissue ground- 
work, with large blood-vessels, which sent delicate vessels up into the 
papillse. If there had been a cystoma of the ovary, it would after cica- 
trization of the pedicle, which connected the part which had penetrated 
the bladder to the rest, have grown in other directions. This occurs 
when such growths penetrate the rectum or the umbilical opening. That 
did not occur. Two years after the operation there was neither any trace 
of an ovarian tumor, nor any return of the vesical papilloma. In July, 
1882, eight years after the first operation, she returned to me, in trouble 
again. I found the entire posterior vesical wall diffusely infiltrated with 
a new growth, extirpated a part, and found that there was carcinomatous 
degeneration. She moved away soon afterwards, and I do not know 
whether she is still alive. CHAPTER XIV. 
NUTRITIVE DISTURBANCES OF THE FEMALE BLADDER. 
A NATOMICAL CHANGES.-The nutritive disturbances of the 
female bladder are of various kinds; they pass one into the other, 
and are often only stages of one and the same malady. Hyperaemia is the 
slightest, though hemorrhages may occur in it. If hyperaemia persist 
long, there will be hyper-secretion, catarrh of the bladder. If with this 
the urine is decomposed, there will be croupous inflammation of the 
mucous membrane, or diphtheritic affections. The muscularis and soon 
the serosa is involved, until we have the so-called cystitis parenchymatosa 
and pericystitis, which may finally end in abscess, gangrene, or necrosis 
of the vesical wall. In many cases we find in one and the same organ the 
various stages of nutritive disturbance side by side. This Cossy has well 
described in his case of bladder disease in typhus fever, as also has Kru- 
kenberg in his collected cases of gangrene of the bladder. 
Of hyperaemia we have an acute and a chronic form. The mucous 
membrane is colored a more or less vivid red, its vessels are congested, its 
tissues swollen. If this congestion persists and becomes chronic, there 
occurs permanent dilatation of the smallest vessels, especially the veins. 
This condition easily leads to hemorrhages from rupture of vessels. If 
this occurs below the epithelium, there occur ecchymoses of the mucous 
membrane only. If the blood is poured into the bladder, it mixes with 
the urine or it may coagulate. If the blood remains any length of time 
in the bladder, it forms a coffee-grounds-like mass in the urine. Occa- 
sionally a firm fibrinous clot forms the nucleus of a calculus. Severe 
hemorrhages are especially liable to occur when there are varicosities of 
the vesical neck, what may be called vesical hemorrhoids. They are 
especially liable to occur in pregnant multipart. 
Catarrh of the urinary bladder also may be acute or chronic. In the 
acute cases there is first dilatation and overfilling of the vessels, the sur- 
face remaining intact. After a few days the epithelium, especially at the 
summit of the folds, is cast off, probably because of the abundant leuco- 
cytic emigration. The bladder is usually contracted, and the folds of the 
mucous membrane contain a milky-white, purulent fluid. The chronic 
form of the malady is very likely to supervene. The redness and swelling, 
formerly diffuse, become localized in spots; and the swollen mucosa is 
bathed with tough mucus or muco-purulent or purulent secretion. The DERANGEMENTS OF THE FEMALE BLADDER. 
177 
swelling of the mucous membrane increases and may go on to a polypoid 
hypertrophy. The submucosa and the intermuscular connective tissue 
now take part in the process; there occur changes in the muscularis and 
the serosa. Under the influence of the abnormal secretion, the urine 
undergoes alkaline decomposition, and becomes a fresh source of irrita- 
tion for the diseased vesicular wall. Incrustations with urine salts occur, 
and more or less deep ulcerative processes set in. The muscle-bundles 
withstand the progressive ulceration better than other tissues; they 
become exposed and undermined, and may be seen as bridges or loose pro- 
jections in the midst of the ulcerated areas. (Klebs.) The muscularis as 
a whole is generally thickened. 
Gradually the bladder-wall is perforated. Yet fistulous openings into 
neighboring organs rarely occur. The peritoneal coat becomes thickened, 
and then occur adhesions between the bladder and surrounding parts. 
Finally, perforation or infiltration of urine and septiccemia may occur. 
The highest stage of inflammation of the bladder-wall terminates in 
gangrene. The organ is relaxed and dilated, its muscularis is paralyzed, 
and its contents are changed into a brownish chocolate-colored fluid. The 
urine contains mucous flakes, blood, pus, and urinary sediments; the mu- 
cosa is softened, discolored, black, covered with flakes of mucous or urin- 
ary salts; the submucosa and the muscularis are infiltrated with pus; the 
peritoneum is injected and covered with flocculi of lymph. 
Thus we have, as a general thing, the entire wall of the bladder parti- 
cipating in the inflammatory process. We have cystitis mucosa, c. paren- 
chymatosa and c. serosa or pericystitis. Any distinction between these 
different varieties which we may make at the post-mortem table is only 
valid in so far as it designates the point of origin and chief seat of the 
malady. 
As special forms of cystitis, especially common in females, we may 
mention the croupous and the diphtheritic types. They may be partial, 
or they may cover the entire inner surface of the viscus. In croupous 
cystitis there is found a fibrinous and cellular layer upon the surface of 
the inflamed mucous membrane, sometimes extensive enough to form a 
complete cast of the bladder. In diphtheritis vesicae there is scattered 
over the surface circumscribed dirty yellow blotches and streaks; the 
exudate infiltrates the substance of the membrane. There is hemorrhagic 
injection of all the coats, and possibly ulceration. In both croupous and 
diphtheritic form there may be partial or total detachment of the mucous 
membrane. Kiwisch, Wittich and others have described vesical croup 
with expulsion of the mucosa. 
In diphtheritis vesicae, microscopical examination of the membrane will 
show that a part of the muscularis as well as the mucosa has been cast off, 
and the exfoliated tissue will be found to be infiltrated with firm fibrinous 
threads and fattily degenerated groups of small round cells. Such cases 178 
THE FEMALE URETHRA AND BLADDER. 
have been observed by Haussmann, Spencer Wells, Barnes, Harley, W. 
Martin, Luschka, Bauer and many others. Schatz's case (See Fig. 62) is 
very interesting. The bladder was dilated and its softened walls measured 
Fro. 62.-Diphtheritis Vesicle with Retroflexio Uteri.-(Schatz.) 
from 1.2 to .2 inches. Its inner surface was encrusted with urine salts, 
and it contained free in its cavity a grayish-black bag about the size of 
a child's head. The walls of this bag were one line in thickness, they 
were soft and granular. It was composed of the exfoliated mucosa, with DERANGEMENTS OF THE FEMALE BLADDER. 
179 
the greater and necrosed half of the muscularis. It was attached only 
in the cervical region, where the dead mucosa was still adherent. It had 
no opening save the one into the urethra. It was 6 inches long by 6 
broad. Its walls were composed of four layers. The innermost one was 
composed of uric acid crystals, elastic fibres, masses of fibrin and detritus; 
hardly any epithelium was visible. Then came the hypertrophied sub- 
mucosa, with many young cells and nuclei. Then followed a layer of 
muscular tissue of an inch thickness, the connective-tissue framework 
of which was greatly hypertrophied, and studded with small degenerated 
hemorrhagic foci, fatty cells, etc. Finally there was a layer which was 
wanting in parts, about the same thickness as the last one, and composed 
of fibrin, detritus, fat granules and pus, with connective-tissue bundles. 
This last layer was due to the previous hemorrhages and secondary in- 
flammations of the bladder wall. The vesical wall that remained was 
composed of only two layers; a necrotic inner one, containing detritus, 
fat granules, fibrin, pus, fresh spindle cells, uric acid and hsematoidin 
crystals; and a white, firm, still living layer infiltrated with leucocytes. 
Schatz remarks that the case is a most typical one of gangrene of the 
mucosa and the muscularis due to diphtheritis. The patient had suffered 
from retroflexio uteri gravidi with constriction, and died seven hours after 
giving birth to a foetus 6 inches long and weighing 4| Ounces. 
Tuberculosis of the urinary bladder is extremely rare in women. Klebs 
is of opinion that it is found exclusively in the male sex; since the genital 
apparatus forms its starting-point, and that of the female gives but little 
chance for neoplastic processes to progress by continuity. There are, 
however, a few cases in which tuberculous ulcerations have occurred in 
the walls of the female bladder. Thus Albers found around the urethra 
and in other places, in a woman forty-four years old, groups of larger and 
smaller tubercles and ulcers. The left ureter was full of tubercles, and 
the medullary substance of the left kidney had undergone complete tuber- 
cular degeneration. Scanzoni mentions such a case. Prescott Hewitt 
had a girl nine years old, in whom the bladder-wall was so perforated that 
it opened on the one side into the peritoneal cavity, and upon the other 
side into the rectum. The mucosa vesicse was much thickened by tuber- 
cular deposit, and showed many ulcers. Finally, among the 2505 necrop- 
sies on female subjects which we mentioned in the introduction, there 
were four cases of vesical tuberculosis. They are as follows: 
No. 1. (May 11, 1860, No. 83.) Woman 31 years old, died of tuber- 
culosis of lungs, with general glandular induration, infiltrated tubercles 
of right kidney, both ureters, and bladder. The latter contained a thin, 
dirty-gray mucus. The entire mucosa was studded with pinhead to pea- 
sized pale gray tubercles. The larger nodules were flat, and had in part 
ecchymosed edges. 
No. 2. (January 24, 1864, No. 21.) Patient 66 years old, had died of 180 
THE FEMALE URETHRA AND BLADDER. 
fracture of the neck of the femur and miliary tuberculosis of the lungs 
and the liver, with tubercular infiltration of the pelvis of the right kid- 
ney, of the right ureter, and of the bladder. The vesical mucous mem- 
brane was extensively infiltrated with tuberculous masses, and had also 
an irregular ulcer with swollen hemorrhagic edges. 
No. 3. (June 14, 1869, No. 180.) Cook, 63 years of age, died with 
pneumonia of the left lower lobe with induration of entire lung. Bron- 
chitis, emphysema. Cheesy infiltration of kidney; enormous hydrone- 
phrosis of right kidney with great dilatation of the ureter. Hypertrophy 
of the vesical wall. Tuberculous process in vesical mucosa, and purulent 
interstitial cystitis. 
No. 4. (1876, No. 90.) Patient 29 years old. Dead of excavations of 
upper lobes of lung. Peri-bronchitis nodosa. Adhesive pleuritis. Dif- 
fuse deep ulceration of small intestine. Tubercular' ulceration of posterior 
bladder wall, pea-sized, and with swollen, hyperaemic edges. 
In the four cases of vesical tuberculosis which the autopsy books of the 
Dresden hospital record, two were plainly secondary, one to pulmonary 
and the other to renal and ureteral tuberculosis. 
Kussmaul claims that tuberculosis of the urinary passages rarely lasts 
longer than one to two years. 
There has recently been described an extremely interesting form of 
chronic catarrhal cystitis with the production of epidermoidal concre- 
ments. Rokitansky long ago described as a sequel to chronic catarrhal 
cystitis a condition of epidermoidal hypertrophy of the vesical mucosa, 
leading to the exfoliation of thick, shiny-white layers of epidermis cells. 
Lbwenson (1862) has described the most instructive case of the kind oc- 
curring in woman. The patient had mitral stenosis, and arrived at the 
hospital moribund. After death the bladder was found to be enormously 
dilated. In it was found a mass weighing 3$ pounds and composed of 
small yellow round bodies, with a few shining discs interspersed, like a 
mass of boiled split peas, with a few beans in it. The entire inner sur- 
face of the bladder was coated with these same placques, which were ^th 
to $ an inch thick. The entire layer was elastic, and had a dull mother- 
of-pearl glance. After removing this pavement epithelium, other mem- 
branous layers could be stripped off from the mucosa. Urethra and 
ureters were normal, kidneys in condition of granular atrophy. Micro- 
scopic examination showed that the epithelial cells of the mucosa had 
gradually acquired the properties of large epidermic cells, and were mostly 
without nuclei and granular. The spheres were composed of granular 
fat, lime, nucleated and epidermic cells. They contained stearin in 
abundance, but no cholestearin (which Reich-see Virchow-Hirsch 
Bericht f. 1875, II., 255-has lately found in the vesical mucosa of a man 
suffering from chronic catarrh of the bladder). The bladder-wall was 
hypertrophic. DERANGEMENTS OF THE FEMALE BLADDER. 
181 
Lbwenson ascribes the degeneration to a great epithelial overgrowth, 
with rapid degeneration and change into epidermic cells, while the blad- 
der was in a continuous state of inflammatory irritation. 
Symptoms.-We can be brief as regards the symptoms of hyperaemia, 
acute and chronic catarrh of the bladder, since they are well known and 
have been thoroughly described in these volumes by Podrazky III. We 
will confine ourselves mostly to the symptoms of croupous and diphther- 
itic inflammation. These consist of disturbances of function, dysuria, 
strangury and tenesmus, and not infrequently ischuria. There are pains 
after passing water, which radiate up to the kidneys. Then occur the 
urinary changes; the water becomes ammoniacal, it often contains blood, 
pus, epithelial cells, urinary sediments, and causes croupous inflammatory 
reaction in the parts which it flows over during evacuation. Thus in 
Bauer-Luschka's case, the entire vestibule was coated with a ragged mem- 
branous layer, which was saturated with foul-smelling urine. The entire 
urethra is swollen, and becomes very sensitive. Not infrequently there 
now appear shreds and flocculi in the urine; the urethra maybe plugged, 
the stream of urine broken, and even complete ischuria occur. Finally 
by increased abdominal pressure or by artificial means, the obstruction is 
removed. These flocculi may attain a considerable size. In Schatz's 
case (Fig. 62) and in that of Kiwsich, they were as large again as the palm 
of the hand; in Godson's case, as large as a clenched fist, and in Hauss- 
mann's 2 inches in diameter. 
In cases of ischuria due to plugging in this manner, it has often hap- 
pened that the urine could not be evacuated, either by soft or metallic 
catheters. In piercing the soft mass, their fenestra become plugged up. 
In Bauer's case the bladder had to be punctured in consequence. Kiwisch 
also failed in the same manner; but after extracting the mass he drew 
off three pounds of urine. Schatz could get nothing with the male instru- 
ment; but with the elastic catheter he evacuated nine pounds of urine. 
Gradually the symptoms of urinary stasis appear. There is continual 
desire to pass water, the appetite fails, there is nausea and gagging, and 
constipation alternating with diarrhoea. 
Not infrequently peritonitis supervenes, as it did in the case recorded 
above. Nevertheless Whitehead rightly calls attention to the fact that 
the general symptoms are often but very slight, in comparison with the 
gravity of the affection. Eclampsia has occasionally occurred in connec- 
tion with a chronic catarrhal cystitis in gravidity. (See Vinet's case.) 
Abortion frequently occurs; in Whitehead's case the expulsion of the 
loosened portions of mucous membrane preceded that of the child by 
several hours. But there are cases, as one of Haussmann and one of 
Madurovicz 1 show, in which in spite of the exfoliation of a large part of 
1 Wiener Med. Wochenschr, 1877, parts 51 and 52. 182 
THE FEMALE URETHRA AND BLADDER. 
the mucous membrane of the bladder, and in spite of high fever, the preg- 
nancy is not interfered with. 
In unfavorable cases death occurs with ursemic symptoms, or with peri- 
tonitis and collapse. Patients who are seized with severe general diseases, 
typhus, uterine diphtheria, smallpox, etc., may easily have their vesical 
symptoms so masked as to be very misleading. 
Lbwenson's patient only entered the St. Petersburg hospital a few days 
before her death; she soon sank into a soporose condition, so that the 
exact symptoms of this remarkable form of chronic cystitis with epider- 
mis production could not be observed. 
Diagnosis.-When a woman complains of urinary difficulty an exact 
digital and specular examination of the internal genitals should be made. 
The orifice of the urethra should be examined, new growths in it looked 
for, the catheter introduced and the posterior bladder-wall examined with 
it. Then the urine that is drawn off should be examined for albumen, 
vesical epithelium, casts, blood, fat, vibriones, crystals of ammonio- 
magnesic phosphate and membranous shreds. Sometimes the tenderness 
of the bladder-wall itself will inform us that we have to do with an 
inflammatory affection of that viscus. To determine its exact seat 
and. extent, and especially to differentiate it from fissure of the neck 
of the bladder, to which Voillemer, Gueneau de Mussy, and Spiegel- 
berg have especially drawn attention, the urethra must be dilated, 
and the collum vesicae examined by palpation and inspection. At the 
same time we may make direct medicinal applications, and extract exfo- 
liated portions of the mucous membrane. But most important in all such 
cases is the microscopic examination of the fragments extracted or passed. 
That only can inform us whether the material is really a portion of the 
vesical mucous membrane, whether we find in it pavement epithelium, 
fibrin threads, mucus or pus cells or smooth muscular fibres, or whether 
it is material that has come from without, from echinococcus-sacs or 
ovarian cystomata (containing hair, heaps of epidermic scales, etc.), or 
whether even, as I once found, and as did Professor Franz Eilhard 
Schulze, it is composed of matter containing straight canals, in which 
we can recognize kidney structure. Since in many of these conditions, 
as, for instance, in diphtheritis, the vesical walls may be extremely soft, 
we must refrain from inflating the bladder with air and using the mirror. 
The lower abdominal region is of course to be examined by palpation, 
percussion, and auscultation; the amount of distension of the bladder, 
the tense or relaxed condition of its walls, and the existence of a friction 
sound are to be thus determined. 
In diphtheritic processes in the genitals of puerperal women, in typhus 
fevers, but especially in retroversion of the pregnant uterus, a constant 
watch must be kept upon the condition of the urine, lest the beginnings 
of a croupous or diphtheritic affection of the bladder be overlooked. DERANGEMENTS OF THE FEMALE BLADDER. 
183 
Etiology and Occurrence.-Among the 2500 post-mortem examinations 
of female subjects mentioned on page 25, inflammatory processes of the 
bladder were found 68 times, 2.7 per cent, of all cases, and 38.3 pei' cent, 
of cases in which any anomalies of bladder and urethra were found. 
Hyperremia was found alone 4 times, ecchymoses and hemorrhages 21 
times, vesical catarrh 16 times, purulent cystitis 16 times, croupous 4, and 
diphtheritic cystitis 5 times, abscess of bladder 3 times, metastatic abscess 
once, chronic cystitis 4 times, oedema of vesical wall and its neighborhood 
twice, pericystitis once. Thus inflammatory affections of the bladder are 
important in women, and there is no doubt that it is the puerperal pro- 
cesses especially that predispose them to them. Two conditions are es- 
pecially prone to do so. One is retroflexion of the pregnant uterus with 
retention of urine, and the other is the early ischuria of the puerperal 
period. Virchow holds that ammoniacal decomposition of the urine 
from one cause or another must occur before the epithelium can be 
loosened and the bacilli obtain a lodgment in vesical diphtheria. As 
May (1869) has proved in dogs, the loosening occurs first at the apex of 
the bladder. Mucosa and muscularis are separated from one another, 
and the space between them is filled with blood or serum or urine that 
has percolated through. The mucosa of the vesical neck is generally 
preserved, as Schatz has shown, and cure is thus rendered more easy. 
A simple spontaneous catarrh of urethra and bladder, such as occasion- 
ally occurs in pregnancy from pressure upon the urethra and the vesical 
neck, or repeated catheterization, may give rise to this decomposition. 
Fischer and Traube, Olshausen and Kaltenbach, have fully demonstrated 
this fact. The latter proved that vesical catarrh during the puerperal 
period might be due to chemical or mechanical irritation from the cathe- 
ter, or to spread of inflammatory affections from the sexual organs to the 
bladder, or from traumata during delivery. P. Dubelt proved by experi- 
mentation upon dogs that the injection of air into the bladder had no 
effect; that decomposed urine injected into a healthy bladder caused but 
slight inflammation; but that it was much more effective as soon as the 
vesical mucosa was injured. Frequent introduction of the catheter he 
found to cause circumscribed redness at the place where the catheter 
touched, with loss of the epithelium there. 
Besides these chief predisposing causes, certain general ones remain to 
be mentioned. These are: Cardiac lesions (Lowenson's case), typhus 
(cases of Cossy and Ebers), small pox (Cruveilhier's case), paraplegia, 
spinal diseases, extreme old age (case in Lancet, see above.) 
To these we may add diseases of vagina and uterus, especially cancer 
of these organs, perforating foetal sacs, etc. In some of these cases the 
cystitis undoubtedly occurs spontaneously. Probably in all these cases a 
ferment is carried in from the vagina, which determines the alkaline 
decomposition of the urine. Klamann found on the vesical epithelium 184 
THE FEMALE URETHRA AND BLADDER. 
both bacteria and leptothrix. A healthy bladder with smooth walls and 
a vigorous muscular structure, soon expels the offending matter; not so 
one irritated by the presence of a foreign body, a catheter, or a new 
growth. 
Prognosis. - Simple hyperaemias, hemorrhages and catarrhal condi- 
tions of the female bladder are of good prognosis. The entire inner 
surface of the bladder can be washed out easily and without much pain, 
and uncomplicated cases can usually be cured in eight to fourteen days. 
It is otherwise with croupous, diphtheritic, or gangrenous processes, 
which are more serious. Of eleven recent cases 5 or 45 per cent, suc- 
cumbed (cases of Bauer, Schatz, Spencer Wells, Krukenberg, and 
Schwartz); and six recovered, (cases of Spencer Wells, Wardell, Hauss- 
mann, Kiwisch, Frankenhauser, and Madurovicz.) The earlier the cause 
of the trouble is recognized, the better the prognosis; and the longer the 
ammoniacal decomposition of the urine persists, the worse it is. High 
fever, considerable swelling of the urethra and the anterior abdominal 
wall, and acute oedema in the neighborhood of the bladder are unfavorable, 
being symptoms of threatening vesical perforation. Adhesion of the 
bladder to neighboring organs may have an unfavorable influence, since 
it favors retention of urine, the entrance of air during catheterization and 
recidives of the catarrh and inflammation. 
It is very evident that the prognosis may depend to a considerable ex- 
tent upon the matter coming from the mucosa; it being better in cases of 
simple croup, where only epithelium and exudate is demonstrable, than 
in cases where portions of the muscularis or even gangrenous pieces are 
present. 
It may also be mentioned that adhesions of the bladder to the intestine 
have subsequently caused a fatal ileus. 
Therapy.-To prevent hypersemia of the bladder, we must regulate 
diet and drink in those predisposed to it. We must see that gravid women 
keep the abdomen and feet warm, and preach especial caution in cases 
where there is the least difficulty in voiding urine, even if due to purely 
mechanical causes. If there be constipation, we must use lavements, mild 
cathartics like magnesia, rhubarb, sulphur, calomel, and cause moderate 
rectal and intestinal irritation, so as to exercise a derivative influence 
upon the bladder, and preventing straining at stool. It is of great im- 
portance in any case in which we have to use the catheter, not only to 
disinfect it with corrosive-sublimate (it should, if frequently used, be 
kept in a 1 per cent, sublimate solution), but also to be careful that no 
air enters the bladder while it is being used. In Rutenberg's method we 
do, it is true, distend the bladder with air; but it immediately escapes 
through the dilated urethra, and we always use antiseptic injections there- 
after. Nevertheless we have twice observed a temporary vesical catarrh 
after its use. In all maternity hospitals every puerperal woman whose DERANGEMENTS OF THE FEMALE BLADDER. 
185 
urine requires drawing off, should have a new or a chemically cleansed 
catheter for her own use alone. This has long been the custom in the 
Dresden Institute, and to it I ascribe the extreme rarity of puerperal 
vesical catarrh there. I think it would be well if the same thing were 
done in private practice, and each patient required to buy a new instru- 
ment for herself. 
If, however, hyperaemia or cystitis has set in, it is my experience after 
many years that, whether it be in full-grown women or in little children, 
the local treatment is of the most importance. I always begin by washing 
out the bladder with lukewarm water or linseed decoction or lime water; 
and to one of these I often add salicylic acid (1:1000) or 3 per cent, of 
boracic acid. The fluid must be at blood heat, and is best applied by 
means of a Hegar funnel, which should not be held too high up. An 
elastic catheter is attached to the tube and introduced into the bladder. 
The fluid is permitted to remain in the viscus a few minutes, and is then 
withdrawn by sinking the funnel. The amount to be used varies with 
the patient's age and the size of the bladder; from one to two pints should 
be thrown in, and the injections are to be repeated 1 to 3 times daily. 
This may be kept up for weeks. When it appears to be of no service, I 
have recourse to solutions of nitrate of silver 1-2-3:500, or tannin, 10 to 
15 grains to 4 ounces. I have never been tempted to try the various 
other injections which have been recommended, since I have always ob- 
tained the desired result by the above means. I order rest, in bed if there 
is much tenderness, warm abdominal applications, and a simple fluid diet 
of milk, tea, yolk of egg, bouillon, and lean meat; rectal injections, and 
the cathartics above recommended, may be used to regulate the bowels. 
I have never used balsam of copaiva in these cases, and I think wo can 
well do without it. Nor have I tried bromide of potassium, lately recom- 
mended by Meinhard for cysto-blenorrhoea. But I can recommend the 
continuous use of chlorate of potash (5:175) in tablespoonful doses 4 to 
6 times a day. A somewhat different method of local treatment was 
recommended by Braxton-Hicks two years ago. During the acute stage 
he first washes out the bladder with two pints of fluid composed of two 
drops of hydrochloric acid to the ounce of water. Then he injects a 
solution of morphine, 1:600, which is to be retained as long as possible. 
Two repetitions, he says, are enough. If the urine is acid, mild carbonate 
of soda solutions are injected twice daily. After the acute symptoms have 
passed off, tannin or solutions of 3 to 4 drops of liquor ferri sesquichlorati 
to 6 drachms of water are injected. For chronic vesical catarrh he uses 
nitrate of silver 1:60 to 1:40 and liquor ferri 3 times as strong as he used 
during the acute stage. He applies this same irritating treatment to the 
urethra also, as a means of counter-irritation, introducing sounds coated 
with nitrate of silver or tannin-covered elastic bougies. He also recom- 186 
THE FEMALE URETHRA AND BLADDER. 
mends dilatation of the urethra and pencilling of its mucous membrane 
with a solution of sulphate of iron. 
Lemaistre-Florian claims to have cured chronic cystitis in twenty-one 
days by means of solutions of sodium chloride 4:1000 and increasing, given 
three times daily for twenty-five minutes. It was formerly the custom to 
draw blood locally by means of leeches and wet cups. Barnes, Parrisch, 
Teale, Gardner, Davidson, and many others have latterly praised rapid 
urethral dilatation as one of oui' most important weapons for fighting 
cystitis. 
It is of great importance in the treatment of these cases, not to let the 
urine remain stagnant in the bladder for any length of time, but to have 
it emptied regularly and completely, if necessary, with the catheter. 
Fritch recommended a non-fenestrated rubber tube G inches long and .2 
inch thick, and disinfected in a 5 per cent, carbolic acid solution. It was to 
be only introduced until the urine flowed. The bladder was to be washed 
out through it with a 1 per cent, carbolic solution 3 to G times a day. It 
may remain in situ 3 days, but must then be removed on account of the 
danger of deposition of urinary salts. Schucking recently applied per- 
manent irrigation of the bladder in 6 cases for 1 to 3 days, using a 10 per 
cent, solution of sulphate of soda with the addition of 5 per cent, of gly- 
cerine. 
General warm baths are very grateful to the patient. As drinks, milk 
of almonds, Vichy, soda, etc., may be used. 
We have already described the treatment for hemorrhages of the bladder. 
We can recognize with the catheter the presence of a considerable amount 
of coagula, and dilating the urethra, let them out or extract them with 
forceps, and then washing out the bladder with very dilute liquor ferri 
sesquichlorati, continue the treatment. 
When membranous matter has passed per urethram, the catheter should 
be employed, and dilatation, if necessary, effected. Then lime water or 
carbolic solution 1:1000 or salicylic acid solution, or, if there be bleeding, 
a solution of liquor ferri sesquichlor 1:800 may be used, the membranes 
having previously been extracted with the forceps. 
In all these cases we shall have to use anodynes occasionally; we had 
best give hypodermatic injections over the mons veneris. The patient's 
strength, also, must be sustained by quinine, wine, analeptics, nourish- 
ing, and readily digested food. 
We will here describe two conditions which occur as sequella? to the 
anomalies already described. These are hypertrophy and atrophy of the 
female bladder. 
Hypertrophy occurs with all the displacements (cystocele, etc.,) when 
they are of long duration, with new growths both of urethra and of blad- 
der, and with inflammatory processes of the vesical neck. The thickening 
may affect all the coats, or only the muscularis totally or in part. If only DERANGEMENTS OF THE FEMALE BLADDER. 
187 
certain portions of the muscularis are hypertrophied, the mucous mem- 
brane may be forced in between the muscle bundles, and, distending the 
peritoneum,- form diverticula of the bladder. This happens, however, 
much more rarely than in the male. 
Most often, however, hypertrophy is caused by some hindrance to the 
outflow of urine and leads to dilatation of the bladder, which in the 
female may attain very considerable dimensions. Thus in the case that 
I have already mentioned, the diameter of the bladder was 10.5 inches; 
its walls were . 6 inch thick. Schatz describes a case in which the organ 
was over 6 inches in length and breadth. 
Diagnosis.-If the bladder is much dilated, we will be able to feel it 
above the symphysis, even after emptying it with the catheter as a hard 
tumor. Its boundaries may be determined by percussion, and the sensi- 
tiveness of its walls by the catheter; and the examination of the urine will 
reveal the composition of its inner surface. We will almost invariably 
find the hypertrophy to be not simple, but complicated with some other 
condition. 
To cure the malady we must attack its causes. All hindrances to the 
free evacuation of urine must be removed. If in spite of this, urination 
is still difficult, the catheter must be regularly used and the expulsive 
effort saved as much as possible by means of external pressure applied at 
the time. The use of a good ceinture hypogastrique is of service, as are 
also cold compresses, the cold douche applied to the lumbar region, cold 
vaginal injections, cold sitz or sea-baths. Of course any complications 
which are present, as catarrh, displacement, (cystocele), etc., must be 
simultaneously treated. The method of vesical irrigation which we have 
already described, enables us admirably to compensate for irregularities 
of contraction of the hypertrophied bladder, by means of variations in 
height of the funnel. 
For irritability of the vesical neck we may use narcotics locally in the 
form of vaginal suppositories, bougies and vesical injections. 
Atrophy of the female bladder may occur in consequence of very great 
distension and dilatation, but happens more frequently from that condi- 
tion of paralysis of the muscularis which we shall describe more fully 
under the head of neuroses of the bladdex- in Chapter XVI. Occasionally 
it is seen with a hypertrophied muscular coat, as in one of our own cases; 
and in old women it may occur without any paralytic condition being 
present, the vesical walls being sometimes almost as thin as paper. All 
three coats seem to participate in the atrophy, and I believe that it is a 
cause of the frequent occurrence of cystocele in advanced life. This latter 
condition is of course only to be treated by mechanical means of retention 
or by anterior colporraphy. If disturbances of micturition still persist, 
the use of local stimulants, cold douches, catheterism, and the induced 
current are indicated. . 188 
THE FEMALE URETHRA AND BLADDER. 
Chronic Vesical Catarrh in an old Woman. Rapid Dilatation of the 
Urethra; Illumination of the Inner Surface of the Bladder with Ru- 
tenberg's Apparatus; Great Mobility of Mucosa upon Muscularis. 
Washing of Bladder twice Daily with Salicylic Acid Solutions. Cure 
in 8 Days. 
A woman 60 years old, large sized and of strong frame, entered my 
gynecological division July 6th, 1876. Since her last pregnancy, 20 years 
before, she had not menstruated. Four weeks ago she underwent severe 
bodily exercise, and began to have pains in the vesical region, especially 
before 'and after micturition. The epi- and hypogastric regions were 
very tender, the vagina was narrow and in condition of senile atrophy; 
the posterior bladder-wall was very sensitive to the touch; the urine was 
pale and muddy, and contained a little albumen. A chronic cystitis was 
diagnosed. The urethra was dilated under chloroform, and to my aston- 
ishment I found that a pale bluish-red portion of the mucous membrane 
forced itself into the lumen of the largest speculum, making me believe 
there was a vesical polypus. But I could feel none when examining with 
the finger, though I recognized then that the entire mucosa was loosened 
and movable upon the muscularis. No polypus were visible when the 
bladder was dilated with air and illuminated. There were only the appear- 
ances of chronic hypenemia, moderate redness, swelling of the mucosa 
and ready bleeding of the inner vesical surface when injured. Injections 
of salicylic acid 1:600 were ordered twice daily, and tra. quinine and later 
decoct. Colombo with tra. thebaica internally for her diarrhoea. The 
urethral dilation, though done strictly according to Simon's rules, did cause 
a moderate-sized bleeding fissure at the base of the clitoris. The urine 
was drawn by catheter for the first two days. There was no other reac- 
tion. The temperature was never over 99.3° F., nor the pulse above 68 
to 84. The burning after injecting lasted about one hour, and then the 
patient felt better. The urine cleared, and on July 15th the patient was 
discharged cured. 
The peculiar loosening of the mucous membrane, which might have 
become inverted through the urethra, and the slight amount of reaction 
in spite of the patienfs age render the case especially interesting. CHAPTER XV. 
FOREIGN BODIES IN THE FEMALE BLADDER. 
WTTE divide all foreign bodies which may be found in the female blad- 
' ' der into those that originate in the organ itself, those that come 
from other parts of the body, and those that are introduced from without. 
1. We have already mentioned a large number of the foreign bodies 
which gradually obtain access to the bladder on page 154, when discussing 
perforation of that organ. We have mentioned perforation by inflamed 
cystomata of the ovary, by the products of extra-uterine pregnancy, from 
exulcerated portions of the intestine and from the gall-bladder. There 
Fig. 63. 
remains to be mentioned penetration by echinococcus vesicles Cases of 
this nature have been recorded recently by S. Eldridge/ and in earlier 
times by Laennec, Parmentier, Vigia, Deckles, Weitenkampf and Freund- 
Chadwick. The latter has given us an excellent representation of the 
condition of things in his patient, which I reproduce here. 
A is the bladder, B the uterus, C the rectum. The echinococcus is 
located in the posterior uterine wall, and thence has penetrated bladder 
and rectum. At F and & respectively, the bladder and rectum have been 
penetrated. 
1 Echinococci in the female bladder; cystitis; excessive dilatation of the urethra; 
cure. Amer. Journ. of Obstetrics, New York, 1881, XIV., 106-108. 190 
THE FEMALE URETHRA AND BLADDER. 
Such an invasion of the bladder is accompanied by the usual signs of 
Vesical irritation and by the subsequent passage of perhaps large num- 
bers of pea- to walnut-sized vesicles in the urine. The diagnosis is 
therefore not difficult. The passage of vesicles may occur periodically 
for years, the patient in the meantime remaining fairly well. (See Vigia's 
case.) Several cases of this kind have got well under the alkaline 
Carlsbad waters. (Parmentier, Weitenkampf, Fleckles.) The echino- 
cocci may reach the bladder from the pelvic connective tissue, from the 
pelvic bones, from the utero-vesical interspace, or from the kidneys 
through the ureters. 
The other parasites which may be present in the bladder are the dis- 
toma haematobium, which Bilharz has described, and Lewis's filaria san- 
guinus hominus, which causes the tropical chyluria. It is not improbable 
that the filaria which I found in the ascitic fluid of a lady who had for- 
merly long resided in Surinam, might penetrate the bladder, although I 
found none in her urine. 
Kussner found leptothrix upon the inner surface of the bladder of a 
diabetic, who had never before been catheterized, and whose water was 
drawn with a clean instrument. 
From the pelvis of the kidney come renal calculi and fragments of renal 
substance, which have been detached by a suppurative nephritis. Taylor 
found such a fragment in a boy of eleven years, who had nephritis absce- 
dens after scarlatina, and I, with Professor F. E. Schulze and Dr. Werd- 
ner, found another in a puerperal woman with high fever, who, however, 
recovered. 
2. Foreign bodies coming from without may reach the female bladder 
in four various ways. They may be forced into the bladder through the 
urethra or the vagina by a fall upon certain objects; or the patient, suffer- 
ing from retention, may attempt to catheterize herself and either break 
the instrument or let it slip out of her hand; or a pregnant woman may 
attempt to bring about abortion by introducing something into the geni- 
tals, 01', probably most frequently during attempts at masturbation, the 
objects used slip into the bladder. The foreign bodies are very various. 
Odone found a piece of wood, Jobert de Lamballe a lead pencil, Dupuy a 
wisp of straw in the bladder as the result of a fall. In consequence of 
careless catherization a patient of Thomas Haigh Martin allowed the stem 
of a tobacco pipe, which she used for that purpose, to glide into the blad- 
der, while one of Leonard's permitted a goosequill, and still another the 
blunt end of a catheter to disappear in the same way. To produce abor- 
tion Zechmeister's patient thrust a splinter of wood 2| inches long into 
her genitals, while Nelaton's pushed one of about the same size into the 
bladder. The number of articles which have been used by women for 
purposes of onanism are extremely various. In 258 of intentional intro- 
duction into the bladder for this purpose, reported by Denuce, 119 were FOREIGN BODIES IN THE FEMALE BLADDER. 
191 
in men and 96 in women; and among them 5 girls under 14 years of age. 
Pins, hairpins, sewing and knitting needles were introduced 82 times; 
needle-boxes 15 times (cases of Dupuy, Dieulafoy, Fleury and others); 
and toothpicks, iron wire, ivory nail-cleaners and many other objects. 
A gradual entry of foreign bodies from the vagina, as occurs from the 
perforation of pessaries, we have already considered under vesico-vaginal 
fistula, (page 101.) 
As to the symptoms of these vesical ingesta, they may be said to be fre- 
quent urination, haematuria, and strangury. Gradually the foreign 
bodies become encrusted with salts, and cause vesical catarrh, ulcerations, 
and perforation of the bladder-wall. Occasionally, if they are not too 
large and are not impacted in the wall of the viscus, they may be sponta- 
neously evacuated; this occurred 31 times in Denuce's 440 cases. If the 
vesico-vaginal wall is pierced, the foreign body, if not too much encrusted 
with salts, may pass off per vaginam, often leaving behind a large vesico- 
vaginal fistula. If the foreign body is not removed it may exhaust the 
patient by reason of the pain it causes, and the vesical catarrh it sets up; 
and abscess, phlebitis, gangrene of the bladder-wall and death of the 
patient may occur. 
The treatment of this class of cases has been much simplified since we 
have learned the distensibility of the female urethra. Besides Simon's 
specula and forceps, wTe need only a pair of toothed forceps. As soon as 
we have recognized with the metallic catheter the existence of a foreign 
body in the bladder, we anaesthetize the patient, dilate the urethra accord- 
ing to rule, find the foreign body with the finger and fix its lower end, 
and, passing a pair of forceps in alongside, seize and extract it. In Octo- 
ber, 1881, I extracted in a few minutes in this way the ivory handle (2.8 
inches long) of a crochet needle. Complicated apparatuses, like those of 
Bianchetti, are no longer necessary; we can introduce in a very short 
time instruments .8 inch in diameter, while his tubes are only 3 to 4 lines 
across. If there is any difficulty in getting the end of the object which 
the forceps has seized into the urethra, a finger in the vagina will assist 
in turning its long axis parallel to that of the canal. Or the largest sized 
speculum may be pressed against the body, which is seized by the forceps 
passed through the speculum, and the forceps gradually worked to the 
lower end of the foreign body. If the body in the bladder is difficult to 
seize, it is often useful to fill it with lukewarm salicylated water and then 
extract. If the object is barbed, like a crochet needle, Denuce recommends 
forcing it through into the vagina; the resulting fistula soon heals spon- 
taneously. If the foreign body is impacted in the vesical walls, or is very 
large, we may endeavor to dislodge it or diminish its size with Hourteloup's 
or Civiale's lithotrite. Thus, Henry Smith had to break a bone nail- 
cleaner into pieces in this way before he could get it out. If the body 
has pierced the vesical wall, and if the portion in the bladder has become 192 
THE FEMALE URETHRA AND BLADDER. 
so encrusted with salts that it cannot be withdrawn through the original 
opening, we must enlarge it with a blunt-pointed bistoury, as Jobert de 
Lamballe had to do with a lead pencil and Mytterhoeven with a pessary. 
If extraction is not possible in this manner, cystotomy is indicated. 
Nevertheless we must not too readily have recourse to it; it is more dan- 
gerous than the former plan, which has often succeeded after days and 
weeks. Where cystotomy is really necessary, it should be done in adults 
by vesico-vaginal incision (see page 15) whenever it is possible; in very 
young girls it will be necessary to do the suprapubic operation. The 
prognosis of the two operations is very different. According to Denuce 
in 34 cystotomies done in females for the extraction of foreign bodies, 
22 were done by the vaginal method, and 12 by suprapubic incision; of 
the former 15 or 70 per cent, got well, of the latter 2 or hardly 17 per 
cent. The after-treatment is that described for vesico-vaginal fistula, 
pages 114 and 134.) 
3. Vesical Calculus in Women.-Podrazky has thoroughly discussed the 
subject of lithiasis in the 3d volume of this work, and we will simply 
recapitulate briefly what he has said, adding whatever has been done in 
the 13 years since his monograph was written. 
Etiology.-Vesical calculi are formed upon all bodies that reach the 
bladder cavity from without, or from within the body, or upon promi- 
nences of the vesicular wall (comp, page 167), or finally they arise from 
the spontaneous precipitation of the urinary salts. They may occur at 
any age, but are found most frequently in childhood. They are much 
less common in the female than in the male, from the shortness of their 
urethra and the consequent rarity of stricture and facility for the cure of 
vesical catarrh. Dr. Klein found in the Moscow city hospital from 1822 
to 1860, among 1792 cases of vesical calculi, only 4 occurring in females. 
The lithotomist of Upper Swabia, Michael Lett, in his practice of 57 
years, did 106 lithotomies in men, and only one in a woman. I have ex- 
amined about 10,000 women and girls in Berlin, Rostock, Dresden and 
Munich from 1860 to 1884, and, save in the case already recorded under 
No. 15, I have only once found a calculus, and this was small and easily 
extracted per urethram. Among the 3500 autopsies done upon women 
at the Dresden city hospital, stone in the bladder was found 6 times. 
Walter Coulson calculates that for 100 cases in males there occur 5 in 
females. Even in childhood there is a marked difference between the 
sexes. Giraldes says that vesical calculus occurs 24 times more frequently 
in boys than in girls. 
We not infrequently find urates in large quantity in the bladder of the 
newborn, and uric-acid infarctions in the kidneys of stillborn infants. 
Vesical calculus may also occur. In England, Russia, Persia and Egypt, 
stone in the bladder is especially frequent.1 
1 Bilharz: Distoma haematobium. 193 
FOREIGN BODIES IN THE FEMALE BLADDER. 
The shape, size, number, and composition of these calculi in women 
vary greatly. We find uric acid, phosphoric acid, oxalic acid, and cystin 
calculi, and combinations of them. The rarest of all are those composed 
of cystin, they being 3 per cent, of all. 
The seat of stone in women is usually in the deepest portion of the 
bladder, in the fundus behind the trigonum. In one case, at the autopsy 
of a patient sixty-seven years old, at the Dresden hospital, I found a cal- 
culus the size of a walnut lodged in a pocket of the bladder, above and 
behind the retroverted fundus uteri. The vesical neck was attached to 
the rectum by firm adhesions which forced the uterus backwards, fixing 
the upper part of the bladder as in retroflexio uteri gravidi, and in this 
curious place was lodged the stone. If the calculi are numerous and 
large, the bladder sinks with them, and a cystocele is produced (comp, 
page 83), as in the cases recorded by Rossel, Tolet, Moreau, Ruysch, and 
others, in which there were from 11 to 55 stones. On the other hand, a 
neglected cystocele may cause vesical catarrh, and so lead to the formation 
of stone. 
In my case the calculus was lodged at one side behind the horizontal 
ramus of the pubis, so that it felt at first like an exostosis attached to that 
bone. Stones may also form in diverticula of the bladder, or may lodge 
in them after formation. Thus, in one of our Dresden city hospital post- 
mortems (No. 10, v. 20, I., 1858) in a woman sixty-four years old, there 
was a sacculated diverticulum in the posterior wall which only communi- 
cated by a very small opening with the general vesical cavity. In it was 
a hard, sharp-edged, cherry-stone-sized calculus. The case recorded by 
Cadge also belongs here. 
The size of these calculi varies from that of a grain of corn to that of a 
child's head. Hugenberger extracted one weighing 3| ounces and meas- 
uring 6 X 5.4 inches in 1871 by colpocystotomy; while Wendel records 
the passage of one per vaginam through a vesico-vaginal fistula in a woman 
sixty-two years old, the size of an apple. 
The number of calculi may be very great. Rosset found 11, Ruysch 
45. P. Adam saw 90 evacuated spontaneously. The cases of Josephi 
(page 154) and Lowenson (page 180) show that hundreds of stones may 
be present in the female bladder. 
Symptoms of Vesical Calculi.-These depend upon the causes, shape, 
surface, size, and number of the stones, and upon the complications. 
Those calculi due to perforation of the bladder by ovarian cystomata, foetal 
sacs, etc., are preceded by symptoms of threatened cystitis with peritoni- 
tis for a long time. On the other hand, calculi which have originated 
inside the bladder, especially when round, small, and smooth, may exist 
for years without the bearer suspecting their presence. In the Dresden 
1 Nouvelles observations sur la pratique der accoucher, Paris, 1714, LVL, p. 297. 194 
THE FEMALE URETHRA AND BLADDER. 
city hospital in 1876, a patient was admitted after whose death 185 calculi 
were found in the bladder, without his having had any trouble during life. 
But if the stone is of rapid formation, if it is heavy and rough, hyper- 
aemia of the mucous membrane, hypersecretion, catarrh, or inflammation 
leading to perforating abscess will soon result. Vesico-vaginal fistula is 
not infrequently caused in this way, Bouque finding it 6 times in 204 
fistulae. Before perforation occurs there will be dysuria, strangury, ischu- 
ria, incontinence, and sudden interruption of the urinary flow; impaction 
of calculi in the urethra and then spontaneous expulsion, are not only 
commoner in women than in men, but occur with much larger stones also. 
Such cases have been recorded in great numbers, most recently by Scan- 
zoni, Hyrtl, Josephi, B. S. Schultze, Cohn, (see llugenberger), Adam, 
Villebrun, etc. Thomas Bryant has collected in English alone the records 
of 13 cases of spontaneous expulsion, in some of which the stone was 6 
inches in circumference and weighed 4 ounces. The seat of the pain, as 
long as the calculus still remains in the bladder, is various; sometimes it 
is above the symphysis, sometimes radiating to urethra and vagina, some- 
times in the legs, the back, the loins, and even the upper extremities. 
In my case, when the finger was introduced into the vagina, there occurred 
a spasmodic contraction of the levator ani so severe, that I could hardly 
move the finger about at all; and touching the cherry-sized stone from 
the vagina was extremely painful. Haematuria, sometimes of considerable 
amount, may also occur. Since calculi occur at all ages, they may be a 
serious complication in pregnancy, confinement and the puerperium. 
Hugenberger (see above) has investigated this subject very thoroughly, 
and has 23 cases of vesical calculus in women during the childbearing 
period, recorded from the 17th century to 1875. There are first 4 
cases of De la Motte, Deschamps, Velpeau and Henry Thomas (Lancet, 
1839, Vol. I., No. 21), who all relieved their patients by operations per- 
formed while gravid. Thomas's case is of some interest. At the 4th 
month he removed, by Lisfranc's vestibular incision, a stone 1| inches long, 
1 inch thick, and weighing 6 drachms. The wound healed entirely in 32 
days, and at the 7th month the woman gave birth to a macerated child. 
The 5th case is one of llugenberger and Heppner, where vesico-vaginal 
incision was done at the 8th month of pregnancy. Pyaemia occurred after 
the sutures were removed, premature labor set in on the 23d day, and 
death followed on the 39th day. 
Seven of the 23 cases did have spontaneous delivery; but some of them 
were badly injured in the process. 
1. Guillemeau. Reposition of-the stone, which fell back again; contu- 
sion of the bladder-wall and perforation. 2. Smellie; the head drove the 
goose-egg sized stone down before it, and both were delivered. Conse- 
quence, incurable incontinence. 3. Lowdell extracted a stone which had 
caused a vesico-vaginal fistula during delivery. Baker Brown found a FOREIGN BODIES IN THE FEMALE BLADDER. 
195 
vesico-vaginal fistula caused by a stone, extracted one 2 inches long, 1 
inch broad and 34 inches in circumference through the dilated uretha, 
and cured the fistula afterwards. 5. Henry Jackson removed by urethral 
incision a round stone 44 inches in circumference, which was impacted 
in the urethra, and prevented delivery. 6. Cohn was about to do a 
Caesarean section on account of pelvic exostosis, when the woman was 
suddenly confined spontaneously, and a day later spontaneously passed a 
calculus If inches in length, f inch broad, and | inch thick. 7. L. 
Bourgeois extracted a stone from the bladder of a woman who had been 
naturally confined 3 months before. 
Eight times obstetric operations were rendered necessary, because of 
calculi, in the cases of Willoughby, Arnaud (extraction with the hand), 
P. Dubois, Richard, Naegeli (forceps), and Erichsen (perforation). 
Operations for stone were done 8 times during labor, by La Gouche, 
Levret (extraction), Denman, Monod (vesico-vaginal incision). Monod 
has twice done the vesico-vaginal incision in pregnant women, in 1849 in 
a primipara forty years old, and in 1857 in a primipara twenty-four years 
old. In the latter case reposition did not succeed, and delivery was ac- 
complished with the forceps after the stone had been removed. The 
fistula healed spontaneously in 20 days. 
The successful reposition of a stone inter partum, has occurred but 
once, and by P. Dubois. 
We may add here a case of Sainclair's in which a gravid woman with 
large vesical calculus and suffering from pain, fever, incontinence and 
cystitis, had a premature delivery. Three months later she spontaneously 
expelled a stone of mixed phosphates, oxalates, and urates 2.8 inches long, 
1.2 thick, and 1.6 broad. The calculus passed out through a large vesico- 
vaginal fistula, which was cured later. 
Thus there have been recorded until now 29 cases of vesical calculi in 
pregnant women, and in all there has been a more or less serious inter- 
ference with the reproductive process. 
Diagnosis.-One would not think that it would be difficult with the 
vaginal touch and the vesical catheter to recognize the existence of a 
calculus in a female. Yet mistakes have occurred from forgetfulness to 
thoroughly examine the bladder. The unusual body which was felt has 
been taken for a pelvic exostosis (cases of Sainclair and of Cohn), or for 
an ovarian tumor if it is situated to one side (Threlfall's case), or as a 
tumor springing from the symphysis (case of P. Dubois). Besides, 
echinococci have been found located between bladder and uterus (case 
of Birnbaum), which might be another source of error. If we feel per 
vaginam a tumor through the anterior vaginal wall, we should never omit 
to pass a metallic catheter, and, fixing the stone from the vagina, en- 
deavor to get the peculiar sound and feeling of a calculus. William 
Donald Napier has given us a sound which gives us ocular demonstration 196 
THE FEMALE URETHRA AND BLADDER. 
of the presence of calculi; it is described on page 21. Before introducing 
it we must examine the point with a magnifying glass, to make sure that 
there are no marks upon it. If there still remains doubt, urethral dila- 
tation and direct palpation of the internal surface of the bladder will 
almost always give us a certainty. At the same time we can recognize 
the seat, size, and surface of the stone, though this can be done fairly 
well from the vagina. In every respect the diagnosis is easier than it is 
in the male. Sometimes the first symptom which leads us to examine 
for stone, is the passage of one or more concretions spontaneously. In 
a cystocele we may be able to feel the stones in the tumor, which is visi- 
ble between the labia minora. (Norreen's case.) 
If after a successful operation for vesico-vaginal fistula, there set in 
symptoms of vesical catarrh, or haematuria, or dysuria, we may suspect 
that fragments of sutures or vesical pockets have caused the formation of 
a stone, and we must carefully examine the bladder with catheter and 
finger. 
Finally, we must decide whether one or several calculi are present, 
whether they are free or fixed (see Heath's case in 1871 in a girl 11 years 
old), or whether they are in a depression (compare Sentin's case page 
154), which perhaps leads to a canal communicating with the ovary or a 
foetal sac, or whether they are in a diverticulum. We will, therefore, fill 
the bladder with lukewarm salicylated water, and then attempt to displace 
the stone from the vagina or with the catheter. If this is not sufficient, 
we will dilate the urethra, and examine the stone with finger and sound. 
Prognosis.-The smaller and softer the stone, and the earlier its pres- 
ence is recognized, the better the prognosis. Calculi .8 of an inch in 
diameter are the largest that can pass through the urethra without sub- 
sequent incontinence. Soft calculi are always more favorable, since their 
size can easily be diminished. Those over 1.2 inch in diameter and not 
suitable for lithotrity are more serious, since they necessitate vesico- 
vaginal incision. In very young girls the prognosis is less favorable from 
the smallness of the parts; but in a general way the prognosis of stone in 
the bladder is far more favorable in women than in men, and has been 
much improved recently by the introduction of Simon's rational method 
of urethral dilatation. And in addition, small fragments left in the blad- 
der after operation are far less likely to cause a new formation of stone in 
women than in men, since they are much more likely to be passed spon- 
taneously. 
Nevertheless, neglected calculi in the female may cause severe suffer- 
ing, exhausting hemorrhages, fistulas, and death. This is sufficiently 
proven by numerous cases, among others by those of Fabricius Hildanus, 
Conradi, Denman, Fox, and Denaux. Cure is often slow, and spontane- 
ous evacuation through a non-dilated urethra may cause incurable incon- 
tinence, as is seen in the cases of Garden, Howship, Nankiwell, Mendel, FOREIGN BODIES IN THE FEMALE BLADDER. 
197 
and many others. The general health may suffer severely from the 
urinary trouble and the haematuria. Pregnancy may be interfered with. 
Walsham found that among 55 girls under fifteen years of age, who had 
stone, 3 died after operative procedures, and 52 were cured; but of these 
52, 9 had permanent and 3 temporary incontinence afterwards. Thus 
23 per cent, of all were left with an incurable and often fatal trouble. 
(Comp, pages 107 and 112.) This frequent occurrence of incontinence is 
to be explained by the use of unsuitable instruments, of dilators such as 
those of Weiss, which do not dilate evenly, and by the fact that we have 
only recently learned the limits to which dilatation can be pushed without 
fear of incontinence. And since we now know how to lessen the calibre 
of the urethral canal by operation, the prognosis has become much better. 
But the malady is not an unimportant one, and we should be chary in 
giving a good prognosis. 
In conclusion it is of great interest to note that the vaginal incision for 
the extraction of foreign bodies from the bladder often closes spontane- 
ously without further treatment. Bouque cites the cases of France 
(1808), Clemot (1817), Cittadini (1826), Bellini (1827), Grillo (1827), 
Rigal and Blandin (1830), Tommaso (1836), Rossini (1847), Marzuttini 
(1862), de Luca (1863), Montini (1863), Burci (1866), and Denaux 
(1872), where this occurred. Such a record speaks strongly for the vesico- 
vaginal operation. 
Therapy.-- There is but one indication as soon as a calculus is recog- 
nized in the bladder, and that is, to remove it as speedily as possible. But 
the physician should prevent the formation of stone. This is to be done 
by the careful treatment of hypersemias and vesical catarrhs, by the re- 
position of displacements of the viscus, by remedies directed against kid- 
ney trouble and gall stones, and by frequent washings of the bladder where 
there has occurred perforation from a neighboring organ. It has been 
proposed, where decomposition of the urine is occurring, to use carbolized 
injections, and thus form the carbolate of ammonia. But we know that 
we cannot expect to accomplish anything by the injection of substances to 
dissolve the stone, as Millot has proposed to do by means of gastric fluid, 
or by electrolytic methods. 
The following are the methods for the removal of vesical calculi from 
the female bladder: 1. Urethral dilatation, and extraction with forceps. 
2. Lithotrity or litholapaxy. 3. Vesico-vaginal incision. 4. Vestibular 
incision. 5. The lateral incision; and 6, the suprapubic incision. 
1. The operation of urethral dilatation in women, for the extraction of 
stone is, as has been mentioned before, an old one. Benevieni recom- 
mended it in 1502, Marianns Sanctus described it in 1526, Peter Franco 
in 1561 proposed a special instrument for its accomplishment, and Alpin 
relates that in 15911 an Arabian whom he knew, named Haly, dilated 
1 Prosper Alpinus de Medicina JEgyptiaca, lib. 3, cap. 14. 198 
THE FEMALE URETHRA AND BLADDER. 
the female urethra by means of tubes of increasing diameter, which were 
inflated withair. Later Solinger (1698), Douglas, Bertrandini (1769), at- 
tempted to dilate the urethra in the course of 7 to 8 days by means of 
tents formed of sponge covered with parchment. Bromfield used the 
processus vermiformis of a small animal, which he introduced with a sound, 
filled with water and tied. Thomas (1815) dilated with compressed 
sponge, as did Astley Cooper, John Wright, and others. Instrumental 
dilators were described by Peter Franco1 (in 1666), his instrument being 
like an aural speculum, while Fabricius Hildanus (1628) has one which is 
like the old four-leaved specula. Mazzoti (Florence, 1770) proposed a tri- 
cuspid dilator. But all these instruments are long since obsolete. In 
England, however, there is still much in use an instrument made by 
eiss of London, after Astley Cooper's model. It consists of two leaves, 
each like one half of a metallic catheter, and separated from each other 
by a screw. It is not only useless, but may do injury, thus causing in 
Brodie's case incontinence, which lasted fourteen days. Rapid dilatation 
may be done even in children under fifteen years of age. In 7 cases it 
has been dona in children successfully; by Curling, Heath, Hillmann, 
Gwinne, Davey, Lolly, and Wakley (cf. Walsham); and the incontinence 
which twice occurred is to be ascribed to improper methods, such as di- 
latation with the finger, or with a pair of forceps. In 15 cases of gradual 
dilatation there was failure to extract the stone in one only, the child dying 
of kidney disease; all the others recovered without incontinence. On 
the other hand, dilatation with incision, or incision alone as practised by 
the English surgeons, has proved to be dangerous; in 17 cases 7 had sub- 
sequent incontinence. There is no danger of this if Simon's method be 
carefully carried out. 
2. Lithotrity or litholapaxy is indicated in the female when the stone 
is over 1 inch in diameter, or when it is composed of salts deposited upon 
some foreign body. Fergusson gives a list of cases in which he has done 
lithotrity in girls with most brilliant results, nearly always removing all 
the fragments at the first sitting. And Walsham has collected altogether 
eight cases of lithotrity in girls under fifteen years of age, with and with- 
out previous urethral dilatation, in all of which there was complete cure 
without incontinence. In three of these latter cases repeated operations 
were necessary on account of the size of the fragments. The patients are 
narcotized and put in the lithotomy position. Then the bladder is filled 
with three to five ounces of lukewarm water, the instrument is warmed, 
greased with carbolized oil. The stone is then guided from the vagina 
in adults, from the rectum in children, into the jaws of the instrument, 
and is broken. After this more water is injected into the bladder, the 
smallest of Simon's specula introduced, and as many calculi as possible 
1 De la cure de la pierre aux femmes. Lyon, 1561, p. 143. FOREIGN BODIES IN THE FEMALE BLADDER. 
199 
removed. Then search should be made for larger fragments which may 
have remained behind per vaginam, and the urethra dilated still further, 
or lithotrity repeated. The after-treatment is that of vesical catarrh. 
3. The vesico-vaginal incision is to be employed when the stone is over 
1.2 inch in size, and is too hard to be crushed. Fabricius Hildanus 
(1628) was the first to do it. It was long the practise when the calculus 
was lodged in a cystocele, to incise the sac for the removal of the stone; 
this has been done by Rosset, and by Ruysch. Or a hollow sound was 
passed into the bladder, the point pressed against the vesico-vaginal sep- 
tum, and the cut made down upon the groove. The description of 
Simon's T-incision, which is only needed with very large stones, is given 
on page 15. Walsham states that by means of the vesico-vaginal incision 
6 out of 8 children were completely cured; 2 remained incontinent from 
laceration of the soft parts and the urethra in extraction. The vesico- 
vaginal incision is in the female by far the best operation for the extrac- 
tion of calculi. According to Aveling there was only 1 death in 34 
operations of this kind. But in children the calculus may be so large 
that it cannot pass through the lesser pelvis, or can only be dragged 
through with much laceration of the soft parts; and this may even be the 
case in adults, as in Josephi's cases of extra-uterine pregnancy with 
penetration of the bladder. 
4. The vestibular incision. We mentioned in the introduction the 
Celsian operation for stone in women, and saw how indefinite his descrip- 
tion was; since we cannot understand what he means by " sed virgini sub 
ima sinisteriora. " The statement " mulieri vero inter urinae iter et 
os pubis incidendum est " is clearer, and evidently means something like 
the operation which Lisfranc proposed in 1823, but did not do upon the 
living subject. He proposed that an assistant should press down the 
point of a male catheter, which had been introduced into the bladder 
with its convexity upwards, while another assistant forcibly separates the 
labia minora. Then the operator cuts with a straight bistoury, begin- 
ning above the urethra, and going from right to left, dividing mucous 
membrane, connective tissue, and the constrictor cunni. Under the 
symphysis, without injuring the pudendal artery, whose pulsations can 
be plainly felt, he enters the anterior vesical wall, and cuts it longitudi- 
nally or transversely. But the space obtained to work in is smaller, and 
the hemorrhage more serious than in other methods. However, as we 
mentioned on page 194, Thomas in 1839 successfully removed a stone 
from a pregnant woman by this method. 
5. Lateral lithotomy in the female is done either in the method of Cel- 
sus before mentioned, or as done by Frere Jacques de Beaulieu from the 
left tuber ischii, against a gorget introduced into the bladder, or in the 
manner more recently (1854) proposed by Buchanan of Glasgow. He has 
an assistant hold a hollow sound introduced into the bladder, and near 200 
THE FEMALE URETHRA AND BLADDER. 
the clitoris begins an oblique cut through the left labium minus parallel to 
the left pubic ramus. As soon as he can feel the gutter of the sound he 
transfixes the vesical wall against it with a straight bistoury; he then en- 
larges the vesical wound above and below without injuring the vagina, 
until he can pass his finger into the bladder. lie operated in this way 
upon four children from four to seven years old, and quickly removed 
stones varying from 15 to 75 grains in weight, and without incontinence. 
Finally, the method by which the urethra and vesical neck is split to the 
left side of the vagina, along a channelled sound, has been called lateral 
lithotomy. During the operation an assistant fixes the left labium with 
one hand, while another pulls the vagina to the right, and protects it 
from injury. The operation may also be done with the lithotome cache; 
and v. Nussbaum (1861) did it repeatedly and with success before lith- 
trity. 
6. Supra pubic lithotomy, epicystotomy, sectio alta, is only indicated in 
the female when the size of the calculus or the number of the stones, or 
the narrowness of the soft parts, renders the vesico-vaginal incision inade- 
quate. In 4 cases, done on girls 4 to 8 years old, 2 ended in death, and 
2 in recovery. The method of operation is exactly the same as in the 
male, and its description here is unnecessary. 
In any operation where an artificial opening is made into the bladder, 
if it is not to be immediately closed with metallic sutures as in vesico- 
vaginal and u re thro-vaginal fistula?, a catheter should be placed within 
the urethra so as to promote the outflow of urine along the natural pas- 
sages. Still, it is not invariably necessary, and sometimes does harm; 
and if urine can be passed spontaneously, it is only to be used for washing 
out the bladder and removing blood clots. CHAPTER XVI. 
NEUROSES OF THE FEMALE BLADDER. 
Cystospasmus and Cystopleg ia. 
rpHOSE affections of the bladder which occur without disease of its 
texture or change in its contents, and which, therefore, must be 
affections of its nervous apparatus, we call neuroses. They consist of 
vesical spasm, and vesical paresis and paralysis. In many, even in most 
of these cases, there is in addition some local disease of the tissues, and the 
neurotic disturbance is but a symptom. There is no doubt that the more 
we make use of urethral dilation as a method of examination, the more 
cases of what we used to call primary vesical neuroses do we recognize as 
secondary ones. Thus several writers have lately described fissure of the 
vesical neck as the cause of cystospasmus. We should be cautious, there- 
fore, in diagnosing neuroses of the bladder, and should arrive at them 
only by process of exclusion. 
1. Vesical Spasm, Cystospasmus, Neuralgia Vesicce.-Causes are chiefly 
nervous. Very excitable women easily have spasm of the bladder. 
Strong mental emotions, onanism, violent coitus, cold, especially at the 
menstrual epoch, sitting upon the damp ground, wetting the feet; all 
these may cause it. The free use of various drinks, as of several kinds 
of beer, and of new sour wine, has induced it, probably from chemical 
action of the kidney secretion upon the sensitive nerves of the vesical 
mucous membrane, causing hyperaemia of the latter. Playfair found in 
a number of women during the latter months of pregnancy, a continual 
desire to urinate, even at night, with a cloudy urine, which resisted all 
manner of medicinal treatment. He believed that in these cases the 
foetus was in faulty position, that its shoulder pressed against the mother's 
bladder; and he found that upon manually altering the position the dis- 
order vanished. As a secondary affection neuralgia of the bladder occurs 
in almost all the diseases of the bladder which we have described. 
Symptoms.-The first and most important symptom of cystospasmus 
is the frequent occurrence of cramping pains and pressure in the vesical 
region, and especially at the vesical neck. When the bladder is full there 
is moderate tenderness; and the pain is worst at the beginning of the act 
of urination, which may be repeatedly unsuccessfully attempted or avoided 
fear. The urine is pale, non-albuminous, contains no sugar, pus, 202 
THE FEMALE URETHRA AND BLADDER. 
blood, urates, or foreign bodies. There may be large quantities of it, 
though only passed in drops. Occasionally the passage of a metallic cathe- 
ter through the urethra and into the vesical neck is dreadfully painful. 
Twelve years ago, before we were acquainted with the method of rapid 
urethral dilatation, I endeavored for months to relieve an affection of this 
kind in a moderately stout patient; relieved for a time, it always returned, 
until finally she left me, I suppose cured. I now believe that she had 
erosions or fissures, and that the remedies which I applied in the form of 
bougies to the urethra and the vesicollum, did no permanent good, be- 
cause they did not act long enough. I once had an opportunity to con- 
vince myself at the autopsy of a puerpera who had suffered from ischuria 
and intense pain on catheterization, that at the neck of the bladder there 
was an ulcer the size of a pea. She had died of septic peritonitis. Here 
also the cystospasmus was only secondary. The pains sometimes radiate 
in all directions, and cause excitement, fear, cold sweat, nausea, anorexia, 
and sleeplessness. If they persist, they may exhaust the patient and 
actually cause melancholia. Marion Sims (Clinic of Uterine Surgery, p. 
248, 18G4) has pointed out that abnormal irritability of the bladder occurs 
with vaginismus; and it is well possible that the cystospasmus is here due 
to extension through the upper part of the hymen into the urethra and 
the vesical neck. The attempt to pass a catheter upon one of these pa- 
tients causes symptoms analogous to those of vaginismus. 
Diagnosis.-If the urine is normal, the urethra healthy; if there are 
no abnormalities detectable in the blood supply or texture of any part of 
the vesical wall when examined with the finger and with the eye; if after 
specular dilatation of the urethra the anterior vesical wall has been ex- 
amined with Rutenberg's speculum and found normal; then and then 
only can we diagnose a primary spasm of the bladder. For not one of 
the above-mentioned symptoms is pathognomonic. 
Prognosis.-Spasm of the bladder may last for months and years, and 
though not dangerous, is exceedingly troublesome. If not of too long 
standing the prognosis is fair; and even in the worst cases it can usually 
be cured in time. 
Therapy.-If possible, remove thecauses; excise the hymen in vaginis- 
mus, forbid sexual intercourse, order hot foot baths, stop the use of wine, 
beer, and tea, and seek to allay vesical irritability by the use of almond 
milk, one wineglassful three times daily. 
At the beginning local opiates will render us most service; and it is 
best to give at once a |th grain morphine injection in the skin of the 
vesical region. Less rapid but as sure are suppositories containing |th 
grain of morphine or | grain of extr. of belladonna to 40 grains of cocoa 
butter. Internally we may use almond emulsion with extract, hyoscyami, 
24 grains to 1 vi.; or opium with lupulin (3 to 5 grains) several times 
daily; or extract, cannabis indicae 2| grains, or tinct. cannabis indicae NEUROSES OF THE FEMALE BLADDER. 
203 
gtt. 10 to 15 t. d. Chloral hydrate is one of the most certain remedies 
that we possess, and it may be injected into the rectnm with a syringe 
to the amount of 15 grains dissolved in half an ounce of water, or ad- 
ministered internally with syrup of orange peel. 
If these means are not sufficient, we must carefully regulate the pa- 
tient's diet and her evacuations. We must use warm baths, and prescribe 
the free use of carbonated waters such as Weldmeyer, Biliner, Vichy, soda 
water, etc. If the malady is still unrelieved we must undertake mechani- 
cal dilatation of the urethra. Hewetson (4, XII., 1875) recently cured 
a cystospasmus of 15 years' duration in this way, and the method has been 
highly recommended by many authorities, including Teale (Lancet, 27, 
XI., 1875) Tilloux (Virchow-Hirsch, Berichtfiir 1873, p. 184), Spiegelberg 
(see obid.), etc. Again we may try the introduction of broad soft pessa- 
ries into the vagina, so as to put a moderate pressure on the bladder. 
Finally we may employ injections of morphine into the bladder with sub- 
sequent cauterization, as done by Braxton-Hicks (page 185) to relieve the 
reflex vesical irritability. Debout recommended bromide of potassium 
internally and also by rectal suppository in combination with tra. opii and 
ext. belladonna. As a last resort we may try the direct application of 
cocaine to the mucous membrane of the bladder. 
2. Weakness and Paralysis of the Bladder.-Paresis et Paralysis vesi- 
cce.-Ischuria, Incontinentia, Enuresis.-The physiologists are not agreed 
as to the exact functions of the two sphincters of the bladder, the internal 
one of smooth muscular fibres, and the external one of striped muscle. 
Some, like Budge and Hertzka, deny the efficacy of the external one, 
holding its function to be merely to assist in the evacuation of urine; 
while others, like Dittel and Kupressow, hold that the transverse internal 
muscular fibres of the vesical neck, like the similar • fibres found in the 
urethra, have for their function the closing of the bladder. From a 
clinical standpoint, we must agree in the main with the latter opinion, 
especially after our experience with fistulas of the vesical neck, which 
may reach to within |th of an inch from the orifice of the urethra, and 
still afford continence after operation. However that may be, all authori- 
ties are to-day agreed that the evacuation of urine is a reflex act. The 
spinal and cerebral centres of the vesical motor nerves are excited to 
action, either from the vesical mucous membrane where there is a large 
collection of urine, or from a drop of urine passing the involuntary inter- 
nal sphincter, and getting into the urethra, or from an effort of the will. 
On the other hand the will is able to resist the reflex action of urination 
by contraction of the external sphincter or compressor urethra?, as Hertzka 
calls it. 
Causes.-Weakness and paralysis of the bladder in women may be due 
to central or to peripheral causes. The peripheral momenta have been 
described in the foregoing chapters, and are mostly of a mechanical 204 
THE FEMALE URETHRA AND BLADDER. 
nature, as from the vesical displacements, so often caused by pregnancy 
and child-bearing; but especially is it due to that post-partum bending of 
the urethra which we have spoken of before, causing retention, and after- 
wards weakening of the detrusor vesicae, paresis vesicae. Pressure of quite 
another kind may, however, cause exactly the same condition. An in- 
terstitial oedema occurs with ulcers of the cervix, with parametritis and 
peritonitis, and disables the detrusor. This usually occurs in the later 
days of the puerperal period, and is generally very obstinate. 
Paralysis of the bladder also occurs not infrequently from peripheral 
causes in typhus, and in dysentery, due to fatty degeneration of the mus- 
cular coats of the bladder. 
In the same way paralysis of the bladder occurs in old women from 
myopathic processes; and in young individuals acute paralysis of the 
bladder has set in from over-distension in consequence of excessive mod- 
esty. 
The central and more general causes for vesical weakness and paralysis 
are cold, blows, falls, acute meningitis and encephalitis, myelitis of the 
lower part of the spinal cord, neuritis propagata from extension of inflam- 
mation from kidney and bladder to the plexus sacro-lumbalis (Kussmaul) 
large doses of opium, and finally, endarteris deformans of the pelvic ves- 
sels. Disturbance of consciousness in brain diseases (apoplexy), sopor, 
delirium, and high fever paralyze the detrusor, remove the influence of 
the will, and, overcoming the reflex contraction of the sphincter muscle, 
cause the urine to flow off involuntarily. 
Symptoms.-The first sign of vesical weakness is increased difficulty in 
voiding urine. It becomes difficult to empty the bladder, the accessory 
abdominal muscles are put into requisition, and finally, the bladder can 
no longer be emptied, and retention of urine, ischuria, sets in. This may 
lead to enormous accumulations of water in the female. Lieven drew 128 
ounces of clear transparent urine from the bladder of a woman thirty- 
three years old, in whom the distended organ formed a tumor as large as 
the uterus at six months, and who had been supposed to have an ovarian 
cyst. Others have emptied 16 beer-bottles full; Schatz, in the patient 
mentioned in page 178, drew 9 pounds of urine; and Hofmeier quarts 
from a bladder which was distended until it reached the navel. Budge 
showed the reason for this enormous distensibility of the viscus in a beau- 
tiful experiment. He cut the dorsal cord across, and proved that there 
ensued great vesical distension with increased reflex contraction of the 
sphincter vesicse. 
After the dilatation of the bladder has gone on to a certain extent, the 
resistance of the sphincter is usually overcome, and the urine partially 
flows off. The bladder is, however, not much diminished in size, and 
the condition known as ischuria paradoxa has set in. 
If this condition lasts long, and if repeated introduction of the catheter NEUROSES OF THE FEMALE BLADDER. 
205 
becomes necessary, there soon arise vesical catarrhs, inflammations of the 
ureters, pyelitis, uraemic symptoms, and death. Or perhaps portions of 
the vesical wall begin to ulcerate, and perforation with peritonitis or 
fistulas may occur. In very rare cases there occurs rupture of the 
bladder. 
Incontinence of urine is a special form of vesical weakness, chiefly occur- 
ring in children. But it may persist after adolescence, and in one form, enu- 
resis nocturna, sometimes remains after marriage. It is very apt to occur 
in scrofulous, cachectic, hysterical, delicate, pale individuals, and is some- 
times more or less hereditary. In some cases it leads to serious catarrhal 
troubles, from the continuous wetting and catching cold, so that we may 
have in consequence inflammatory conditions of the bladder, rectum, 
lungs, and bronchi. Undoubtedly the non-efficient exercise of will power 
is of great importance in the causation of this affection; many authors 
explain enuresis nocturna by the absence of will control over the sphinc- 
ters, which is the condition in deep sleep. If the incontinence lasts for a 
length of time, the muscular fibres are gradually weakened, and the in- 
voluntary evacuations may occur also during tire day. Some authorities, 
and among them B. Erdmann, regard enuresis nocturna as an incom- 
plete anaesthesia of the sensitive vesical nerves. The sensation caused by 
the filling of the bladder is present; but it is not strong enough to wake 
the child out of its ordinary sleep. Reflex evacuation then takes place. 
Diagnosis of Vesical Weakness and Paralysis.-We must first decide 
in any case of difficulty in urination whether the bladder is filled and 
tense, and whether its walls are tender. This is to be ascertained by the 
physical examination of the lower abdomen, percussion of the vesical 
region, vaginal, or in very young girls rectal exploration. Then the ure- 
thral opening must be examined, the catheter introduced, and the strength 
and rapidity of the flow of urine observed. The inner vesical surface is 
then to be examined as to sensibility with the catheter. Then the urine 
is to be examined; and it must be decided whether the bladder is ever in 
a contracted state, and if so, how long it takes to fill up again. In 
enuresis infrequent urination is a sign of deficient action; too frequent 
action is a symptom of paralysis of the detrusor. 
In pregnant and puerperal women, and in patients suffering from ty- 
phus and dysentery, the bladder should be constantly watched. 
If we cannot find any local causes for the paresis, we must search for 
the rarer central ones. Active and mechanical incontinence has been 
differentiated (Ilertzka) from the dribbling of urine which occurs in is- 
churia paradoxa or incontinentia paralytica. The latter is regarded as a 
symptom of vesical hyperaesthesia, while the former is considered as due 
to hindered extensibility of the bladder either from the enormous mass 
of its contents or from pressure of neighboring organs or tumors. 
Vesical paresis from endarteritis occurs either in old people or in indi- 206 
THE FEMALE URETHRA AND BLADDER. 
viduals in whom the premature calcification of the arterial coats will be 
easily recognized in the accessible radial, vesical, and uterine arteries. 
Prognosis.-Paralyses and pareses due to local causes may usually be 
removed in a short time when the cause is remedied. But when they are 
complicated with disease of the vesical wall, as occurs in chronic and ne- 
glected cases, and especially when there is retroflexio uteri gravidi, they are 
very obstinate and more serious. V esical paresis from central or other 
causes, as apoplexy, meningitis, etc., increase the original trouble, and 
hasten death by the rapid formation of decubitus. The paralysis of 
typhus, dysentery, and peritonitis is not dangerous, and is usually entirely 
cured when the process is ended. 
Enuresis nocturna is a very obstinate and very unpleasant malady; it 
injures the general health and is very difficult to cure. Sometimes it 
stops spontaneously at puberty. Recent cases are sometimes quickly 
cured. 
Treatment.-Many cases of vesical paresis in women may be avoided by 
a regular use of the catheter in conditions where the hindrance to evac- 
uation might lead to paralysis of the detrusor. That is especially the 
case with retroflexio uteri gravidi and in puerperal ischuria. In typhus, 
dysentery, peritonitis, the complication may be prevented by warm baths, 
by regular evacuation of the bladder, cold abdominal application, and 
the use of the catheter if the patient does not completely evacuate her 
bladder. The best means to prevent ischuria is complete evacuation of 
the bladder with the catheter and then washing out the viscus with a 1 per 
cent, salicylic acid solution. 
If paresis or paralysis has already set in, there should be regular cathe- 
terization every four hours. But the best remedy at our disposal is in- 
duced electricity, which has given good results after a few applications 
in ischuria, in paralytic and paradoxic incontinence, and even in enu- 
resis nocturna. One pole is introduced into the bladder, and the other 
placed upon the symphysis or the os sacrum or in the rectum. In atony 
and paresis of the bladder with vesical catarrh left after hyper-distension, 
we may use besides the direct faradic current the galvanic one, but only 
externally. Erdmann recommends that the anode be applied to the back 
of the head and the third cervical vertebra, while the cathode is placed 
over the symphysis or upon the perineum. Fifteen to twenty elements 
may be used for two to four minutes. In children the poles are only ap- 
plied externally The applications are to be made daily, and should last 
from three to five minutes. If there are signs of hyperfemia or vesical 
catarrh, the course of treatment laid down on page 184, should be begun. 
In some cases irrigation of the bladder with a 1 to 1000 salicylic acid 
solution through a Hegar's funnel every three to four hours will suffice 
to remedy a vesical paresis. Internally we should order a robirant diet, 
good wines, especially champagne, and weiss-beer, since it contains so NEUROSES OF THE FEMALE BLADDER. 
207 
much carbonic acid. Camphor in small doses and tra. of cantharides five 
to twenty drops one to three times a day may be employed; but they are 
liable to irritate. 
In a recent paresis of the bladder from catching cold, or long-continued 
retention, secale has often done good service, given as fresh powder 
ten to fifteen grains four to five times a day, even when the affection 
occurs in consequence of cerebral apoplexies and other affections of the 
nerve centres. Allier claims that this drug has done great good in 3 i 
doses daily. (Roth, Jacksch, and many others.) 
Strychnine has been used both internally and externally in paralysis 
vesicie; internally in ^th grain doses (Cory). 
If there is incurable paralysis of the sphincter vesicas C. Rutenberg1 
has recommended the opening of the bladder above the symphysis, the 
keeping open of the fistula, and the subsequent operative closure of the 
urethra. The urine can then only be voided by bending forward or 
using a soft catheter. A suitable retaining bandage and pad maybe used. 
Finally, to restore continence when the urethra is weak and relaxed, 
the operation described on page 36 may be had recourse to. 
As Barclay has so excellently expounded to us, the treatment of enure- 
sis nocturna must be constitutional, moral, mechanical and specific. 
Constitutional means are nourishing solid and soluble food, little fluid to 
be taken towards the close of the day. For medicines we may use qui- 
nine and iron. Barclay and Brugelmann join with me in praising syrup 
ferri iodat. in doses of Si. to 3 i. taken several times a day for months 
together. Brugelmann cured a girl in this way (S. f. iod. 7; aq. dest. 
syr. simpl. 50. 3 iq. 2 hours) in fourteen days. 
Moral Means.-Mustard plasters (i.e., beatings) after every wetting, 
and regular awakening for urination in the very young. For older chil- 
dren and adults, the avoidance of pleasures, balls, concerts, theatres, and 
society. They should be awakened two to three times every night. 
Some authors do not believe in punishing the children. 
Mechanical means are: Washing out the bladder to diminish its torpor. 
If the bladder is very small it should be mechanically dilated with injec- 
tions of warm water. Braxton-Hicks claims to have cured incontinence, 
which persisted after puberty, in a girl in this way. In a similar case 
the same surgeon cured a relapse which set in after three months, with 
first injections of a nitrate of silver solution followed by injections of a 
solution of morphine. 
As specific remedies we may mention chloral-hydrate and belladonna. 
I have used them both for long periods of time in large and constantly 
increasing doses in girls from twelve to fifteen years (chloral gr. fifteen to 
twenty every night.) But I have not seen the permanent good effect 
which has been claimed to result from their use by Thomson, Bradbury, 
'Wiener Med. Wochenschrft, 1875, No. 37. 208 
THE FEMALE URETHRA AND BLADDER. 
and Leonardi. We may use extr. belladonna, or the tincture in five to 
twenty drop doses several times daily, or £ grain as rectal suppositories. 
Campbell Black praises narcotics with chloride of iron in cases of atony 
of the sphincter. Great improvement is sometimes effected by giving 
girls of ten to fourteen years of age four to five drops of tincture of the- 
biaca before going to bed. 
Baths and cold effusions to the back and loins at night have sometimes 
succeeded when every other method has failed. (Savage.) In one of 
my cases the malady always got much better in summer; so that I sent 
her to live in the South. So the warm thermae of Gastein, mud baths, 
and even iron-baths may do good in certain cases. Sea bathing is always 
useful after a cure has been effected. THE 
DISEASES OE THE VAGINA. 
BY 
A. BREISKY, M.D. 
Professor of Obstetrics and Gynecology at the German University at Prague. THE 
DISEASES OF THE VAGINA. 
CHAPTER I. 
ANAT0MIC0-PHYSI0L0GICAL INTRODUCTION. 
Q INCE the time when the researches of Thiersch 1 and Leukart2 de- 
monstrated that, in the mammalian embryo, the entire vagina as well 
as the tubes and the uterus are developed from the Mullerian ducts, all 
later observers have accepted their conclusions, and have applied them to 
the human foetus. And while in the human embryo the union of the 
Mullerian ducts takes place at a very early period, and is completed ac- 
cording to Dohrn by the ninth week of embryonal life,3 the differentiation 
of the simple genital canal into uterus and vagina does not occur until 
much later. Kussmaul places it at the end of the third month;4 though 
Dohrn 5 could not appreciate the existence of a cervix until the fifteenth 
oi' sixteenth week. The lower edge of the tube, which later bears the 
hymen, is found where the genital canal opens into the sinus uro-genitalis. 
The hymen does not appeal- before the beginning of the nineteenth week, 
and is at first a simple projection of the posterior wall from the introitus; 
soon a smaller process from the anterior wall unites with it to form the 
half-moon fold.6 
1 Illustr. Med. Zeitung, Munich, 1852, vol. I., part 2, p. 69. 
2 Ibid., vol. 1., part 1, p. 1. 
3 Contribution to our knowledge of the Mullerian ducts and the development of 
the uterus.-Proceedings of the Ges. z. Beforderung der gesammten Naturwissen- 
schaften at Marburg, 1869, No. 3. 
4 On absence, etc., of the uterus, Wurzburg, 1859, p. 10. 
5 On the development of the hymen. Proceedings of theSoc., etc., of Marburg. 
Cassel, 1875 (Th. Kay). 
6 In regard to the hymen, whose vaginal origin is admitted by all later investi- 
gators, comp. P. Budin, Recherches sur 1'hymen et 1'orifice vaginal, Paris, 1879, 
(Public, du Progres Medical), and Dohrn, Zeitschrift f. Gebh. v. Gynakol., 1884, 
vol. II., part 1, p. 1. 212 
THE DISEASES OF THE VAGINA. 
We will follow Dohrn, who thus describes the vaginal changes: only 
after the portio vaginalis is fully formed does the smooth-walled genital 
canal undergo change. Longitudinal growth is rapid during the seven- 
teenth to nineteenth weeks, and the redundant internal coat is forced 
Fig. 1.-Sagittal Section through the Pelvis of a Female Embryo at the end of the 8d 
Month. Relatively large sexual tubercle. The utero-vaginal canal shows no trace of cervix, 
and opens into the sinus uro-genitalis. (Celloidin.) 
into tranverse folds, which interlace with one another. At the same time 
the upper part of the vagina dilates, while its lower portion to the extent 
of ^5 th to |th inch, contracts markedly. At the end of that period, a 
papillary growth appears in the vagina, especially in its middle portion. 
Fig. 2.-Frontal Section made in the Vaginal Axis (posterior half removed) of the Pel- 
vis of a Female Fcetus at 6 months. (Muller's fluid and alcohol.) Hymen thick. Vagina relatively 
wide. 
Above these, papillae continue to the vaginal portion of the uterus, and 
below they extend to the raphe of the sinus uro-genitalis. They are found 
upon the upper surface of the hymen only; the lower surface and the 
vestibule being smooth. One week after the first appearance of the 
hymen it is as fully developed as is usual in the newborn. After the ANATOMICO-PHYSIOLOGICAL INTRODUCTION. 
213 
lower portion of the vagina has been almost closed by the hymen, its in- 
ferior section dilates, and is limited above by a projecting fold, which may 
be mistaken for a second hymen. In newborn females the vagina is a 
relatively wide and long tube, the lower portion being partly closed by the 
hymenal fold. The structures of its wall and the papillas are well devel- 
oped, and an abundant layer of desquamated epithelium is present. Ac- 
cording to Huschke,1 the relative length of the vagina to the entire body 
is as 1:9, while in the adult it is as 1:15. 
Fig. 3.-Sagittal Section through the Pelvic Organs of a Female Fcetus at the end of 
the 5th month. Pelvic bones removed. Portio vaginalis and hymen distinguishable. Papillae on 
the mucous membrane. Columnae rugarum well marked. Celloidin embedding. 
Freund2 and Kocks3 have recently reopened the question as to the per- 
sistency of the remains of the Wolffian duct, the Gartner canals. They 
have described a case in which there were two small openings correspond- 
ing to the mouths of these canals near the urethra. The researches 
made upon the human embryo for the purpose have not sustained the 
conclusions of these two observers. Kblliker,4 Dohrn5 and Rieder® found 
no trace of the Wolffian ducts in the lower portions of the vaginal canal. 
1 Sommering. Eingeweide lehre, Leipzig, 1844, p. 536. 
2 Bericht. d. Naturforscherrersammlung zu Cassel, 1878. 
3Arch. f. Gynakol. 1883, volxx., p. 487. 
4 Sitzungsberichte d. phys., Med. Ges. zu Wurzburg, 1883. 
6 Arch. f. Gynakol, 1883, vol. xxi., p. 328. 
6 Virchow's Archiv., vol. 96, p. 100. 214 
THE DISEASES OF THE VAGINA. 
According to Dohrn, at about the middle of pregnancy Gartner's canal 
reaches the uterine substance in the neighborhood of the spot which will 
later become the internal os. It penetrates the outer muscular layers of 
the uterus, and then descends forwards and inwards to the vaginal vault. 
In the fornix itself Gartner's canal lies in the concentric tissue layer 
which surrounds the Laquear vagina, underneath the mucosa. The canal 
dwindles as it proceeds downwards; and in not a single case could Dohrn 
follow it to the urethral orifice. But he noticed that traces of the duct 
extend further down upon the right than upon the left side, and he ex- 
plains this as being due to the pressure of the rectum. Dohrn finds the 
Fig. 4.-Sagittal Median Section through the Frozen I'elvis of a Girl aged 9 months. 
f, p, Ligamentuni infundibulo pelvicum. /, o, Fimbria ovarica. t, Tuba. The axis of the uterus 
and vagina follows that of the urinary organs, d, i, Urethra and bladder. (After Kolliker.) 
cause of the early disappearance of these ducts in the lower portion of 
the vagina, in the rarification and stretching which the urethro-vaginal 
septum undergoes in embryonal growth; and Rieder upholds the same 
view. 
The vagina is situated high up in the foetus (Figs. 1 and 3), in the new- 
born child, and in early youth (Fig. 4); and it is much nearer the anterior 
pelvic wall than is the case in adults. This position is largely dependent 
upon the situation of the bladder, which in early years lies mostly above 
the true pelvis; it was formerly supposed to be the normal position of the 
organ in the mature woman. Recent sections have shown, in agreement 
with clinical observation, that, leaving out of account the change caused 
by a full rectum or bladder, the normal position of the vagina is quite a ANATOMICO-PHYSIOLOGICAL INTRODUCTION. 
215 
different one. Frankenhauser1 is right in his statement that when blad- 
der and rectum are empty, the vagina is not in the pelvis at all, but lies 
among the soft parts of the pelvic outlet; and that its axis does not cor- 
respond with that of the pelvis, but lies in the antero-posterior diameter 
of the pelvic outlet. (Fig. 5.) The length and breadth of the vagina 
vary considerably. According to Henle, the posterior wall is 2.8 inches 
long upon the average, while the anterior wall is i to f inch shorter. Its 
greatest width is at its upper portion near the fornix vaginae; it is nar- 
rowest at the entrance, where the hymen is situated. The walls of the 
Fig. 5.-Sagittal Pelvic Section. After a preparation by Prof. Waldeyer; from a drawing 
kindly loaned to me by the Strasburg Gynecological Clinic. 
vagina are applied together so as to form a square, transverse slit, about 1 
inch in breadth; and so that a sagittal section will give one a linear ori- 
fice. At various places we will, however, find upon minute examination 
that, owing to the columna rugarum, the transverse slit is irregular. 
Thus Henle makes the section | 1 -shaped. (Fig. 6.) In children and 
young people the square is relatively narrow. 
Since the vagina is the tubular duct of the uterus, and is formed with 
it from the Mullerian ducts, the tissues and various layers of the two 
organs are directly continuous and of the same construction. The walls 
1 Correspondenzbl. f. Schweizer aerzte, 1876, VI. Jahrg., p. 415. 216 
THE DISEASES OF THE VAGINA. 
are thinnest in the upper part, being not over ^th of an inch when empty 
of blood. Towards the orifice they become thicker. The anterior pillar 
of the columna rugarum is the stouter; it reaches to the introitus, when 
its projection beneath the orificium urethras forms the carina vaginae 
(Kohlrausch), or the tuberculam vaginae (Luschka). The posterior column 
usually lies somewhat higher up. Irregular lateral branches spring from 
both columns, anastomosing at their extremities; hence the roughness of 
surface of the virgin vagina. For further details we must refer the reader 
to the anatomical text-books, and especially to Henle. 
Cross sections of the vaginal wall show an internal and dense mucous 
Fig. 6.-Horizontal Section through the soft parts at the Pelvic Outlet. (After Henle.) 
coat, and an outer looser muscular coat, intimately connected with it. 
Around the latter is a connective-tissue envelope, in which the larger 
vessels and nerves ramify. (Membrana cellularis s. adventitia.) This 
latter coat is not of the same density throughout; in the recto-vaginal 
and vesico-vaginal septa it is looser, and in the former position it contains 
fat. The mucosa is provided in varying degree in different places with 
microscopic papillae; they are mostly simple, though on the columna and 
near the introitus they are compound. The mucosa consists essentially 
of a dense connective tissue, containing abundant elastic elements and deli- 
cate bundles of muscular fibres. The vascular muscularis is formed of 
masses of smooth muscular fibres, bound together by a connective-tissue 
framework. ANATOMICO-PHYSIOLOGICAL INTRODUCTION. 
217 
According to the most recent authorities, the innermost muscular layer 
is longitudinal, while the external one runs in a circular direction.1 So 
far as I know, Luschka2 only is of a different opinion. I myself have ex- 
amined a number of preparations in conjunction with Professor Eppinger, 
Fig. 7.-Longitudinal Section. 
Fig. 8.-Transverse Section through the Posterior Vaginal Wall of a Girl 24 Years 
Old. Letters alike for both, a, Mucosa, b, Muscularis. c, Submuscular layer containing fat. a, 
Circula. Longitudinal muscular layers. 
Fig. 7. 
and have always found the inner layer to be transversely and the external 
to be longitudinally arranged (Figs. 7 and $), and Professor Toldt has had 
1 Henle, l.c.; Klein in Stricker's Handb., Leipzig, 1871, p. 160. Frey, Handb. d. 
Histolog., Leipzig, 1876, p. 543. 
2 Anatomie des Beckens, Tubingen, 1868, n. 387. 218 
THE DISEASES OF THE VAGINA. 
the kindness to show me some preparations Of his which show the same 
arrangement. But we saw the arrangement, described by the authorities, 
where the section fell exactly upon a columna, especially the anterior one. 
And not only does the arrangement, as we found it, conform to the general 
type of muscular layers surrounding passages, and especially to that of 
the uterus, but it better explains the circular vaginal contraction which 
we occasionally meet with clinically. Toldt (1. c.) has recently stated that 
we can find in a general way an external dense layer of longitudinal fibres, 
and an inner non-continuous one which is mostly circular, but still it con- 
tains longitudinal and oblique bundles of fibres. 
Several layers of epithelial cells cover the mucous membrane, consisting 
of large, nucleated, angular cells. According to v. Preuschen1 the deep- 
est layers contain cylindrical cells with elongated nuclei. The scanty 
mucus which normally covers the surface is sour in reaction; it is just 
sufficient to keep the surface moist, and contains no formed elements 
save epithelial cells. Foreign substances are, of course, often present, 
from the free access which atmospheric air may have to the part; and 
among these foreign substances the lowest organisms are especially worthy 
of our attention. We will consider them elsewhere. V. Preuschen2 has 
described in the crypts of the mucosa of the upper vagina conglomerate 
glands, lined with ciliated epithelium. Most anatomists deny their exist- 
ence, and they certainly occur exceptionally, if at all. Some recent ob- 
servations, however, would seem to confirm the statement.3 Gland-like 
crypts of the mucous membrane are common enough, and sometimes form 
extensive blind passages, especially in the vicinity of the introitus and the 
extremities of the columns. It is doubtful whether the conglomerate 
glands which Henle saw in one case are not to be regarded as pathological 
appearances. Lymph follicles, similar in structure to the solitary glands 
of the small intestine, have been found by Lowenstein 4 in the human 
vagina. Toldt and Chiari have also noticed lymph-follicle-like bodies im- 
bedded in the mucosa. 
The vagina gets its arterial blood chiefly from the vaginal arteries which 
run along its posterior wall. Their mode of origin is variable; usually 
they are branches of the uterine, hypogastric, internal pudendal, or 
hemorrhoidalis media arteries; but Farre 6 has seen them arise from the 
obturators. As a rule two of them run down the posterior wall. In every 
case, however, branches of the pudendal and the vesical take part in the 
'Virchow's Archiv., vol. 70, p. 6. 
2 Ibidem. 
8 Thus C. Ruge found in a case of atresia hymenalis very distinct glandular 
structures upon the inner service of the hymen. Huckel and Heitzmann found 
them where v. Preuschen did. 
4Centralbl. f. Med. Wissensch, 1871, p. 546. 
6 Todd, Cyclopaedia of Anat, and Phys., vol. 5 (Supplem.), London. 1859. ANATOMICO-PH YSIOLOGICAL INTRODUCTION. 
219 
arterial supply of the vagina. According to Gussenbauer1 the art. vagin. 
is usually a fairly large branch of the haemorrhoidalis media, and it runs 
in the median line from behind forwards in the posterior vaginal wall out- 
side the muscular layer. As it runs it gives off branches which pass off 
at right angles to supply the lateral vaginal walls. These branches pierce 
the muscular layer obliquely, and, breaking up into a capillary network 
in the submucosa, send loops of vessels into the papillae of the mucous 
mem brane. 
While at the fornix and its neighborhood simple vascular loops supply 
the papillae, at the ostium vaginae, and especially over the columna ruga- 
rum, the compound papillae are supplied by an anastomosing capillary 
plexus, which springs from the submucosa by fairly strong branches. In 
the middle of this net-work the veins arise. In the columns these latter 
vessels are numerous and large, and arranged in plexuses, and especially 
at the lower portions of the columns they give the tissue a cavernous 
appearance. The veins which collect the blood from the mucous mem- 
brane form elongated meshes in the submucosa parallel to the longitudinal 
axis of the vagina. They unite into larger branches in the muscularis, 
and form in the connective tissue between vagina, urethra, bladder and 
rectum the so-called plexus venosus vaginalis. Many veins from the bul- 
bus vestibuli enter the plexus in its anterior part; while its posterior di-' 
vision is gained by those labial veins which do not join the pudendal. In 
the posterior vaginal wall, alongside the art. vagin. run two fairly large 
veins, which receive the blood of the plexus; they empty into the plexus 
hemorrhoidalis. 
Gussenbauer does indeed find that the structure of this plexus ven. 
vag. is similar to that of the cavernous erectile organs; but the vaginal 
vessels, when full, never attain that degree of stiffness which the vestibu- 
lar structures do, resembling rather, as Henle puts it, a filled sponge 
which can easily be emptied by pressure. 
We know but little concerning the minute ramification of the vaginal 
lymphatic system. The nerves come from the sympathetic and the pu- 
dendal plexus. Isolated groups of ganglion cells are found where two or 
more medullated fibres come together. (Klein.) Their mode of termi- 
nation in the human subject is not known. In rabbits and dogs Chrsch- 
tschonowitsch2 traced them as delicate non-medullated fibres accompany- 
ing the vessels and forming a sub-epithelial net-work. From this plexus 
the finest fibres penetrated the deeper layers of the epithelium, and formed 
a mesh of nerve-fibres surrounding the epithelial cells, among which 
larger branched bodies were found, analogous to the Langerhans bodies 
of the rete Malphigi. In general the sensibility of the human vagina is 
1 " On the vascular system of the external female genitals." Sitzungsber, d. K. 
K. Akad. d. Wissensch, Wien. 1870, vol GO, p. 534. 
2 Sitzungsber, d. K. K. Akad. d. Wissensch, Wien. 1871, Bd. 63, p. 301. 220 
THE DISEASES OF THE VAGINA. 
but small. Even in the neighborhood of the introitus, operations can be 
done without narcosis. There are, however, exceptions; and the vagina 
may be the seat of violent neuralgias. 
The connections of the vagina are most intimate at the entrance. The 
lower portion of the anterior wall is closely bound to the urethra, and 
the lower part of the posterior wall is attached to the perineum. Further 
Fig. 9.-Direction and Shape of a Sagittal Vaginal Section with the Bladder Hyper- 
distended. (After Pirogoff.) 
up the connective-tissue union with the bladder, rectum, and the liga- 
mentum latum is looser. Since the peritoneum of Douglas's cul-de-sac 
covers a part of the upper posterior wall, we can divide the hinder vaginal 
surface into an upper peritoneal, a median rectal, and a lower perineal 
portion. The anterior wall may be said to consist of a lower urethral, 
and an upper vesical part. The lateral portions of the vaginal vault are, 
corresponding to the base of the ligamentum latum, partially covered 
with peritoneum. ANATOMICO-PHYSIOLOGICAL INTRODUCTION. 
221 
According to Luschka,1 the ureters must not be forgotten here; in spite 
of their convergence, their vesical mouths are still an inch apart. The 
lateral portions of the vagina are covered by the vascular connective tis- 
sue, which is supported by the diaphragma pelvis. Both this tissue and 
the connective tissue surrounding the lower posterior portion of the vagina 
contain much fat, which forms an elastic cushion for the vaginal walls. 
(Kiwisch.) 
Fig. 10.-Direction and Shape of a Sagittal Vaginal Section with the Rectum Distended. 
(After Pirogoff.) 
These connections make plain the fact that the organ in question 
must be subject to many changes of position and axis. This is not only 
the case during conception and childbirth, though the dilatation and dis- 
location they may cause may be very considerable. A distended bladder 
and rectum may change the direction, shape, and length of the vagina. 
This will be plain from the sections shown in Figs. 9 and 10. If in spite 
'Arch. f. Gynak., Bd. 3, p. 378. 222 
THE DISEASES OF THE VAGINA. 
of these variations the general position and shape of the vagina is main- 
tained, it is due to the elasticity and tonus of the stretched recto- and 
vesico-vaginal septa, and to the integrity of the suspensory and support- 
ing structures. So long as the ligamentous connections between pelvis, 
bladder, uterus, and rectum (lig. vesicalia, pubo-vesico-uterina, recto- 
uterina, recto-sacralia) remain- tense, and the peritoneal covering of the 
posterior and lateral vault is intact, the vagina will be sustained by its 
connections with other organs. The best supported of all is the anterior 
division of the anterior wall; it is attached to the urethra by the pelvic 
connective tissue. The posterior vesical portion rests upon the posterior 
wall; and the posterior wall rests with its supra-perineal portion upon the 
rectum, while its perineal portion rests upon the structures of the peri- 
neum. Clinical experience teaches us that the muscular floor of the 
pelvis plays an important part in sustaining the vagina; but the subject has 
not been examined into anatomically.1 
There may be very considerable variations within normal limits in adults. 
I will only mention congenital shortness of the vagina, always combined 
with prolapse and retroversion of the uterus. In another place we will 
consider the variations in length and breadth, which are dependent upon 
age. In children the conditions of later foetal life persist for a long time. 
When senile involution of the genitals occurs, the vagina shrinks in length 
and breadth, especially in the vault, and the atrophied mucous membrane 
becomes smooth and pale. 
Nor are the disturbances caused by gravidity of less moment. The 
general hyperplastic development of the part causes increase in size and 
in laxity of texture. The participation of the muscularis in the process 
can be not only anatomically but also functionally proven in the vagime 
of advanced pregnancy. We often feei contractions when examining 
women pregnant for the first time, especially of the crescent-shaped folds 
of the anterior wall; at other places they are not so plain, and are only 
noticeable during delivery, when the vagina has not been over-dilated, 
nor has lost contractility from too long-continued pressure of the fcetal 
head. The peri-vaginal connective tissue is also greatly loosened in preg- 
nancy; its fat disappears (Kiwisch) and its vessels dilate.2 These changes 
enable the vagina to undergo the enormous dilatation, the traumatisms 
and displacements to which it is inevitably subjected during delivery. 
The greatest amount of longitudinal stretching during delivery occurs in 
the posterior wall; hence the frequent ruptures in this situation. We 
1 Not that there have been no excellent and minute anatomical studies; but 
that they have not been made with reference to this point. Comp. Lesshaft on 
the perineal muscles and fascia in women, in Gegenbauer's Morph. Jahrb. 1884, 
vol. 9, p. 475. 
8 Klin. Vortrage, vol. 2, 3d ed., p. 363, Prag. 1857. ANATOMICO-PIIYSIOLOGICAL INTRODUCTION. 
223 
can appreciate even at the beginning of labor the fact that the posterior 
vaginal cul-de-sac ascends, sometimes even to the height of the middle of 
the pubis, while before it was at the level of the tuberosities of the ischia. 
As the head descends into the vagina, the anterior wall also descends, but 
the posterioi- wall remains higher up, and is therefore more tense. CHAPTER II. 
CONGENITAL MALFORMATIONS OF THE VAGINA. 
OOME malformations of the vagina have been already considered with 
malformations of the rectum 1 and the bladder;2 and some others 
occur in connection with so faulty a development of the internal genitals, 
that they do not form the object of surgical treatment.3 
We will only here consider those malformations which give rise to dan- 
gers which we must try to prevent, or cause physiological disturbances of 
function which we can endeavor to rectify. There must be no important 
developmental fault in uterus and ovaries, so that the difficulties which 
our surgical interference is called upon to allay are those due to vaginal 
malformations alone. * 
We will, therefore, have chiefly to deal with the congenital atresias and 
stenoses of the simple and divided vagina, and those cases in which lon- 
gitudinal septa exist. 
The mode of origin of these malformations is not entirely clear. The 
presence of longitudinal vaginal septa may be due to a survival of a struc- 
ture which normally disappears at about the ninth wee'k of embryonal 
life, namely the septum of the coalesced Mullerian ducts; but the causes 
of atresia are not so simple. 
There is some reason to believe that the supposition is correct which 
explains atresias of the upper and middle portions of the vagina as being 
due to the loss of the existing lumen of the divided or united vaginal por- 
tions of Muller's ducts. Inflammatory compression, etc., after loss of 
the vaginal epithelium in the foetus, may perhaps cause pathological con- 
traction of the original lumen; but we can hardly understand how, when 
there is a complete upper and a lower vestibular portion of vagina, an inter- 
1 Esmarch. Diseases of the Rectum and Anus (in this collection). 
2 Winckel. Diseases of the Female Urethra and Bladder (this work. 
3 We would refer our readers for a full consideration of these anomalies to the 
later text books of pathological anatomy-especially Klebs, Handbuch, 4th ed., 
Berlin, 1873. 
4 The repeated attempts which are made to form a vagina where no developed 
uterus exists have failed to provide an organ of copulation where there was none. 
L. Heister in his Surgery (2d ed., Nuremberg, 1752, p. 889), has long ago given 
the correct surgical indications for the operation. CONGENITAL MALFORMATIONS. 
225 
mediate portion may be absent.1 It is different when the lower vaginal 
part is wanting. Of course there may have been a total defect of the 
lower parts of the Mullerian ducts, and their ends may not have reached 
the aditus uro-genitalis• thus ending as blind sacs, and causing the vagina 
to be absent in part. 
There are very great difficulties in the way of a decision as to the genesis 
of individual cases, both clinically and pathologically. The clinical ob- 
server may even be unable to decide whether a simple atresia in an adult 
is congenital or not; the history will often leave us unable to exclude 
stenosis acquired in early childhood; since other undoubted congenital 
malformations may be absent; and the cicatricial contractions and bridges 
which generally point to an acquired atresia, may have been left by a late 
foetal inflammation. Hymenal atresia, however, is excessively rarely found 
as an acquired condition.2 It is of relatively late foetal formation, since, 
as Dohrn3 has recently shown again, the first traces of the hymen are 
only shown at the nineteenth week of foetal life. The union of the hy- 
menal folds would therefore cause a hymen imperforatus. 
Let us first consider congenital atresia with a simple genital canal. For 
practical purposes we may divide them into those of the lowest portion of 
the vagina, and those that lie above that portion, and into broad and nar- 
row atresias, in accordance as they involve broader or narrower vaginal 
zones. 
The breadth of the atresia is of course partly dependent upon the 
amount of stretching the part undergoes from the accumulated men- 
strual blood; it maybe of membranous thinness, or 1.2 inchesthick. The 
older authors record cases where the atresias were three, four, or more 
inches broad. White is said to have successfully operated upon one five 
inches long. These figures are not to be taken exactly, and probably 
only represent the length estimated by the surgeon. 
Atresias which involve the entire length of the vagina, are probably 
only found in connection with atrophied uteri. 
Among seven specimens4 of congenital atresia of the simple vagina, 
1 Some confusion has crept into our genetic conceptions of vaginal atresia, from 
the repeated statement that the vagina is formed of two parts, an upper and a 
lower, which grow towards one another, and which occasionally do not meet. The 
lower portion does not belong to the vagina at all, not being formed from the 
vaginal portion of the Mullerian duct. It represents the vestibulum vulvae 
(Aditus uro-genitalis). 
2 Steiner's communication from Billroth's Klinik. Wien. Med. Wochenschr. 1871, 
No. 30. 
3 On the Development of the Hymen. 1. c. 
41 examined these specimens in 1878. I owe it to the friendship of my esteemed 
colleague E. Klebs that I had an opportunity to examine the rich stores of the 
Path. Anat. Institute, then under his direction. A later review of this portion of 
the collection, at which the present director of the Institute, Prof. Chiari, was 226 
THE DISEASES OF THE VAGINA. 
which are contained in the patholog-anatoni. collection in Prague, there 
is but one case of high-seated atresia of some breadth (1.2 inch), while 
two specimens show total atresia with atrophy of the uterus. In the 
remaining four cases the atresia was in the lower third or near the en- 
trance. In five cases of total atresia in the living subject, I observed 
rudimentary development of the uterus; and in three cases there was no 
trace of the organ at all. In one large handsome woman, twenty years 
old, with large and well-developed mammae, but undeveloped nipples, I 
found a regular vulva with ruptured hymen; but the labia minora were 
very small, and there was exceptionally little hair upon the mons veneris. 
The vagina formed a blind sac 2| inches long, and its columns were im- 
perfectly marked. A careful recto-abdominal examination showed no 
trace of the uterus; the plicae Douglassii lay directly against the bladder. 
In the left inguinal region of the abdominal cavity was an elongated, 
smooth, somewhat movable body, the size of an almond; on the right side, 
deeper and more difficult to reach, was a similar one. The pelvis was 
but little inclined; and though the hips were broad, the pubic arch was 
narrow. The palpably incorrect statement was made that there had been 
occasional slight menstruation since the sixteenth year. The case re- 
minded me vividly of the one Steglehner observed, of female external 
genitals with the presence of the testicle, though I could not demonstrate 
the existence of the vasa deferentia. I was told, however, that the patient 
had been repeatedly noticed to manifest erotic inclinations for young 
girls, which would point towards hermaphroditism. 
The sequelae of atresia, which depend upon the accumulation of secre- 
tion above the place, seldom appear before puberty; hence the majority 
of cases have been observed in adults. 
Nevertheless, dilatation above the atresia may occur in young children 
and in the newborn, and may provoke an investigation. G. Veit men- 
tions an observation of Godefroy,1 where, in a child two months old, there 
was such an accumulation of mucus behind an imperforate hymen, that 
it caused difficulty in the evacuation of urine and ffeces.2 I have myself 
seen dilatation from retention of the vagina and the collum uteri in 
specimens showing atresia in newborn girls. I also saw later, in two new- 
born females, a very thin membrane closing the lower portion of the 
vagina, close behind a well-formed hymen. Through the dilated hy- 
menal membrane the colorless, transparent, and shining septum was 
seen to project in an arched form as soon as the children cried. When 
kind enough to demonstrate the new specimens to me, revealed the important 
fact that there was not a single specimen which showed atresia of the fully de- 
veloped genital apparatus. This is to be explained by the fact that none of the 
clinically observed cases were fatal. 
1 Godefroy, Gaz. der Hop., 1856, No. 142. 
2 Arch f. Gyn., vol. 2, p. 84. CONGENITAL MALFORMATIONS. 
227 
tlie tension was relaxed the little finger could be passed into the opening 
of the hymen, and the fact be ascertained that the septum was entirely 
distinct from it. The bladder-like, cherry-sized tumor, which during 
the first two days projected through the vulva when the child cried, caused 
the parents great anxiety; but the tumor disappeared without a trace upon 
the third day, with the evacuation of a large amount of thick, milky 
mucus, containing much desquamated vaginal epithelium. The thin, 
transparent nature of these membranes, and their sudden disappearance 
when once they are ruptured by abdominal pressure, render it probable 
that there were only adhesions of folds of the mucous membrane behind 
the hymen. Since then I have encountered a case of a firmer septum 
retro-hymenale of this nature, in a virgin fifty-four years old, suffering 
from sarcoma uteri.1 Perhaps some cases of so-called double hymen be- 
long to this little-noticed form of atresia. 
I have but once met with true atresia hymenalis in a newborn girl. 
The child was well developed, measured 20.3 inches, and weighed 118 
ounces. Its genitals were otherwise perfectly normal. The hymen was 
formed by a closed membrane, the posterior portion of which was bellied 
forwards as a pea-sized, yellowish-white bladder. The walls of this blad- 
der were continuous with the surface of the hymen, and the margins were 
covered with vascular twigs. On opening it a copious thick, mucoid 
secretion appeared, which showed under the microscope masses of well- 
preserved pavement epithelial cells. (Table No. I.) 
After completed sexual development, the consequences of vaginal 
atresia depend naturally upon whether a regular menstrual hemorrhage oc- 
curs or not. Thus exceptionally vaginal occlusion, or atresia of one canal in 
a divided vagina, may exist in cases where maladies accompanied by amen- 
orrhoea are present, and no retention of blood above the atresia occurs. 
Mucus rarely causes trouble in adults. (Bryk.)2 
As a rule, the blood accumulation causes the usual sequelae of the 
molina menstrualia, and the development of haematokolpos and haema- 
tometra. The troubles depend partly upon the height at which the 
atresia is seated, and partly upon the amount of menstrual blood which 
has been poured out. Occasionally, after three months' menstruation, 
with deep-seated atresias, we may be able to detect considerable stagna- 
tion tumors; while in other cases the accumulations may be very small 
after the molimena have lasted for years. 
In every deep-seated atresia the vaginal tube dilated with blood will 
form a large part of the retention-tumor. As G. Veit remarks, it may 
occasionally, even before dilating the uterus, cause such difficulties in 
urination and defecation, as to lead the patient to consult a physician.3 
1 Prager Med. Wochenschr. 1878, No. 18. 
2 Wien. Med. Wochenschr. 1865, No's. 11-18. 
31 saw a splendid case of this kind recently in a strong girl, 19 years old. With- 228 
THE DISEASES OF THE VAGINA. 
When uterine dilatation occurs, it is chiefly the cervical portion which is 
affected, and which, with the vagina, contains the great mass of the 
blood. The vaginal dilatation may be so great in every direction, that 
its upper end projects above the lesser pelvis, while its lower end (when 
there is hymenal atresia) presses the labia and perineum outwards; it 
occupies the greater part of the pelvic cavity, and compresses and displaces 
both bladder and rectum. 
Nevertheless the dilatation causes hypertrophy, and not thinning of 
Fig. 11.-a, Vaginal wall above the atresia. 
the vaginal walls. In the specimens which I examined, the thickness of 
the hypertrophied vaginal wall above the atresia was |th to £d of an inch; 
out any characteristic molimena a haematokolpos had formed which filled the entire 
true pelvis, and projected above it. 1 was consulted because the physician who 
was treating it had caused suppurative decomposition of the retained blood and 
high fever by an attempt at sounding. There were some thin places in the hymen, 
one of which had been raptured in the attempt to pass the sound, which had thus 
given rise to decomposition. At the operation I emptied out a large amount of de- 
composed hemorrhagic matter ; and I noticed the enormously dilated and thick- 
ened but smooth vaginal walls, whilst the portio was closed and of the normal shape. 
Antiseptic injections were at once necessary. The fever disappeared promptly ; 
but the mucosa was so altered by the endokolpitis that though the patient's gen- 
eral health was perfectly good, it took several weeks of antiseptic irrigation to 
restore it to its normal condition. (Table No. 5). CONGENITAL SIALFORMATIONS. 
229 
and in two alcoholic specimens it reached |ths of an inch. The microscope 
showed that it was the muscularis which was chiefly involved in the hy- 
pertrophy. In the living subject I could very plainly convince myself, 
in four cases of atresia hymenalis, that with the hypertrophy there was a 
marked increase in the contractility of the vaginal wall.1 This dilatation 
with hypertrophy may be well characterized by Rokitansky's term " ec- 
centric hypertrophy." 
Fig. 12 gives an anterior and Fig. Ila posterior view of a preparation 
Fig. 12.- b, Vaginal wall below the atresia. 
(No. 164), which is opened so as to show the condition of the vaginal 
walls above and below the atresia. 
The case was that of a girl twenty-three years old, who was operated 
upon by Professor Fritz, on the occasion of the meeting of the " Deutscher 
Naturforscherversammlung " at Prague, on September 21st, 1837, and 
who died upon the same day. There is no history nor record of autopsy; 
the preserved specimen appears as follows: 
External genitals normal; remains of hymen small, and absent at the 
rear; frenulum lab. preserved; vaginal entrance large. The lower part 
of the vagina below the atresia stretches 2.8 inches posteriorly and to the 
left, and two inches anteriorly and to the right, measured from the pos- 
1 Prager Med. Wochenschr. 1876, No. 7, and Tables Nos. 2, 3, 4, and 5. 230 
THE DISEASES OF THE VAGINA. 
terior commissure. The mucosa is everywhere well preserved, without 
scars; the vaginal wall averages of an inch in thickness. This lower 
portion of the vagina is closed from above by a convex mass with smooth 
mucous membrane, which bears some resemblance to an enlarged portio 
vaginalis. It is formed by the depressed and closed portion of the vagina, 
and is pierced towards its middle by an angular opening, ■which leads into 
the anterior wall of the upper and greatly dilated portion. 
Above the atresia the vagina is perfectly smooth, much dilated, and its 
walls are | of an inch thick. Its length is about two inches. The collum 
is also dilated; the isthmus is marked by a constriction which can be 
seen externally; and the internal os is large and prominent. Length of 
collum is 1.4 inches. Its mucous membrane shows the net-work of an 
arbor vitas; and over the body it has been somewhat shrunken by the 
spirit. The uterine wall at its thickest cervical part is .8 of an inch, in 
the body it is .G of an inch in thickness. The body cavity is small as 
compared with the common cavity formed by the collum and the upper 
segment of the vagina. Uterus is 4.4 inches long, 3.8 inches broad be- 
tween the opening of the tubes, and 1.8 inches broad at the isthmus. 
The left tube is much dilated, though it is not bent; and 1.2 inches from 
the ost. abdom. it is transformed into a thin-walled blood sac about .8 
of an inch in breadth, which shows a longitudinal tear with irregular edges. 
In the neighborhood of this sac, the parietal layer shows peritonitic 
pseudo-membranous adhesions. Ovaries large and smooth; left shows 
false membranes. Right adnexa are free, tube not dilated, and no blood- 
clots upon it. No trace of a fresh superficial corpus luteum. 
The amount and quantity of the retained blood, depends upon the seat 
and duration of the atresia. In contra-distinction to what is seen in 
haematometra, the blood in h^maTokolpos often contains a considerable 
admixture of vaginal epithelium. 
In the section on haematometra the effects of blood retention upon the 
tubes will be thoroughly considered. Here we need only state that the 
dangers of haemato-salpinx only exceptionally end in a spontaneous and 
favorable way. This occurs when the membrane causing the atresia is 
thin enough to give way finally before the ever-increasing pressure of the 
retained fluid, aided by the force of the utero-vaginal and abdominal 
pressure. This occurred for instance in Zannini's case, where a girl twenty 
years old had hymenal atresia and retentio mensium for seven years. 
And the point of rupture is not always at the most favorable spot; Schaible 
saw one perforate the rectum, and in the cases of unilateral atresia to 
which we shall shortly refer, it most frequently occurs through the sep- 
tum uterinum. 
From the rarity and uncertainty of spontaneous evacuation, we must 
regard the prognosis of vaginal atresias which are left to themselves as 
bad, and the indications for operation are pressing in every case. CONGENITAL MALFORMATIONS. 
231 
The diagnosis of congenital vaginal atresia will be aided by the history. 
It will be stated that the menses have never set in, though there occurred 
at first typical and later atypical molimena. In the meantime a tumor 
had developed. If the atresia is high up, it has grown upwards; if low 
down it has appeared in the pelvis, and has caused difficulties in urination 
and defecation. 
In general the objective diagnosis of atresia presents few difficulties; 
the retaining membrane can generally be seen or felt, and the tumor ap- 
preciated above it. It will be useful for diagnostic purposes to separate 
hymenal atresia from the other congenital vaginal atresias. 
Atresia hymenea or hymenalis, not only differs in situation from 
more deep-seated atresias, but, since the passage is closed by a mem- 
brane composed of a duplicature of the mucous membrane, it will, 
even when greatly developed, retain the characteristics of a narrow 
and very elastic diaphragm-like atresia. These features are important 
to distinguish it from deep-seated and depressed vaginal atresias, 
when the vestibule leads into a blind sac; for with the latter we 
never have that distension of the vulva and the perineal region which 
has caused hymenal atresia to be often compared to the tense bag of 
waters during delivery. When this vulvar and perineal distension is great, 
the fraenulum laborium and the labia are dragged out of place, and the 
position of the hymen is altered. The relation of the membrane to the 
orif. urethrae indeed is not altered; but it reaches immediately down to 
the perineum posteriorly, and laterally presses against the internal surface 
of the labia. It is further to be remarked, that by many observers the 
imperforate hymen has been found to be unusually thick and fleshy; 
hence the rarity of spontaneous rupture. According to two observations, 
(comp. Tables No. 5 and 6), it appears to me that the hymen septus im- 
perforatus is most prone to spontaneous opening; since in both I found 
thin places in the walls of the median septum. 
The following case of atresia hym. is very characteristic, and deserves 
mention. (Figs. 13 and 14.) 
Christine S., seventeen years old, always healthy, has never menstru- 
ated. For three months has suffered from severe monthly molimena, 
lasting several days. The patient has noticed a tumor growing in her 
abdomen, which she says extended from the external genitals up into the 
abdomen. Latterly she had had considerable difficulty in urination and 
defecation, and this had led her to apply for relief. The amenorrhoea 
and the abdominal tumor, and especially the distension of the external 
genitals described below, had caused her friends to suspect pregnancy and 
the beginning of labor; so that it was not deemed wise to permit the 
patient to journey from her home to Prague, without being accompanied 
by a midwife. 
On December 27th, 1875, I found her condition to be as follows: Small 232 
THE DISEASES OF THE VAGINA. 
strongly-built girl of healthy appearance. No fever. Breasts well devel- 
oped, but contained no milk; papillae and areola almost pigmentless. 
Pelvis well developed. Slight pigmentation along the linea alba. Ab- 
domen swollen, mostly below the navel, where she measured thirty inches 
in circumference. The swelling is caused by a median tumor, which 
projects above the symphysis; it is elongated and rounded, of slight lateral 
mobility, and reaches 8.2 inches above the symphysis. Its upper part is 
3.6 and its lower portion 3.2 inches broad; the latter is slightly sensitive 
to pressure. The external genitals are regularly developed, and both they 
and the perineal region are distended so as to form a hemispherical mass, 
the size of a child's head. The vulva is open to the extent of two inches; 
Fig. 13.-Atresia Hymenalis. 
and between its lips there projects a hard and tough dry vascularized 
membrane, of the color of ordinary skin. This membrane is laterally in 
connection with the internal surface of the labia, posteriorly with the 
anus, which is two inches long, and anteriorly with the posterior border 
of the urethral orifice. It is the imperforate hymen. Fluctuation is 
distinct, and it can be gotten between the abdominal wall and the hy- 
menal membrane. Occasionally there is a spontaneous increase of pres- 
sure in the tumor. Per rectum the tumor appears as a fluctuating mass, 
which almost completely fills the true pelvis, and compromises the cali- 
bre of the rectum. 
On the next day, under chloroform, and avoiding all external pressure, 
I made the usual crucial incision of the hymen. Fifty ounces of thick- CONGENITAL MALFORMATIONS. 
233 
ened dark odorless blood at once flowed out; it contained both fresh and 
shrivelled blood corpuscles, and much large pavement epithelium. 
Recovery was perfect. The patient was kept strictly to bed; no inter- 
nal examination wras allowed; and cloths soaked in chlorine water w'ere 
placed over the external genitals. Only on the day after the operation was 
there a moderate sanguineous flow. At the next examination, (January 4th, 
1876,) I found the opening plenty large enough to admit a finger, though 
the hymenal flaps were thick. The vagina, greatly lengthened and dilated, 
was much folded upon itself, the anterior and posterior walls being in 
apposition. During the examination there occurred violent vaginal con- 
tractions, which the patient herself could feel. January 7th: Hymenal 
opening relaxed; remnants over ^th of an inch thick; edges slightly ex- 
Fig. 14.-Case of Fig. 13. 7 Days after the Operation-Eccentric Vaginal Hypertrophy. 
coriated. In the vagina was a little mucus. The thickened and hyper- 
trophied vagina contracts palpably upon the finger. No formed vaginal 
portion can yet be distinguished; but a long tubular speculum shows the 
os as a star-shaped and gaping opening. Abdominal tumor gone. Dis- 
missed at request on same day. (Table No. 3.) 
The other congenital atresias of the simple vagina do not give way and 
dilate so much under the pressure of the retained blood. Their connective- 
tissue texture and their thickness enables them to resist; so that dilatation 
of the lower portions of the vagina and opening of the vulva do not occur. 
On the contrary, the lower part of the vagina is usually narrow, or cone- 
shaped, although there may be considerable eccentric hypertrophy of the 
upper portion. Viewed from below, the atresia sometimes appears flat; 234 
THE DISEASES OF THE VAGINA. 
but this is more commonly seen with extensive vaginal defects and atrophy 
of the uterus, than in circumscribed vaginal atresia. In an exceptional 
case (comp. Fig. 12), the upper dilated retention-sac appeared like a 
rounded and enlarged portio vaginalis at the extremity of the blind 
lower portion of the vagina; and in the specimen the likeness is even 
more striking, since a central opening has been made. 
In a woman of twenty-one, who was married three years, the molimena 
had lasted a year, and had culminated in the development of a distinct 
haematometra. The vagina ended .6 inch above the well-developed 
hymen, and formed a blind sac directed somewhat to the left. From the 
vulva the limiting membrane appeared as a tough, flat, whitish wall, 
through which fluctuation could be distinctly appreciated when pressure 
was made upon the abdominal tumor. In two preparations now lying 
before me, in which there is marked atrophy of the vagina and the uterus, 
the closure is effected by a tough membrane, in which there are slight 
furrows to the right and the left. 
This form of vaginal closure can be seen by vaginal examination to be 
of more than membranous consistency; but the thickness of the septum 
cannot be so determined. Nevertheless it is very important to find this 
out; and a careful rectal examination must be made for the purpose. 
The free hand must press the vaginal surface of the septum against the 
finger, which is in the rectum; and thus an attempt at least at a proxi- 
mate estimation must be made.1 A combined vesical and vaginal exami- 
nation might be made in the same way, but it need only be had recourse 
to in exceptional instances. 
It must not be forgotten, when estimating the height of the atresia, that 
the lower portion of the vagina may have been considerably enlarged by 
repeated attempts at cohabitation, examples of which are numerous 
enough. (Comp, among others, Kussmaul, 1. c.) It is worthy of mention 
that cases have been found in which there were several septa lying one 
above the other in the vaginal tube. Thus Thompson2 reports a case of 
double occlusion of the vagina, deficiency of the upper part (?), and atresia 
of the orifice, with retention of catarrhal secretion between the layers, 
while hasmatometra was present above. Charrier mentions a similar case.3 
Steiner4 records a case from Billroth's clinic in which with a congenital 
atresia of the upper portion of the vagina, there was an acquired closure 
at the introitus. It is the only case I know of in which an acquired 
atresia occurred at the hymen. (Fig. 15.) The patient was eighteen 
years old, and was said to have fallen with violence upon the pubic region, 
' Kiwisch and Scanzoni prefer to use the thumb in the vagina and the fore- 
finger of the same hand in the rectum-and thus to estimate the thickness of the 
membrane. 
2Dubl. Hosp. Gaz., June 15, 1856. 3Gaz. d. Hop., 1866, No. 71. 
4 Wien. Med. Wochenschr, ,1871, Nos. 29 and 30. CONGENITAL MALFORMATIONS. 
235 
against a block of wood when two years old. Soon afterwards tne mother 
noticed that the child's external genitals were suppurating; and two years 
after an abscess, which broke spontaneously, is said to have formed. It 
was stated that the suppuration continued until the child's twelfth year. 
From that time to her seventeenth year the girl remained well. Since 
then molimin. menst. and formation of haematometra and haematosal- 
pinx. " The examination of the external genitals showed a complete 
atresia of the vagina by a peculiarly hard, tense hymen containing many 
cicatricial bands. In its lower portion was an extremely fine opening, 
Fig. 15.-From a Drawing of Steiner's Case, kindly lent to me by Prof. Billroth. 
into which the smallest sized sound could just be passed. On incision 
there was first found a blind sac an inch long; it was the rudimenary 
vagina filled with masses of smegma, and was separated from the blood- 
retention tumor by a stenosed area half an inch in depth. This was 
opened under full antiseptic precautions, and a large quantity of tar-like 
blood evacuated." The patient died on the fifteenth day of septic peri- 
tonitis and pleuritis. The tubal blood sacs showed in places some de- 
composed and ruptured spots. 
For differential diagnosis we need only exclude acquired atresias and 
marked stenoses. In the first case we will find cicatricial bands and an 
irregular lumen, with traces of inflammatory and ulcerative processes. 236 
THE DISEASES OF THE VAGINA. 
But we should remember that irregular cicatrices may not always point 
to an acquired atresia, but may be the remains of foetal inflammations. 
The presence of other developmental anomalies, especially absence of the 
hymen, may enable us to decide as to the congenital origin of the atresia. 
The history is valuable, since it will show that the symptoms began at 
puberty; but it will not always enable us to exclude atresias acquired in 
early childhood. But it will always give us valuable data in regard to 
atresias acquired later. Marked stenoses, which ©occasionally cause the 
same retention-symptoms as do the atresias, are much rarer as congenital 
defects; and acquired stenoses can often be distinguished from the atresias 
only with difficulty. Sometimes the history of the case is, that, after pro- 
longed retentio mensium, there occurred a sudden evacuation of blood, 
and the patient was relieved. The lumen must be demonstrated with, 
the sound. 
Vaginal atresias with duplexity of the genital canal which have been 
operated upon for the relief of retention, have so far only been seen uni- 
laterally.1 They cause hsematometra and luematokolpos lateralis. Ina 
simple vaginal canal they may be seated at the hymen, where, as is by no 
means always the case, that organ is double. The case that Simon and 
Veit observed together is of this kind. Much more commonly more or 
less of the lower end of one half of the vagina is wanting. (Fig. 16.) 
Unilateral accumulation of menstrual blood causes molimena ex-reten- 
tione to occur together with regular menses, and a tumor to appear at the 
side of an apparently simple uterus. It was therefore long overlooked, 
and is even now usually recognized only at the autopsy. Only since 
about 1860, has the subject been elucidated by the observations of Holst,4 
Veit,3 and Simon,4 as also by Schroder's 6 critical studies of the diagnosis 
1 I know of but a single case in which the anamnesis renders the existence of 
a bilateral atresia probable. Neudorfer (Diss, inaug. Tubingen, 1873), reports that 
in R. M., 24 years old, with a fist-sized tumor in the right lower abdominal region, 
which had appeared in her 16th year, a smaller one formed upon the left side. 
Both tumors long remained stationary; but from the Fall of 1864, they regularly 
swelled up and became harder every three weeks, the patient suffering great pain. 
By May, 1865, the right one was the size of a man's fist, and the left one larger 
than an apple. There then suddenly occurred a large vaginal hemorrhage, which 
lasted 14 days. The left tumor then entirely disappeared, whilst the right one 
remained unchanged. Two years later, with similar symptoms, there occurred a 
sudden diminution in the size of the right tumor ; and the symptoms of pyometra 
and pyokolpos lat. dextr. set in. This history points to bilateral atresia, and 
to a spontaneous vaginal evacuation of the left haematometra, with a rupture of 
the septum uterinum and evacuation of the contents of the right one into the 
left half of the uterus. 
2 Beitr. z. Gynak. u. Geb., part I., Tubingen, 1865, p. 63. 
3 Krankh. d. Weibl. Geschk, 2d ed., Erlangen, 1867. 
4 Monatschrift. f. Geb., vol. 24, p. 292 (Enke), p. 536. 
6 Bonn, 1866. CONGENITAL MALFORMATIONS. 
237 
of haamatocele retro-uterina. Since that time the number of cases observed 
has grown very numerous.1 Puech (comp, below) has drawn attention 
to the great preponderance of closure of the right side, finding it in 20 
out of 28 cases; and the cases not included by Puech in his lists confirm 
his conclusions. With rare exceptions the uterus is bicorned to a vary- 
ing degree in all these cases. 
It is very evident that in this affection also the symptoms will not 
appear until menstruation sets in. Thereafter they increase with each 
menstrual epoch. Their regular appearance in youth is a circumstance 
whichVeit has laid stress upon for differential diagnosis.2 They are ex- 
Fig. 16.-Schematic frontal Section of Hjematometra and ELematokolpos lat. dextr.-c. u. 
d, Right cornu, c. u. s, Left cornu, o. e, Orif. ext. o. i, Int. of the dilated collum of the right side. 
r.v, Vaginal rudiment in the patent left vagina, forming a blind sac. v. s, Distended, p.v, Nor- 
mal left vaginal portion, h, Hymen. 
actly analogous to the troubles caused by congenital atresia with simple 
genital canal, and are due to the development of retention tumors, here 
characterized by their lateral situation. If the closure is not quite high 
up in the vagina, the blind sac is driven down, and, though not situated 
near the vaginal entrance, may cause opening of the vulva and a moderate 
prolapse of the vagina. Urinary difficulties are comparatively frequent. 
1 In the first edition of this article, I referred to 46 cases of the kind. Since 
then I have met with another. (Compare Table No. 15.) 
2 Even in cases which are observed late the beginning of the malady dates back 
to the commencement of menstruation. If development is late, and the collec- 
tion of retained blood small, the pains may long remain slight. Holst's patient 
(Eva Pumberg) began to menstruate in her 27th year, and only came under his 
care when 42 years old. 238 
THE DISE/kSES OF THE VAGINA. 
Menstruation may remain quite normal in type and quality, though it is 
sometimes irregular; the complications which occur are due to the accom- 
panying unilateral stasis and catarrh of the patent portion of the uterus 
and the vagina, and the patients often suffer from leucorrhoea. As is 
noticed in the section upon uterine diseases, the distension of the womb 
may be very considerable here also; and as Puech points out, rupture of 
the tubal blood-sacs occurs relatively more frequently here than with sim- 
ple atresias, it being observed 3 times in 32 cases as against only 25 
times in 500 cases of the simple variety. And spontaneous perforation 
with evacuation into the vagina can more easily occur here than in the 
latter class of cases. In Puech's 32 cases it was seen 4 times, the perfo- 
ration always occurring in the septum colli uteri. (Fig. 17.) Two recent 
cases observed at Tubingen (Neudorffer, Tueffel) belong here. 
Unfortunately, however, perforation at this point causes the relief ob- 
tained from the heematometra to be but a temporary one. The patient 
Fig. 17.-Schematic frontal Section of Pyometra' and Pyokolpos lat. 
remains exposed to the dangers of pyometra and pyokolpos, as I first 
proved in two cases of my own. This occurred from the appearance of a 
purulent catarrh of the mucous membrane of the utero-vaginal space. 
The necessary conditions are a partial stagnation of the retained blood and 
an imperfect outflow from the small orifice in the septum cerv. ut. Pur- 
ulent decomposition manifestly begins in the open side. When purulent 
catarrh has once set in, the retained secretion causes still further dilatation 
and explains the obstinacy of the process. As the pus accumulates the 
tumor enlarges; until finally an abundant flow of matter comes from the 
cervix and the vagina of the patent side. Immediately the patient feels 
relieved. But the sac soon refills, and the pus in the course of time 
becomes thin and very foul-smelling. The patient loses flesh from the 
constant loss, and the attacks of pain and the evacuation of the malo- 
dorous pus annoy both the sick woman and her friends. More than this: 
' Arch. f. Gyn., vol 2, p. 84, and Correspondenzblatt filr Schweitzer Aerzte, 
vol. 1, p. 100. CONGENITAL MALFORMATIONS. 
239 
A number of serious dangers threaten the patient from extension of the 
inflammation to the tube, from ulceration of the diseased mucous mem- 
brane, from the development of pelvio-peritonitic abscesses, and from the 
secondary consequences of these occurrences. The lesions found by 
Rokitansky1 and by Wrung'1 post-mortem bear out this opinion. Neither 
case was diagnosed during the patient's life. The latter one occurred in 
Seyfert's clinic, and Siixinger has lately completed the description of it 
given by Neudbrfer in his dissertation by a careful history. Its entire 
clinical aspect is that of a pyometra lateralis. 
We can only designate the prognosis of cases of haematometra and 
haematokolpos, which are left to themselves, as unfavorable, even when 
spontaneous perforatio septi and evacuation occurs. Pyometra and pyo- 
kolpos regularly set in, and bring renewed danger to the patient. These 
cases, therefore, always require artificial aid. 
The diagnosis of unilateral vaginal atresia is connected intimately with 
that of unilateral haemato- or pyometra with retention. As Veit remarks, 
it is not difficult when we once fully appreciate the possibility of the occur- 
rence of the abnormality, and remember that the symptoms are those of 
haematometra with flowing menses. The anamnesis will reveal the char- 
acteristic symptom of menstrual colics during the formation of the lateral 
and vaginal tumor. If there is pyometra and pyokolpos lat., our patients 
will tell us that after the above-mentioned troubles have been present for 
some time, there suddenly occurred an evacuation of blood. This gave 
great relief, but only for a time; new retention pains appeared at the old 
place, and an abundant purulent genital flow set in. Often they will tell 
us that considerable quantities of thin foul-smelling pus have been voided 
from time to time, to their great temporary relief. 
The evacuation of the haematometra is not always spontaneous; but the 
conditions of incomplete drainage also occurred in cases where puncture 
was done.3 
In a single case of unilateral retention, and one in which hydrometra 
lateralis was present,4 there was an entire absence of any history of a pre- 
vious haematometra. 
In every case examination reveals a tumor beside the uterus filled with 
fluid, which projects more or less deeply into the vaginal lumen in accord- 
ance with the height of the occluding septum. Often the vaginal portion 
of the tumor projects forward; and several times the closed half of the 
genital canal has been seen applied in spiral fashion to the open half. 
Fluctuation can be felt between the upper and the lower portions of the 
tumor. If the vaginal portions are unseparated, the os uteri, as Veit 
1 Zeitschr. d. Ges. d. Aerzte, Wien. 1860, No. 31, p. 481. 
2 Vierteljahrsschrift f. prakt. Heilk., Brag. 1868, vol. 99, p. 39. 
3 Magenau 1. c. Braus, Berl. Klin. Wochenschrift, 1874, Nos. 10 and 11. 
4 Arch. f. Gyn. vol. 6, p. 89. 240 
THE DISEASES OF THE VAGINA. 
remarks, will take a lateral position as regards the tumor, forming an 
elongated, crescentic opening with its concavity directed to the occluded 
side. If the tension of the tumor's contents is not too great, the vaginal 
portion of the tumor will be recognized as being softer than the vaginal 
portion of the uterus. Often, as I have recently seen renewed proof of 
in the case Johannowsky has described, we can distinctly appreciate vari- 
ations in the tension of the vaginal tumor, due to contractions of the sac. 
After the sac is opened the smooth vaginal portion may be distinguished 
from the uterus by the ring-shaped os. When the mucous membrane of 
the exposed sac is scraped with a curette, we can sometimes get epithe- 
lium characteristic of vagina or uterus. This I succeeded in demonstrat- 
ing in two cases in which there was only a short rudiment of the vagina 
present. The diagnosis will probably be easiest in those cases in which 
the unilateral atresia is at the vaginal entrance, and in which the cylin- 
drical tumor runs the whole length of the vagina. It will be especially 
easy when, as in Simon's case, the bloody contents of the tumor can be 
seen through the transparent sac-wall. 
Pyometra and pyokolpos will give us a tumor with the same situation 
and characteristics; and pressure upon the vaginal tumor will cause pus 
to appear freely in the vagina from the os if spontaneous perforatio sept, 
ut. has occurred, and from the puncture or incision if there has been an 
artificial opening made. 
As Schroder has shown, the differential diagnosis of unilateral atresia 
is chiefly with haamatocele periuterina; before our more exact clinical 
knowledge of to-day more than one case of atresia has been confounded 
with it. (Comp, the section on hematocele.) Besides the history, the 
shape and the location of the tumor, the characters described in the 
foregoing sections ought to suffice for diagnosis. In high-seated atresias, 
forming a broad flat tumor, it is not impossible to mistake the affection 
for a cystic tumor of the ovary or tube attached to the uterus or true 
pelvis; or even, as I myself once saw, with a large laterally-seated soft 
myoma. In this last case an exploratory puncture will decide the matter. 
The treatment of congenital vaginal atresia only becomes a necessity 
after puberty has set in, except in those rare cases where the collection of 
catarrhal secretion within the sac necessitates surgical interference in 
childhood. Most authorities have rightly held that the demonstration of 
a blood-retention tumor is a sine qua non for the operation; since only 
when this is made can we be certain of the dilatation of the atresia and de- 
cide upon the direction of the incision. We are then sure also of the 
existence of a uterine cavity above the atresia. These considerations are 
of the greatest importance. It would be very desirable, if it were possi- 
ble, to prevent the difficulties and dangers of the condition by a prophy- 
lactic operation. At present we can only attempt it in cases of atresia 
hymenalis. The closed hymen can be recognized without any great. CONGENITAL .MALFORMATIONS. 
241 
accumulation of fluid behind it; it can be drawn down with sharp hooks 
and then incised. But even in these cases the differentiation of the con- 
dition from other deep-seated atresias may be rendered difficult by excessive 
firmness and thickness of the membrane; and if, in the adult, amenor- 
rhcea is present, so that retentio mensium does not occur, repeated attempts 
at coitus may so invaginate and displace it as to render its recognition 
almost impossible. Seyfert demonstrated a case of the latter kind in my 
presence. But as a rule, there is no question as to the time for interfer- 
ence. The patient does not present herself for examination until violent 
molimena-menstruatia and blood-stasis symptoms have set in. In fact 
they rather allow the accumulation to continue as long as they can bear 
it before seeking aid; and they do not as a rule come under our observa- 
tion while the accumulation is confined to the utero-vaginal tube, and 
before the pernicious tubal blood sac with its pseudo-membranous 
adhesions, have been formed. 
In every case the indication is to open the sac, and keep it so; so that 
a free evacuation of the retained contents may be secured and the func- 
tional activity of the genital system be restored. Unfortunately we can 
only completely fill the indication in exceptional cases, when the genital 
canal is a simple one and a thin septum and atresia hymenalis is present. 
In other cases it is rarely possible, although we may obtain fair results. 
In unilateral atresia the prospects of establishing a permanent opening 
by surgical means are better. 
As is well known, the dangers attendant upon operation in these cases 
are by no means slight. Many examples show us that not only operations 
upon difficult cases with extensive defects of tissue, but simple measures 
in thin-walled and superficial atresias may lead to most fatal results. The 
correctness of the warnings which Dupuytren, Labatier, Cazeaux and 
others have given us in regard to these operations have been proven by 
the fatal cases which have occurred in the practice of such experienced 
surgeons as Langenbeck, Schuh, Nelaton, Billroth, cte. 
The dangers of the operation are: 
1. Injuries to neighboring organs. (Bladder, rectum, peritoneum. 
2. Rupture of tubes distended with blood. 
3. Septic infection. 
The first danger is one which is only present when broad atresias caus- 
ing considerable technical difficulties, are to be' operated upon. The 
second and third, however, are present in all varieties. We will proceed 
to a more detailed consideration of these points. 
In large defects and atresias of the vagina, where there is not simply an 
adhesion, but a connective-tissue obliteration of the lumen of the canal, 
a bloodless dilatation is out of the question, and injuries to the bladder 
and rectum can easily occur, and have been repeatedly done. To avoid 242 
THE DISEASES OF THE VAGINA. 
them Emmet1 advises that after opening the dome of the blind sac with 
knife or scissors, a blunt instrument, a finger or the handle of the 
scalpel, is to be forced into the sac to enlarge the opening. While 
the atresia is being divided the bladder must be protected by a cathe- 
ter, and the rectum by a finger introduced into it. Or the finger 
of the operator may be passed into the bladder, while an assistant may 
place his finger in the rectum. This is necessary even when the apex of 
the retention-tumor can be attained without the preliminary division of 
an atresiad stretch of tissue; since the bladder has been injured by the 
direct puncture of a trocar.2 Where cutting instruments are used there 
may be considerable hemorrhage, as occurred in one of Hildebrandt's 
cases,3 and tamponade may be necessary when irrigation, ice, etc., fail 
to control it. 
Nevertheless a bad result even in cases of broad atresia occurs less fre- 
quently from operative injuries than from rupture of the tube or septic 
infection. The former accident has especially attracted the attention of 
surgeons. To Rose belongs the credit of having demonstrated its impor- 
tance by the collection of numerous cases which have been verified by 
post-mortem examination.4 The connective-tissue adhesions of the dilated 
tube to neighboring organs, especially to the parietal peritoneum, are of 
importance for the correct understanding of the mode of origin of these 
tears. They have been observed among others by G. Gosselin,5 and 
recently, in Winckel's case,6 by Birch-Hirschfeld. They are also to be seen 
in two preparations of the Prague collection, in which tubal rupture oc- 
curred after the operation for haematometra. The diminution in size and 
the change of position which occur in the uterus and the portion of the 
vagina above the atresia, after the evacuation of the haematometra, cannot 
be followed by the adherent tubal sac; and the sudden contraction of the 
emptied tumor and the increased pressure from the abdominal walls, to 
which it is subjected, causes a rupture of the thin walls of the sac. In 
addition to this Nacke lays stress upon the sudden diminution of the 
pressure to which the tubal sac is subjected; which is especially to be 
feared when the haematometra is large.7 The uterine contractions, to 
1 New York Med. Rec., ii. No. 26, p. 35. 
2 In the Prague collection is a preparation showing a bladder injured by such 
a puncture, with consecutive septic phlegmon of the pelvic connective-tissue. It 
is especially interesting, inasmuch as it is complicated with a colossal right-sided 
tubal dilatation, equaling the moderately filled large intestine in size. Rupture 
did not occur. The ostium internum of this tube was relatively very large, 
mitting a thick sound; whilst the ost. abdom. was closed by adhesions. 
3 Comp. Krause's Dissert. 1. c. 
4 Monatschrift f. Geb., vol. 29, p. 401. 
5 Gazette des Hop. 1867, No. 57, p. 225. 
6 Nacke, Arch. f. Gyn., vol. 9, p. 471. 
1 Nacke's idea, that the sinking of the pressure in the true pelvis is a factor in CONGENITAL MALFORMATIONS. 
243 
which attention was directed by the older authors, and to which the pre- 
ponderating influence in the occurrence of rupture has been ascribed 
more recently by Steiner, Billroth,1 and Freund,2 may act in one of three 
ways. It may directly express the uterine contents into the tube. This, 
however, can only occur in those rare cases where the ostium uterinum 
is much dilated. I know of but a single case of the kind, which has just 
been described in a foot-note. Then rupture from a sudden and consider- 
able increase of pressure in the tubal sac may occur from the propagation 
of uterine contractions into the tubes. It is not probable, however, that 
the chief cause of the occurrence is to be found here; for violent contrac- 
tions may have been present before operation without causing rupture, 
and rupture may occur without any specially noteworthy contractions. 
Finally, contractions of the uterus and of the hypertrophied portions of 
the vagina may directly increase the tension to which the tube is already 
subjected by the changes in position and diminution in size of the 
emptied organs. This latter seems to be an important factor in influenc- 
ing rupture. Nevertheless it is not to be regarded as alone responsible, 
since important and sudden increases of pressure may spring from other 
causes, such as the action of abdominal pressure. It seems to me that 
the tension upon the adherent tubal sac in consequence of the change in 
size and position of the evacuated organ, is the most important purely 
mechanical factor in causing tubal rupture. It hardly needs to be men- 
tioned that in the times when the anatomical relations of the tubes in 
hgematometra were less thoroughly appreciated than they are now, acci- 
dental external pressure upon the tumor or upon the abdominal walls may 
have determined a rupture. 
While it may not always be possible to avoid this danger, the recognition 
of its importance will always contribute to the safety of the operation. 
Therefore Puech, Rose, and others advise above all that the operation be 
done as speedily as possible. This depends, however, as we have said, 
more upon the patient than upon the surgeon. It is important also to 
operate at the middle time between two menstrual epochs, so as to avoid 
encountering a renewed increase of volume of the retention tumor 
the occurrence of rupture of the tube, has wrongly been denied by Rennert (Cen- 
tralbl. f. Gyn., 1882, p. 40). The incompressibility of the fluid contents of the sac 
does not cause, as Rennert believes, an equal pressure upon all portions of the 
sac, so that the diminution of external pressure can have no special influence upon 
any one part of it. The incompressible fluid is comparable to the liquor kmnii, 
and like it is enclosed within distensible walls. If the external pressure upon one 
part of the sac is diminished, the fluid contents will be displaced, and the walls 
of the sac be ballooned out in the direction of least resistance, and may be made 
so tense as to rupture. On the conditions influencing such pressure changes in 
the true pelvis, comp. p. 40. 
1 L. c. 
2 Zeitschrift. f. Geb. u. Gyn., vol. 1, part 2, p. 247, Stuttgart, 1877. 244 
TUB DISEASES OF THE VAGINA. 
from the menstrual flow. During evacuation, not only must all external 
pressure be avoided, but the abdominal pressure must be removed. This 
latter result is to be obtained by skilfully conducted and complete anaes- 
thesia. 1 
Much stress has been laid upon the importance of gradually emptying 
the tumor with a trocar, or by means of repeated aspiration with a canula 
or a Dieulafoy aspirator. But few cases have terminated favorably when 
this method was employed; and the unfavorable ones show us that the 
possible ill consequences of the operation are not to be averted in this way. 
Though the plan appears to be a rational one,' it is an unfortunate fact 
that with incomplete evacuation the dangers of septic infection are in- 
creased. If septic infection does occur, the dangers of a secondary rup- 
ture of the tubal sac are much greater, since the septic tissue-changes 
largely increase the friability of its walls; and the ulceration caused ex- 
ternally by pelvio-peritonitic abscesses may also lead to a solution of con- 
tinuity. It is my opinion that no small proportion of the cases of tubal 
rupture have occurred in exactly this way; and I believe that Spiegelberg 
is right when, as reported by Elischer,' he classifies a number of Rose's 
cases of tubal rupture under the heading of septic infection. Here also, 
I think, belongs the above-mentioned and extremely interesting case of 
Billroth-Steiner. For the sudden collapse to be looked for in tubal 
rupture was absent, and the peritonitic symptoms first appeared accom- 
panied with high fever upon the evening of the third day Chills, pleu- 
risy, a foul-smelling genital discharge, and an erysipelas beginning at the 
genitals, followed. The autopsy showed that besides the septic exudates 
which were found mixed with blood in the true pelvis, there were several 
small openings into the tubal sac, the tissue around which was in a state 
of decomposition. 
If many cases of tubal rupture are dependent simply upon septic in- 
fection, we are entitled to hope that with a more thorough prophylactic 
antisepsis many of these patients may be saved. 
It would certainly be proper during the operation to take care that the 
retained blood be gradually evacuated, so as to avoid any sudden altera- 
tion in the contents or position of the pelvic organs, and prevent a too 
rapid change of pressure. This must not prevent our fulfilling the 
antiseptic indication which demands that there be a free outflow of the 
retained blood. It has been sought to accomplish this by opera- 
1 Kaltenbach's objection that vomiting may occur during the anaasthesia and 
cause rupture is an important one, but is not weighty enough to lead me to reject 
narcosis. If the patient's stomach is empty and a pure chloroform is used, vom- 
iting will but rarely occur during the operation in the youthful and generally 
healthy patients in which the affection occurs. Later vomiting is not of so much 
importance. I have never seen any evil results from the anaesthesia. 
2 Berl. Klin. Wochenschrift, 1876, No. 30. CONGENITAL MALFORMATIONS. 
245 
ting at two different times, the first time puncturing with trocar 
or exploring needle, and the other time doing the incision. The opera- 
tion should under all circumstances be done at one sitting, and a suffi- 
ciently free opening be made at once. We can provide for a slow outflow 
by allowing the thickened fluid to run out slowly through the preliminary 
puncture (see below) before making the freer incision. A few minutes 
are enough to allow a gradual adaptation of the pelvic organs to the 
altered relations. In seven cases of haematometra, with broad atresia, I 
was compelled to operate in two cases where a unilateral tubal sac had 
been diagnosed; yet no evil results followed from the operation. I 
thoroughly agree with Emmet in that the most important point in the 
unilateral operation is to establish a free outflow; and I attribute our good 
results very largely to our appreciation of this fact. (Comp, table.) 
Rennert1 recommends that we distend the vaginal canal by permanent 
irrigation during the operation, and for a few days afterwards, so as to 
prevent a too rapid change of position of the pelvic organs. 
We have no recorded cases to show whether this idea of Rennert's would 
really render an adherent tubal sac less dangerous, since the case of 
hymenal or retro-hymenal atresia in which he used it, was not complicated 
with hamiatosalpinx. 
But not even all these precautions will avert all the dangers of a tubal 
blood sac. And it may be proper in some cases of haematosalpinx to do 
laparotomy and extirpate the tumor, or, if that is impossible, to practise 
incision and drainage. In both cases the laparotomy operation must pre- 
cede the atresia operation, and in the latter the tubal sac must be stitched 
to the abdominal walls before the incision is made.3 
The third danger in the operation for vaginal atresia is that of septic 
infection, which has caused death in many cases with symptoms exactly 
like those of puerperal fever. Several gynecologists have preferred to 
divide the atresia with the thermo-cautery, thinking to protect the surface 
of the wound from infection by the eschar more thoroughly than by means 
of the ordinary antiseptic measures. It is very evident that this could 
only be done with very accessible or narrow atresias, such as atresia 
hymenalis or retro-hymenalis (M. Duncan3), or with lateral hsematokolpos 
(Neugebauer). For in cases where the guidance of the fingers is indis- 
pensable, and where we wrork in the immediate vicinity of bladder, rectum, 
and peritoneum, some instrument which is not red hot must be employed. 
In suitable cases the method has been successful enough; but according to 
1 Centralbl. f. Gyn., 1882, p. 40. 
2 Schroder (Zeitschrift f. Geb. u. Gyn., vol. 8, p. 202), extirpated the blood-dis- 
tended left tube in a case of unilateral haematometra. The patient recovered, and 
spontaneous rupture of the haematometra into the vagina occurred. The orifice 
had to be dilated later. 
3 Obst. trans. London, 1882, p. 212. 246 
THE DISEASES OF THE VAGINA. 
my experience, we can dispense with it entirely. The electrolytic action 
of the constant current has also been tried. Lefort1 reports that he thus 
succeeded in making an artificial passage through a vaginal atresia, on 
which ten previous operations had been tried in vain. He passed a cop- 
per wire into the funnel-shaped blind sac, which was l-£ inches long, and 
applied the constant current. He says that menstruation thereupon 
appeared regularly, the speculum could be introduced, and the portio 
seen. Several of the older observers thought that the entrance of air and 
the decomposition of the retained blood was the cause of the infection. 
Vidal2 claimed as the cause of the entrance of air the previous dilatation 
of the uterus, which was then unable to close. Scanzoni also calls atten- 
tion to the danger of a septic endometritis, caused by the entrance of air; 
Clarke,3 who believes that rupture of the tubes is caused by ulceration, 
fears the entrance of air, lest it start up the destructive process, and seeks 
to prevent it by the exhibition of secale and turpentine. It is undeniable 
that the decomposition of the stagnating menstrual blood which is left 
behind, is much more often the cause of septic endometritis and pelvio- 
peritonitis than is the direct infection of the wound during the operation; 
explainable perhaps in that the bacteria find a very suitable nutriment in 
the decomposing semi-fluid matter. Infection during and after the opera- 
tion will be avoided by the general care in regard to the minute clean- 
liness of instruments and of the fingers which is now the rule. When 
it is necessary we may disinfect the entire seat of operation, use the spray, 
and avoid all untrustworthy dressings; and afterwards frequently change 
the dressings after having steeped them in an antiseptic fluid. 
As to the entrance of air into the retention-cavity, later experience has 
shown us that its danger depends upon whether it has been disinfected 
or not; the contact of even hospital air, which has been made aseptic by 
means of a carbolic or salicylic spray, being innocuous. Nevertheless, it 
is advisable in places where an efficient drainage is difficult to obtain, to 
prevent the entrance of air as much as possible. M. Sims, Schatz, and 
Hegar have studied the conditions upon which depend the entrance of 
air. Schatz has especially made it clear that the pressure-relations within 
the pelvis, whether the patient be in the knee-elbow, in Sims's, or in any 
other position, is changed as soon as any organs which occupy the true 
pelvis are lifted out of it. Since the bony walls will not give way, as 
soon as the pressure sinks below that of the atmosphere air will enter if 
allowed to. When the elevated and dilated organs, the uterus and the 
vagina, cannot sink down en masse after evacuation, so as to prevent a 
negative pressure in the pelvis, air will rush in through the gaping wound. 
1 Ann. d. Gyn., Tome vi., Sept. 1876, p. 206 : Creation d'un vagin artificiel par 
l'61ectrolyse. 
2 Bardeleben, Lehrb. d. Chir., vol. 4. 
3 Brit. Med. Journ., Dec. 1865. CONGENITAL MALFORMATIONS. 
247 
This may occur by any operation, but is especially liable to happen when 
we use the trocar and canula. In fact the change in shape and position 
of the emptying sac is often an insufficient one; and this on account not 
only of the pseudo-membranous fixation of the uterus and tubes, but 
perhaps oftener because of the hypertrophy and dilatation of the collum 
uteri, and that portion of the vagina which lies above the atresia. 
It is, therefore, advisable not to elevate the patient's pelvis too much; 
and in narrow, septum-like atresias not to keep the orifice open with the 
knife, until the pressure of the fluid has sunken so that it ceases to flow. 
We cannot make use of the ordinary measures to prevent the entrance of 
air when puncturing, because we do not employ the simple puncture with 
the trocar. When it is absolutely necessary, as in broad atresias, to leave 
the canula in situ, we must use antiseptic injections and see that there is 
a free outflow; for the entrance of air and the decomposition of the secre- 
tion which is left behind is unavoidable. At least we should attempt to 
disinfect the entering air as much as possible, by packing the end of the 
canula in disinfectant absorbent cotton or gauze; or, if short canulae which 
do not project from the vagina are employed, closing the external genitals 
with an antiseptic pad. We have often used compresses soaked in dilute 
chlorine water for this purpose. 
At least as important as the above-mentioned precautions during the 
operation, is the prevention of the entrance of air after the operation. 
We must especially avoid any manipulations which would cause the vaginal 
canal to gape, such as digital or specular explorations, the introduction of 
sounds, etc. Attempts to do these things have caused the ill-success of 
operations which had otherwise turned out well, and in cases in which 
all danger was supposed to be over. I called attention to this point some 
time ago,1 and Elischer2 has since then published certain cases of Spiegel- 
berg which show its importance. 
Since the entering air does most harm when abundant stagnating secre- 
tion is present, it is extremely desirable to obtain as thorough an outflow 
of the contents of the tumor as is possible. For this reason I must sus- 
tain Puech in his criticism of the process recommended by Scanzoni3 and 
Baker-Brown, to puncture through the rectum. In favorable cases it 
palliates the trouble for a time; but our experience is hardly sufficient as 
yet upon this point. 
It is difficult to say whether Simon's idea to open the sac from the blad- 
der can be successfully accomplished. W. Krause in his dissertation 
(Marburg, 1872) recommends it. It would possess the advantage that no 
foul gases would enter the sac, and the menstrual blood could flow off 
perfectly well through the bladder, if the fistula is only large enough. 
1 Progr. Med. Wochenschr., 1876, No. 7. 
2 Berl. KI. Wochenschr., 1876, No. 30. 
3 Dis. of the female sexual organs, 5th ed. 1875, p. 646. 248 
THE DISEASES OF THE VAGINA. 
We see this in successful cases of vaginal obliteration. But the same ob- 
jection which has recently led many surgeons to reject Simon's transverse 
obliteration would apply here. It would occasionally lead to cystitis and 
pylonephritis, and sometimes give rise to vesical concrements. 
It has been recommended for the purpose of avoiding septic infection 
to wash out the retention-sac, and thus get rid of all the blood immedi- 
ately after the operation. Emmet is the most prominent advocate of this 
proceeding, and lays especial stress upon the use of very hot water for the 
purpose. Others use disinfecting fluids. 
In our experience the washing out of the sac is only necessary when 
the evacuated fluid is already in a state of decomposition. Under ordinary 
circumstances antiseptic injections are only necessary later, when the pres- 
sure in the sac has so far sunk that no more blood flows out, and the 
vaginal secretions easily undergo decomposition, or when air has entered 
into the sac through the canula. The indications for injections are rarely 
present before the second or third day. Not only is it not necessary to 
use injections immediately after each operation; but to do so would inter- 
fere with the measures which have been recommended to prevent rupture 
of a hsematosalpinx. If there is no hsematosalpinx, irrigation will cer- 
tainly do no harm. 
In considering its dangers, we have described most of the steps of the 
operation, and there only remain a few special points to be described. 
In hymenal atresia, where an opening can most easily be made, the old 
method of cruciform incision recommended by Celsus fulfills all the in- 
dications. Only when we find a lateral tubal blood tumor, are the above 
precautions in regard to free outflow, etc., necessary. Baker-Brown's1 
practice of ablating the hymen all the way round, and the recommendation 
of Vidal and Bockel, to encircle the margins of the wound with stitches 
after excision, are unnecessary complications in any case save when tl*e 
hymen is exceptionally fleshy. 
In atresias, where the lower blind sac doesnot end in a projection cov- 
ered by smooth mucous membrane, an attempt at bloodless dilatation 
may be made with the finger or a straight metallic catheter. In some 
few cases astonishing results have been attained in this way. Thus in 
Amussat's2 well-known case, a total vaginal occlusion in a girl fifteen 
years old was rendered patent by simple digital pressure, and the continu- 
ous use of sponge tents, so that eventually the collum could be incised 
and the retained menstrual blood evacuated. Two years later the patient 
was perfectly well. In a similar way Gantvoort3 obtained a permanently 
good result in a girl fourteen years old, in whom there was supposed to 
1 On Surg. Dis. of Worn., 2d ed., Load. 1861, p. 229. 
2 Gaz. Med., 12 Dec. 1835. 
8 Nederl. Arch. f. Genees. u. Naturh., 1866, vol. 3, p. 380. CONGENITAL MALFORMATIONS. 
249 
be an entire absence of the vagina. Bidder' also succeeded with his fin- 
ger in opening the apparently absent vagina in a girl seventeen years old 
suffering from hsematometra, so that puncture of the collum could be 
done, and the patient relieved, although a vaginal stenosis remained be- 
hind. 
There is no doubt that in these cases there was no real defect or cica- 
tricial stenosis, but rather a firm adhesion of the vaginal walls to one an- 
other. Veit has claimed that this was the fact in Amussat's case; and 
this not so much because the membrane covering the atresia offered 
so little resistance as because the right passage to the portio vag. was so 
quickly found and so easily kept open. Since it is impossible before at- 
tempting dilatation, to distinguish these adhesions from real obliterations, 
it would be well before proceeding to operate to make an attempt to force 
a passage in this way. 
If the atresia is covered with a smooth mucous membrane, or if the 
attempt to effect a passage with the finger has failed, we now proceed to 
split the mucous membrane with scissors or knife, bearing in mind the 
precautions recommended above. Then we make our way with a blunt 
instrument through the deeper layers of tissue towards the tumor, while 
an assistant with a metallic catheter controls the urethra and the bladder, 
and with his finger guards the rectum. The finger, aided occasionally 
by a blunt closed pair of scissors, is the best instrument that we can em- 
ploy. If bands of firm tissue are met with, they may be divided with the 
latter instrument.2 When we thus reach the fluctuating wall of the 
retention-tumor, we must palpate carefully to decide whether we cannot 
distinguish the region of the cervix as a soft, depressible round spot in its 
walls. This is often the case when only a small remnant of the fornix 
division of the vagina is preserved above the atresia. It cannot be felt, 
of course, when the lower portion of the tumor is formed of a large sec- 
tion of vagina, and is tense. I have repeatedly succeeded in finding it, 
and have experienced its usefulness in facilitating future utero-vaginal 
communication; since it is only when the place is properly selected that 
the cervix assumes its position in the lumen of the vagina. I use a long- 
handled lancet-shaped knife, to effect the opening, either at the site of 
the cervix, or, if it cannot be found, at the lowest part of the vault of 
the tumor; the blade being protected by a large canula controlled by a 
spring. (Fig. 19,/.) Drawn back into the canula, and thus guarded, 
the knife may be safely passed under guidance of the finger to the selected 
1 Berl. Klin. Wochenschr., 1874, No. 46. 
2 Emmet's rule, to make the division with the blunt instrument as large as pos- 
sible, so as to obtain a wide passage, is only to be followed with great caution. 
Too extensive lateral movements of the finger injure the pelvic connective tissue 
needlessly, and if the course of the wound is not a thoroughly aseptic one, favor 
the occurrence of extensive phlegmona pelvica. (Compare Table No. 10.) 250 
THE DISEASES OF THE VAGINA. 
spot, and applied to it. The blade is then projected until it enters the 
retention tumor; and then the puncture is enlarged to right and left 
with the knife. The opening should be about fth of an inch broad. 
Then the blade is withdrawn into the canula, the knife removed entirely, 
and the canula pushed deep into the tumor. I then use the instrument 
which I call my forceps canula. (Fig. 18.) It consists in principle of a 
canula split into two halves, to which a strong, double curved dilatation 
Fig. 18.-a, b, c, Forceps Canula ; closed in a and b, open in c. 
forceps has been added. This instrument is passed over the canula, which 
it exactly fits, and is pushed closed into the retention sac. Now the jaws 
of the forceps-canula are forcibly opened, and they are fixed by means of 
the catch. Immediately after incision the thickened blood begins to flow 
out; but after the wound is dilated it appears in larger quantity. By 
dilating slowly, the rapidity of outflow may be controlled, and the dis- 
turbing influence upon the position of the pelvic organs be more gradually 
brought to bear. The advantages of this course have been fully described CONGENITAL MALFORMATIONS. 
251 
above; and we may thus prevent the danger of rupture when hemato- 
salpinx is present, while retaining the advantages of complete dilatation 
at one sitting. As soon as dilatation is complete, a fenestrated double tube 
of German silver, about 2^ inches long, is introduced between the jaws 
of the forceps canula; thus ensuring free outflow and enabling us to make 
antiseptic injections. This tube has an olive-shaped end, at the apex of 
.which is the opening of the canals.1 The olive end is bent at an obtuse 
angle to the axis of the tube; and the whole very much resembles a 
Dutch clay pipe, so that we usually call it the pipe-canula. (Fig. 19, 
Fig. 19.-d. e, Short, pipe-shaped double canula, at d with extra tube attached, at e with it 
withdrawn. /, Trocar-knife. 
d, e.) For introduction, and to facilitate future washing through it, a 
tube of German silver about six inches long can be put into the lower 
opening of the olive. This can be done easily with the guidance of the 
fingers. When the double canula has been introduced, the forceps 
canula may be withdrawn, the former instrument being left in situ. The 
bulb protects the mouths of the tubes from vaginal pressure, and its 
larger volume tends to dilate the atresiad spot. A few days later, when 
the uterus has contracted considerably, the tube may be replaced by a 
thinner one not over inches long. It may be left in place for a con- 
siderable time, though of coarse it should be cleaned occasionally. 
' I have lately had the " dead end " of the double canula, like those of the 
metallic catheters, covered with tin. 252 
THE DISEASES OF THE VAGINA. 
This method is the only one that I have used since 1878; it has done 
me good service in seven cases of broad atresias. But other methods 
will do as well; and the operation depends much less upon the instruments 
used than upon the appreciation of the correct principles which should 
guide it. But from the peculiar difficulties offered by a field of operation 
where we must rely upon the touch, it is desirable to render the technical 
difficulties as small as possible by the use of suitable instruments. 
As regards the tubes used in broad-seated atresias, their purpose is not 
to dilate the stenosed region, but to maintain the communication between 
the uterus and the vagina, and to provide for outflow and for antiseptic 
injections. To accomplish its object, the tube must partially lie in the 
cervix itself when the atresia is high up and near the uterus. In these 
cases it is important that the tube be not too large, since it would other- 
wise interfere with the involution of the portio. The portion that lies 
in the atresia should be somewhat thicker. I have endeavored to accom- 
plish this with the clay-pipe canula. 
If there is a considerable portion of vagina above the atresia, we need 
not be so careful, and any incompressible tube will answer our purpose. 
It may then be thicker in calibre, and must of course be provided with 
a number of not tpo small openings for purposes of drainage and irriga- 
tion. Drainage tubes of hard rubber, German silver, or glass, have not 
done well; the small orifices in them soon becoming clogged. 
If we have a small, membranous and vaulted atresia to deal with, we 
shall choose our instrument in accordance with its accessibility, bearing in 
mind what we have already stated as regards the advantages of a free in- 
cision. The higher we have to operate, the more necessary will it be for 
us to use canula-protected instruments; for which purpose the above- 
described instrument is to be recommended. It cannot be done so well 
with the "dilating trocar'' which Clinton Cushing 1 has described, while 
Bixby's double trocar and the ordinary trocar do not allow a sufficiently 
free outflow, and, being difficult of access, render subsequent dilatation 
very inconvenient. In unilateral vaginal atresias the knife and scissors 
can always be used. With the aid of the duck-bill speculum, a puncture 
can be made into the vaginal septum, and then the entire partition be 
split with curved scissors or probe-pointed bistoury.' Veit and Freund 
recommend the excision of a piece of the septum ; but I do not see that it 
has any advantages over the simple incision, which I have done five times. 
1 St. Francisco Western Lancet, vol. xii. No. 11, 1883. On the treatment of 
pelvic abscess. Cl. Cushing's instrument consists of a slightly curved forceps, on 
compression of the ring-shaped handles of which the leaves which form a trocar 
in the closed state are separated. 
2 A new instrument for the ready and effective use of the double current in 
the treatment of suppurating cavities and pelvic drainage. Bost. Med. & Surg. 
Journ., 18 Nov. 1875. CONGENITAL MALFORMATIONS. 
253 
As to after-treatment, in addition to the precautions already mentioned 
in regard to the prevention of the entrance of air and the stagnation of 
secretion, it has been recommended by many surgeons to apply a com- 
pression bandage to the abdomen.1 I do not think its use will be of much 
avail either in favoring complete evacuation or in preventing rupture of 
the sac; and the necessary pelvic movements which the patient must 
make while it is being applied, might not be wholly harmless. It will be 
better, therefore, not to employ it save in cases where the tumor is very 
extensive. Here it may be useful in enabling us to apply an even exter- 
nal pressure to replace the diminished intra-abdominal pressure, and to 
immobilize the lower abdomen. Even here, however, it will be simpler 
to apply a linen bandage over a few layers of absorbent cotton. 
It is of the greatest importance to maintain a free outflow from the 
tumor, and to prevent the closure of the vaginal passage. If the atresia 
is of small extent, and the incision sufficiently large, it will not be neces- 
sary to take any special measures to secure this. But if the new passage 
is broad, or long, the maintenance of its patency will be the most difficult 
part of the after-treatment. The extreme tendency to contraction dur- 
ing cicatrization unfortunately but too frequently interferes wi th the suc- 
cess of our efforts. 
Various means have been employed to overcome this^endency. 
1. By wearing or introducing glass tubes (M. Sims, Emmet). In this 
way cicatrization is said to occur throughout the dilated tube. A num- 
ber of successful cases have been recorded by the American gynecologists; 
but instances of non-success are not wanting, though they are ascribed to 
the neglect or the carelessness of the patients. The method is open to 
the objection that it readily causes decubitus. Indeed Galabin2 saw the 
pressure of a Sim's dilator twice cause an opening into the bladder, in a 
girl eighteen years old. And it hardly seems proper to accustom young 
girls to these manipulations, which can scarcely be accomplished without 
disagreeable secondary consequences. 
2. By repeated dilatation with finger and speculum. This procedure, 
if done without anaesthesia, is quite painful, and if done at first every 
two or three days, and latei .ess often, it is not liable to irritate the 
sexual nerves. It may not be out of place to mention expressly that the 
manipulation is not to be begun until the uterine cavity is entirely free 
from secretion, and the surface of the wound is everywhere covered with 
granulations; thus ensuring some safety against the dangers of infection. 
Until that time, about eight days, we must rely upon the canulae to main- 
tain the calibre of the canal. 
3. By covering the surface of die new passage with mucous membrane 
1 Comp. Hegar and Kaltenbaeh. Oper. Gynaec., 2d ed. Stuttgart, 1881, pp. 566 
et seq. 
2 Obst. Trans. London, 1880, p. 257. 254 
THE DISEASES OF THE VAGINA. 
or integument. Thus Heppner1 proposed in 1872 to make an H-shaped 
incision into the skin, and thus to form skin flaps which could be sewn 
into the newly-formed vagina. 
Without knowing anything of Heppner's process, B. Crede 2 took from 
the left labium ma jus a piece of skin 2.4 inches broad and 4.8 inches long, 
leaving it attached to the perineum. With this he covered the wound, 
putting the apex towards the cervjx, and stitching the edges to the bor- 
ders of the mucous membrane. The patient was a virgin fifty years old, 
and had suffered from a high grade of acquired vaginal stenosis, which 
Crede had incised and then had dilated with a blunt instrument. The 
vagina was tamponed with iodoform gauze after the operation, and a 
catheter was allowed to remain in the bladder for five days. Three- 
fourths of the wound healed prima int., the rest by granulation. The 
vagina remained enlarged, the hair of the flap causing no disturbance. 
A. Martin,* who always sews the mucous membrane of the atresiad 
cavity to the external skin or the nearest sound mucous membrane, uses 
the vaginal mucous membrane to cover the canal in deep-seated atresias, 
suturing the mucous membrane of the cavity to it. Nevertheless he 
reports a case in which a marked cicatricial stenosis appeared.4 Braith- 
waite attempts by the transplantation of one or two strips of mucous 
membrane from each side of the vulva to counteract the tendency of the 
newly-established passage to close up. 
It will readily be seen that the stitching of flaps of mucous membrane 
or skin into the new tract requires a field of operation freer than will usu- 
ally be found available. If it can be done, it of course affords protection 
against complete obliteration, though probably not against stenosis. At 
least Martin's observation would show this to be the case. 
I have always employed the second of the three methods above de- 
scribed, that of periodic dilatation, as soon as the canula first introduced 
has been in situ long enough. In two out of seven cases of broad atresia, 
I have observed a complete cure without noticeable stenosis after one or 
more years; two fingers or a medium-sized speculum being easily intro- 
duced in either case. Of the remaining five cases, four were not seen 
after primary healing had occurred, while in the fifth a marked stenosis 
reappeared, though menstruation was not interfered with, and the gene- 
ral health remained good. • 
Of course the result depends largely upon the extent of the atresia, and 
the amount of new connective tissue which is formed after the operation. 
The first condition is indeed beyond our control; but we may perhaps be 
1 St. Petersb. Med. Wochenschr., 1872, pt. 6, p. 552. I only know it from 
Schroder's handbook. 
2 Arch. f. Gyn., 1884, vol. 22, p. 229. 
3 Path. u. Ther. d. Frauenkrankheiten, Wien. u. Leipzig, p. 54 et seq. 
4 Obst. Trans., Lond. 1880, p. 259. CONGENITAL MALFORMATIONS. 
255 
able to limit the scar by attempting to secure a completely aseptic course 
for the operative wound. Where suppuration occurs, extensive strata of 
the surrounding tissues will become transformed into cicatricial masses. 
The table on succeeding pages gives the results of the cases which I have 
operated upon in accordance with the above principles. 
Congenital vaginal stenoses are less dangerous to life than are the 
atresias. They cause no permanent retentio mensium, and only when 
the stricture is very tight do they lead to a temporary retention. These 
temporary retentions are overcome by the uterine and vaginal contrac- 
tions from time to time, marked dysmenorrhceal symptoms being present. 
The less the stenosis, and the nearer to the introitus vaginae it is located, 
the less prominent will be the symptoms of irregular menstruation. 
Thus vaginal stenoses are generally brought to our notice as obstacles to 
intercourse and to childbirth. 
They may occur at the hymen as a narrow opening of that membrane, 
or in the lumen of the vaginal canal. In the latter case we find at one 
or more, rarely at several places, contractions, usually of small breadth; 
and we perceive that the vagina is narrowed by prominent transverse or 
spiral ring-shaped folds. The broader stenoses are usually acquired; but 
there are some instances of broad congenital stenoses on record. 
As is the case with atresia, the cause of congenital vaginal stenoses is 
to be sought in foetal inflammatory processes. They probably most often 
occur during the later period of intra-uterine development, for in the 
earlier ones the smaller width and less abundant epithelial desquamation 
offer more favorable conditions for total obliteration. Hymenal stenosis, 
hymen with only a small orifice, has a different origin; as with the im- 
perforate hymen, it is due to the rapid growth and too extensive union of 
the hymenal folds. Although a number of them have been recorded, 
the hymenal are among the rarer of the partial congenital strictures. 
This is probably partly due to the fact that they only come under obser- 
vation when they form an obstacle to coitus, or in the rare cases in which 
pregnancy has occurred with a persistent hymen. G. Braun 1 has re- 
cently given us the history of two such cases. I myself recently had 
occasion to see a woman twenty-two years old, and pregnant for the first 
time, in whose distensible and skin-like hymen there was only a central 
opening into which a uterine sound could just be passed. The elasticity 
might of course be partly due to the softening consequent upon her preg- 
nant condition. During the delivery the hymen became very tense, and 
was incised. In cases of hyperaesthesia of the vaginal entrance, and of 
vaginismus, I have seen hymenal stenosis a few times in young women; 
but the membrane was always very tough and resistent; and this, as is 
well known, would be alone sufficient to be an obstinate hindrance to co- 
habitation, and form the starting-point of a vaginismus. 
1 Wien. Med. Wochenschr., 1876, No. 13 and 14. 256 
THE DISEASES OF THE VAGINA. 
No. 
Variety Qf 
Atresia. 
Age. 
Duration of 
Molimena. 
Retention sac. 
Hremato- 
salpinx. 
Date of 
Operation. 
Result. 
Remarks. 
1. 
Hymenalis. 
New born. 
- 
Vaginal. 
- 
December 
1878. 
Cure. 
- 
2. 
Hymenalis. 
17 years. 
6 months. 
Vaginal. 
- 
May 
1875. 
Cure. 
40 ounces. Eccentric hypertrophy of 
vagina; hypertrophic hymen. 
3. 
Hymenalis. 
17 years. 
3 months. 
Vaginal 
and cervical. 
- 
December 
1875. 
Cure. 
46 ounces. Eccentric hypertrophy of 
vagina; hypertrophic hymen. 
4. 
Hymenalis. 
14 years. 
2 months. 
Vaginal. 
- 
January 
1880. 
Cure. 
- 
5. 
Hymenalis. 
19 years. 
No pro- 
nounced 
molimena. 
Vaginal. 
February 
1885. 
Cure. 
Imperforate hymen septus with their 
places near the median columns, the left 
having probably been perforated by the 
sound. Decomposition of the retained 
blood. Fever on reception. Eccentric 
hypertrophy of the vagina. Recent en- 
dokolpitis septica. 
6. 
Hymenalis. 
18 years. 
2 years. 
Vaginal 
and cervical. 
- 
March 
1885. 
Cure. 
Imperforate hymen septus with irregu- 
lar thinned out spots near the columns. 
15 ounces collected. Eccentric hypertro- 
phy of vagina. 
7. 
Broad Atre- 
sia (in the 
upper half.) 
14| years. 
1 month. 
Formed of the uter- 
us and the remains 
of the fornix. 
Left side 
mobile. 
June 
1878. 
Cure. 
Per rectum there could be felt at the 
apex of the hsematometra tumor a promi- 
nent curved margin with convexity di- 
rected backwards ; in its middle was a hol- 
low into which the tip of the finger could 
be pressed. This place was opened. Later, 
a portio with a thick anterior lip and a 
transverse slit for the os, was formed. 
Moderate stenosis, no menstrual difficul- 
ties. Atresia probably acquired in child- 
hood. Has had Typhus and Diphtheria. 
List of Cases of Vaginal Atresia Operated upon by the Author. 8. 
Broad Atre- 
sia (in the 
upper half.] 
17 
years. 
16 months. 
Formed of the uter- 
us and the remains 
of the fornix. 
August 
1878. 
Cure. 
When a child, had a purulent vaginal 
discharge. According to statement of 
physician, the hymen was closed, and was 
opened by him, and 8 ounces of an odor- 
less, thick, pale-yellow fluid was evacu- 
ated. Haimatometra tumor, larger than 
a child's head. Per rectum the os uteri 
could be distinctly felt as a soft, round 
spot into which two fingers could be in- 
troduced. A portio, with thick, anterior 
lips, was formed later. 
9. 
Broad Atre- 
sia (in mid- 
dle third.) 
15 
years. 
3 months. 
Formed of the uterus 
and the upper one- 
third of the vagina 
- 
July 
1881. 
Cure. 
Measles and Scarlet in children. No 
trace of cervix. Cure without stenosis. 
10. 
Broad Atre- 
sia (involv- 
ing- the en- 
tire vagina 
with the ex- 
ception of a 
remnant of 
the fornix. 
22 
years. 
1 year reg- 
u 1 a r 1 y, 2 
years pre- 
viously ir- 
regularly. 
Formed of the uterus 
and a portion of 
the fornix. 
March 
1881. 
Cure. 
Measles at 6 years. Rudiments of hymen only. 
Urethra dilated. Anterior rectal wall drawn to- 
wards the atresia. Per vesicam the os felt as a soft 
spot the size of a 10 cent piece ; it w-as situated at 
the lower portion of the tumor, and directed an- 
teriorly and to the right. Too extensive tearing 
apart of tissues during operation. Could not ob- 
tain complete asepsis after operation. Hence seven 
septic phlegmons; nevertheless recovered after 
the formation of a fistulous abscess towards the 
perineum. After the cure, stenosis. 1 year later, 
in the asylum with melancholia. Returned thence 
with renewed haimatometra. Dilation of the ste 
nosis. Cure of the psychopathic symptoms. Per- 
sistence of the stenosis ; no menstrual difficulties. 
Repeated attempts at dilatation useless. Persist- 
ence of fistula in perineum. 
11. 
Broad Atre- 
sia (in the 
lower half.) 
18 
years. 
1 year. 
Formed of uterus 
and fornix. 
- 
April 
1882. 
Cure. 
Per rectum the os uteri felt like a spot as large as 
a 10 cent piece at apex of tumor. Later, os appear- 
ed as an oblique slit. No stenosis in the first weeks: 
1 year later, moderate stenosis without further re- 
tention. Melancholic depression. After repeated 
dilatation, complete cure of the stenosis, and of the 
psychic depression. Observed during 1884 and 1885. 
12. 
Broad Atre- 
sia (in the 
lower half.) 
16 
years. 
5 months. 
Formed of uterus 
and fornix. 
Left. 
May 
1882. 
Cure. 
Per rectum the os felt as a small, soft 
spot with prominent margin. 
CONGENITAL MALFORMATIONS. 
257 258 
THE DISEASES OF THE VAGINA. 
No. 
Variety of 
Atresia. 
Age. 
Duration of 
Molimena. 
Retention tumor. 
Haemato- 
salpinx. 
Date of 
Operation. 
Result. 
Remarks. 
13. 
Broad Atre- 
sia (in the 
upper half.) 
17 years. 
1 year. 
Formed of uterus 
and fornix. 
- 
July 
1884. 
Cure. 
Os uteri not distinguishable. Scarlatina 
at 10 years, followed for 10 weeks by a 
foul-smelling, discolored genital dis- 
charge with evacuation of membranes. 
14. 
Haematome- 
tra and Hae- 
matokolpos 
lateralis 
dextra. 
19 years. 
3 months. 
Formed of the right 
horn of the uterus 
bicornis septus and 
the short vaginal 
rudiment belong- 
ing to it. 
- 
February 
1877. 
Cure. 
Described by Johannowsky, (Prager 
Med. W. 1877, p. 297). Since then has 
menstruated regularly and has had three 
normal childbirths. 
15. 
Haematome- 
traandHae- 
matokol pos 
lateralis 
dextra. 
25 years. 
10 years. 
Formed of the right 
horn of the uterus 
bicornis septus and 
the vaginal rudi- 
ment belonging to 
it. 
- 
May 
1879. 
Cure. 
Has menstruated regularly since, and 
has had one child. 
16. 
P y o m e t r a 
and pyokol- 
pos lateralis 
dextra. 
26 years. 
10 years. 
Formed of the right 
horn of uterus bi- 
locularis and the 
vaginal rudiment 
belonging to it. 
- 
November 
1869. 
Cure. 
Five years previously spontaneous 
rupture of the unilateral haematometra 
through the septum cervic. 
Arch. f. Gyn.. Vol. II., p 84. 
17. 
Py ometra 
andpyokol- 
pos lateralis 
sinistra. 
20 years. 
Irregular and 
infrequent 
menses for 
3 years. 
Formed of the left 
horn of the uterus 
bilocularis and the 
vaginal rudiment 
belonging to it. 
January 
1871. 
Cure. 
1J years before spontaneous rupture of 
the unilateral haematometra through the 
septum cervic supravaginal. The os uteri 
could be felt as a dollar-sized soft spot. 
(Correspondenzblatt fur Schweizer 
Aerzte 1871, I., p. 100.) 
18. 
Hydrometra 
lateralis si- 
nistra. 
38 years. 
None. 
Formed of the left 
horn and short va- 
ginal rudiment of 
a uterus duplex. 
- 
July 
1872. 
Cure. 
Cervix recognizable as a round, soft 
spot. 
(Arch. f. Gyn., Vol. VI., p. 89.) 
List of Cases of Vaginal Atresia Operated upon by the Author. CONGENITAL MALFORMATIONS. 
259 
I have encountered a number of circular stenoses in women pregnant 
for the first time, in whom there was no history which would point to an 
acquired affection. They rarely offer any serious hindrance to coitus or 
childbirth. As a rule, the softened tissues give way before the pressure 
of the head, as I have recently again had occasion to see in a case of spiral 
stenosis of the vaginal vault; so that active interference is unnecessary. 
Yet cases of marked stenoses of this nature have been recorded, which, 
when deep-seated, have doubtless been referred to duplexity of the 
hymen.* Thus Dr. Murphy found in a young and newly-married woman 
a transverse membrane pierced by a small opening above the hymen, 
which he divided on account of the trouble it caused in menstruation and 
coitus. Hemmer saw a similar membrane at delivery. 
Extensive congenital strictures of the vagina have been repeatedly seen 
with defective development of the rest of the genitals, though but rarely 
when these latter were in perfect condition. And in the latter cases we 
have not always satisfactory proof of their congenital origin. Scanzoni3 
tells of a case he saw in 1851, in which in a woman who had been eight 
years married and who had remained sterile, he could barely introduce 
his little finger into the vagina, and coitus had never been properly ac- 
complished. Nevertheless, the women became pregnant without dilata- 
tion being done, and the delivery was a normal one. Beigel observed * 
a case in which the vagina was stenosed to such an extent that only a 
uterine soiind could be passed up it. The woman was twenty-three years 
old, and extremely delicate; she had menstruated regularly though scantily 
since her eighteenth year, had been three years married, and consulted 
Beigel for her sterility. The breasts were well developed; but the exter- 
nal genitals and the pubis were unusually small. The hymen appears to 
have been absent, since it is only remarked that the vestibule formed a 
small, mussel-shaped depression. Rectal examination revealed a small 
but otherwise normal uterus. The walls of the vagina were unusually 
hard and thick; and Beigel regarded this condition as the cause of the 
stenosis. Attempts at dilatation with compressed sponge and laminaria 
were fruitless. The same observer saw a sterile woman who had been 
married ten years, having menstruated irregularly since her fifteenth 
year, and never having had any disease of the genital apparatus, in whom 
there was a thick-walled stenosis of the upper third of the vagina. 
When the vaginal canal is double, an irregularity in calibre has often 
been noticed, without there being any extra dilatation upon the other 
side. Veit claims that with this condition and with a single uterus, some- 
times only that half of the vagina is used for coitus which is not con- 
nected with the portio vag. 
1 Meissner, Frauenkrankheiten, vol. 1, p. 353. 
2 Krankheiten d. Weibl. Sexual Org., 5th ed. p. 641. 
3 Krankheiten d. Weibl. Geschl., Stuttgart, 1875 (F. Enke), vol. 2, p. 563. 260 
THE DISEASES OF THE VAGINA. 
We must be cautious in declaring blind canals in the mucous membrane, 
though they may occasionally be large enough to admit the little linger, 
to be rudimentary vaginae. They usually lie just behind the vaginal en- 
trance at one side of the columna rug. post., and are placed along the 
mucous membrane, or in the peri-vaginal connective tissue. They are 
often only unusually large and long lacunae of the mucous membrane, 
and are characterized by their location, their smooth surfaces and thin 
walls, and by the fact that their axis is often a different one from that of 
the vagina. In two cases of this kind, which I have observed, these canals 
were 1.2 and 1.6 inches long; into one I could pass a thick sound, and 
into the other my little finger. Both were upon the left side; the nar- 
rower one was in a normally menstruating old maid, with perfect genitals, 
and caused occasional trouble by retention of secretion; and so I slit it 
up; the wider one was in a case far advanced in pregnancy, with great 
vaginal relaxation. 
The diagnosis of congenital vaginal stenosis usually presents no especial 
difficulties; it can be recognized by sight in the hymenal form, and with 
the finger when seated higher up. The decision as to its being congenital 
depends upon the factors already considered under the head of atresia, 
and is sometimes very difficult to make. Here we usually have no reten- 
tion-tumors of blood, as in atresia, although it has exceptionally occurred 
above very narrow or displaced stenoses. Therefore we will miss the his- 
tory of gradual growth which is so characteristic of atresia. If there is 
retention at all, we will get a history of temporary amenorrhoea, followed 
by dysmenorrhoea, and a period of ease. Married women usually, but 
not always, complain of difficulties in cohabitation; but if both husband 
and wife are inexperienced, they may not notice anything. Naturally 
the mere absence of a retention tumor is not sufficient to warrant us in 
excluding a complete atresia; and when the stenosis is marked, the sound 
must be employed to demonstrate the uterine cavity. 
We must also, as Scanzoni has warned us, be careful to avoid con- 
founding the condition under consideration, with spastic stricture of the 
vagina. We ■will not always succeed in excluding it at the first examina- 
tion, especially if we do not use anaesthesia. The vaginal contraction 
must not occur while we are examining the patient. Spastic contraction 
has been seen to occur limited to the upper segment of the vagina (with 
spasm of the levator ani; comp. Hildebrandt), thus simulating a blind sac 
with a narrow orifice. If there is any doubt, it is well to postpone a de- 
cision until a second examination has been made. 
As regards the prognosis of these congenital atresias, we must recollect 
that the menstrual blood can flow off, and that the membranous and by 
far most frequent forms of the affection presents no insuperable obstacle 
to coitus, and is gradually dilated by it. Even when this is not the case, 
conception may occasionally occur, and the swelling and softening coin- CONGENITAL MALFORMATIONS 
261 
cident to gravidity may make the parts so yielding, that delivery may 
take place without any artificial aid whatsoever. 
A few of the cases of marked stenosis in which childbirth occurred in 
this way, undoubtedly belong in this category, though most of them are 
acquired. Thus in van Swieten's1 case, the girl at sixteen years had a 
vagina so stenosed that a goose-quill could hardly be passed through it; 
but she became pregnant eleven years later, and had a perfectly natural 
labor, the stricture being noticeably more yielding after the fifth month. 
Evory Kennedy3 observed with Dr. Johnson the first childbirth of a 
woman with very bad congenital vaginal stenosis, for the relief of whose 
difficulties in coition the sponge tent had been used. The first stage of 
labor lasted forty-eight hours; at the beginning the finger could only be in- 
troduced with great difficulty; but complete dilatation gradually occurred, 
and, without any other assistance than that derived from ergot, the labor 
terminated happily. Nevertheless experience teaches us that this result 
is obtained much less frequently spontaneously, than when the proper 
mechanical measures are applied. We must repeatedly examine the dis- 
tensibility of the stenosed places during birth, so that when necessary we 
may make incisions, which should be done in several places, and as super- 
ficially as is compatible with our object. We may easily miss the favora- 
ble time for operation; as happened to E. Kennedy, who delayed operat- 
ing in a case in which the head was pressing against a sickle-shaped 
membranous stenosis, so as to give his assistant an opportunity to examine 
the case, and saw a fatal rupture of the uterus occur. If the child is in 
a normal position it will probably be well to content ourselves with super- 
ficial incision with knife or scissors, and to avoid the use of the forceps, 
since it is undeniable that dilatation will be better effected by the sponta- 
neously advancing head than it will be by the forceps. 
In any case we obtain in this way the best results as regards the cure of 
the stenosis, although the stricture may possibly return as puerperal in- 
volution proceeds. Artificial dilatation of broad stenoses in non-pregnant 
women, whether done with tents, sounds, or dilators, gives, as a rule, 
insufficient and merely temporary results. In the case of thin membra- 
nous stenoses, incision of the edges with subsequent specular dilatation is 
the best method. Tamponing, also, when done with the proper precau- 
tions, may be of use. 
In conclusion, we may mention the longitudinal septa among the devel- 
opmental faults of the vagina, which occasionally form an obstacle to 
coitus, but more frequently interfere with delivery. They occur occa- 
sionally with uterus septus, though sometimes with a simple uterine 
cavity. Where the sept. vag. is extensive, it was probably originally a 
1 Comment., Tome iv. p. 1315. 
2 Dublin Journ., vol. 16, p. 88. 262 
THE DISEASES OF THE VAGINA. 
complete septum, in which previous confinements have made an orifice.1 
More rarely it is seen in virgins, marking the ununited ends of the Mul- 
lerian ducts near the vaginal entrance. In either case it may happen that 
at a later delivery the advancing head may not displace the septum to one 
side, but may push it before it in such a way that as a sagittal or oblique- 
situated band it may form an obstacle to delivery. In three such cases, 
division of the septum became a necessity. As a general thing, there are 
no large vessels in the septum, and it may be cut without fearing hemor- 
rhage, in spite of its apparent succulence. Other and bloodless methods 
of division, such as the method by elastic ligature, which Freund has 
lately recommended under other circumstances, are inapplicable here, on 
account of the want of time. During the puerperium the divided ends 
of the septum will shrink considerably. 
The only other difficulty which would lead us to divide such septa 
would be trouble in cohabitation; and also when the presence of the sep- 
tum interferes with the local treatment of other troubles with pessaries, 
specula, tampons, etc. Under these latter circumstances it may be de- 
sirable to divide a complete septum, as Gehrung2 did successfully in one 
case. 
There is little difficulty in locating, incising or excising a hymen septus; 
for the fold of mucous membrane is always a thin one. Our interest in 
the condition is rather genetic than practical. We are easily inclined to 
look upon it as the remains of the ununited Mullerian ducts, and to draw 
therefrom conclusions as to the origin of the hymen. But the later 
development of the hymen is such as to disprove such an idea. I have 
seen hymen septus once in the living subject; there are five instances of 
it in the Prague collection. In two of these specimens the septum runs 
to the right, in one to the left, and in two it is placed fairly in the middle 
line. 
1 This is shown by the atrophy in spots of uterine and vaginal septa in puer- 
peral women, which may go on until the tissues become transparent or distinct 
orifices appear. A preparation in the Prague collection shows an atrophic thin- 
ning of this kind in the septum uteri the size of the palm of the hand. 
2 Amer. Journ. of Med. Sciences, 1874, cxxxvi. 445. CHAPTER III. 
ACQUIRED ATRESIAS AND STENOSES. 
OTENOSES and atresias of the normal vagina, with the exception of 
those cases in which tumors and infiltrations dislocate or twist the 
canal, and which do not belong under this heading, are always due to 
cicatricial contractions and adhesions. Their most frequent cause is un- 
doubtedly puerperal necrosis and ulceration; as is proven by the extensive 
literature of acquired vaginal atresia.1 In the thirty-six cases which 
Trask2 has collected, not less than fifteen were due to childbirth. As is 
the case with vesico-vaginal fistula, it is the prolonged pressure in tedious 
labors rather than traumata incidental to artificial deliveries which forms 
the starting-point of the pathological changes. Rarely are other injuries 
the cause, as in Matheyssen's3 case, where vaginal adhesions had occurred 
from a fall upon the genitals against the edge of a chair, at the age of 
four years. Schulze4 had a case in which it was caused by a fall against 
the shaft of a wagon, and Hennig5 one due to a girl three years old being 
run over. Osgood, Danyau, Thomas, and others, have observed cases of 
traumatic origin which were acquired in childhood. Cicatricial strictures 
and adhesions occur relatively frequently in connection with the wearing 
of pessaries, especially when retained for a long time. The Prague ana- 
tomical collection contains an example of the kind which occurred in a 
woman sixty-eight years old, who had worn a pessary thirty-four years 
for prolapsus. Other foreign bodies may also lead to prolapsus. Ch. H. 
Carter and I (comp, foreign bodies) have seen very marked cicatricial 
stenosis in consequence of the introduction of spools of cotton. Cauteri- 
zations have also been seen to cause them. Thus in the cases recorded 
by Madame Boivin and Duges, a woman injected half a glassful of sul- 
phuric acid into the vagina to produce an abortion, and entirely obliterated 
the upper § of the channel; the uterus ruptured and death occurred 
1 Comp. Meissner, Forschungen, etc., und Frauenzimmer Krankheiten. 
2 Amer. Journ. of Med. Sciences, July, 1848, p. 114. 
3 Annales de Med., Belg. August, 1835. 
4 Allg. Med. Zeitg. July, Altenburg, 1832. 
6 Archiv. f. Gynakologie, vol. 2, part 2, p. 372. 264 
THE DISEASES OF THE VAGINA. 
when labor began later on. And Levy,1 who had to do a Caesarean sec- 
tion, on account of such an atresia, and Lombard," report two cases due 
to cauterization with sulphuric acid. And after an operation atresias 
and cicatricial stenoses have been seen to occur, not only following the 
use of cauterizing agents (ferrum candens and the galvano-cautery), but 
even after a polypus operation (O'Reilly).3 But diseases are most often 
the cause, especially puerperal ulceration, and diphtheritic destruction in 
the course of other diseases, such as cholera (White, Nelaton); typhus 
(Bohm, L. Mayer, A. Martin); erysipelas (Renouard, Bourgeois); acute ex- 
anthemata, especially variola, (Richter, Murray, Scanzoni, Hennig). Ex- 
tensive syphilitic ulceration has been repeatedly seen to cause incomplete 
and complete vaginal occlusion (Lisfranc, T. G. Thomas). 
But the vaginal affection is sometimes purely a local one. Thus 
Simpson4 calls attention to a variety of vaginal inflammation occurring in 
children, which he calls vaginitis adhesiva, and the peculiarity of which 
consists that it leads to adhesions without precedent ulceration. And 
the ulcerative form of adhesive vaginitis in adults which Hildebrandt has 
described, may lead to more or less extensive occlusion of the vaginal 
lumen.6 If a ring-shaped or spiral cicatricial stenosis, either congenital 
or acquired in early childhood (see above), is present, it may lead in the 
course of a pregnancy to a secondary stenosis by adhesive inflammation 
of the hyper-plastic folds of mucous membrane, if the vaginitis has led to 
epithelial defects or superficial losses of substance. I have observed a 
very marked case of this kind in a primipara.6 There was an apparently 
complete closure between the upper and middle third of the vagina; and 
only at the apex of the blind sac, which was strongly drawn over to the 
left, was an opening the size of a pin's head, which just admitted a sound. 
At one sitting the tissue gave way, with but little hemorrhage, to dilatation 
with sound and finger; a large amount of the retained yellowish mucus 
was evacuated, and the part of the fornix above the stenosis, together 
with the normal portio vag. became accessible to finger and speculum. 
Although the tissue which was torn only consisted of mucous membrane, 
it contained a cicatricial and resistant spiral ring at least .8 of an inch 
broad; and after complete opening of the vagina two fingers could hardly 
be passed through it, while the walls of the canal above and below were of 
normal elasticity and width. 
In the light of these observations we can understand the reports which 
wd occasionally see of the rare complication of a high grade of stenosis 
1 Bibi, for Laeger, October, 1860, p. 39. 
2 Gaz. Med. de Paris, vol. 1, No. 14, p. 831. 
3 E. Kennedy, Dubl. Journ., vol. 16. 
4 Clin. Leet, on Dis. of Women, Edinbg. 1872, p. 259. 
5 Monatschrift f. Geb., vol. 32, p. 128. 
6 Breisky, Stenosis Vaginae in Gravida, Prager Med. Wochenschr. 1883, No. 49. ACQUIRED ATRESIAS AND STENOSES. 
265 
with pregnancy, and where the stenosis was relieved with disproportion- 
ate ease, and was only present to a slight degree after delivery.1 
Naturally, vaginal obliteration is not solely dependent upon morbid 
processes which are confined to the mucous membrane; the accompanying 
phlegmonous inflammation of the peri-vaginal connective tissue often 
plays an important part in it. Thick cicatricial bands and great shrink- 
age are the more common the more layers of tissue in the vagina and its 
neighborhood have been affected by the loss of substance. Hence the 
very large atresias from masses of new connective tissue after puerperal 
phlegmons, and the callous obliteration of the vagina in syphilitic peri- 
proctitis and peri-vaginitis, which often accompany stenoses and chronic 
ulcerations of the rectum. And the rare affection which Marconnet first 
described as peri-vaginitis phlegmonosa dessicans,' in which form of in- 
flammation the entire vaginal mucous membrane is cast off, may, if it be 
survived, lead to extensive stenoses or obliteration. 
The course of acquired atresia differs from that of the congenital form, 
only in that the symptoms, being dependent upon some especial etiologi- 
cal moment, do not necessarily begin at puberty, and that they are not 
infrequently accompanied by other pathological appearances, due to the 
same cause. Thus we find puerperal vaginal obliterations comparatively 
frequently with vesical fistulae, and syphilitic stenosis with chronic 
ulceration, stenosis, and fistula of the rectum. For the rest, their course 
is the same as that of congenital occlusions; the menstrual blood accu- 
mulates above the atresia, if the same causes which have led to the atresia 
have not caused amenhorrhcea also. 
The treatment does not differ from that of congenital atresias and sten- 
oses. But there is one difficulty which often makes our task a very 
thankless one. That is, that the ulcerative processes which are at the 
base of the malady frequently cause extensive and firm cicatricial adhe- 
sions of the vagina, with partial destruction, approximation, and fixation 
of neighboring structures. Thus, besides the frequent complication with 
fistulae which we have already mentioned, there is often a loss of tissue of 
the portio vag. in puerperal atresias.3 
Nevertheless we have the records of not a few cases of complete cure. 
One of the most interesting of them, by Dieffenbach,4 may be mentioned 
here. A lady whose vagina had become completely closed in consequence 
of injuries received in childbed, permitted a physician to attempt to re- 
establish the passage. But the doctor, instead of reopening the vagina, 
1 Heywood Smith, Obst. Trans. London, 1881, p. 117. Pilat, Ann. de Gynec. 
1882, Tome xvii. p. 133. 
2 Comp. chap. vii. 
3 Comp. Peter Muller, on Utero-vaginal Atresias. Scanzoni's Beitrage, 1869, 
vol. 5, p. 67. 
4 Operat. Chirurgie, vol. 1, p. 663. 266 
THE DISEASES OF THE VAGINA. 
made liis way into the bladder; thus adding a large vesico-vaginal fistula 
at the introitus to her atresia. Another physician sought to make his 
way to the uterus more posteriorly, and get into the rectum. The latter 
false passage, however, closed of itself. Dieffenbach succeeded in open- 
ing the vagina by a most difficult operation; and he kept it open by 
using bougies of gradually increasing sizes for a long time. The vesical 
fistula, large enough to admit a finger, was not cured, as the patient be- 
came disgusted after an unsuccessful attempt to close it had been made. 
On account of the difficulties which the dense cicatricial masses accom- 
panying large fistulas add to the operation for haematometra, Kleinwachter1 
prefers to follow Hegar's proposal, and leave it unopened, and prevents 
further menstruation by castration. Acute sepsis caused a fatal termi- 
nation in the case he operated upon. 
If the atresia occurs during gravidity, and is a broad one, as occurred 
in the cases which Levy, Lombard, and others have recorded, it may form 
an irremovable obstacle to spontaneous or even artificial delivery per vias 
naturales. In these cases the Caesarean section is indicated, though under 
conditions which render the prognosis of the worst for the mother, since 
the free outflow of the lochia is interfered with. It has never yet been 
successfully done by the old methods. Porro's operation2 is the only one 
available, as is admitted even by those who would restrict the indications 
for it in favor of the simple sectio Caesarea. 
Acquired vaginal stenoses are seen much more frequently than are com- 
plete closures. If a broad extent of vaginal surface is involved, treatment 
offers hardly fewer difficulties than in the class of cases we have just been 
considering. Such is the tendency of the stenosed cicatricial tissue to 
contract that the results of dilatation are but temporary in the majority 
of cases. Here also the best results are obtained when operation is done 
during childbirth. Then the atresiad zone is loosened and stretched, 
the incisions are more easily made, and the amount of dilatation attained 
is much greater than could be gotten at any other time; thus giving us 
better prospects of permanent benefit. Even under these circumstances, 
however, complete cure can only be attained when there are no extensive 
cicatricial masses present. I observed a case of probably acquired stenosis 
in a primipara twenty-six years old, with a justo minor pelvis. Unfor- 
tunately the history is wanting. The ring-shaped stenosis was situated 
in the upper third of the vagina, and was bounded by hard, cicatricial 
bands. The tips of two fingers could barely be passed into it. Since her 
sixteenth year the patient had menstruated regularly, abundantly, and 
without pain every four weeks. She saw blood last about the middle of 
1 Prager Zeitschrift f. Hielkunde, 1883, vol. 4, p. 11. 
2 Della amputazione utero ovarica come complimento di Taglio Cesareo, 
Milano, 1876. HIRED ATRESIAS AND STENOSES. 
267 
February, 1877, and claimed that March 14th was the date of conception. 
Pains began on December 8th at 2 a.m., the child being in the first occi- 
pito-posterior position. On December 9th, 2 a.m., the os was sufficiently 
dilated to admit the tips of the fingers. The collum was driven down 
deep into the pelvis, and lay against the stenosis. This latter was in the 
same condition as before labor, and formed an entirely unyielding ring 
through which the tips of two fingers could just be passed.' 5 a.m., the 
os was somewhat more open, lying close behind the stenosis. Edges of 
latter moderately swollen; pains very violent. Three small cuts with the 
scissors opened the stenosis at once, so that three fingers could be passed 
in. 5| a.m., os the size of a quarter dollar, rupture of membranes; 
chloroform for the pains. 5.45 a.m., another incision into the right bor- 
der of the stricture, and a superficial incision of the cervix. Pains very 
marked, but the intervals quiet and painless. 6.45 a.m., under the in- 
fluence of violent pains the obstacle gives way; the head descends, and 
faeces are expressed. As the heart-sounds were weak and irregular, at 
7.15 a.m., extracted easily with forceps. Male child, premature, 17.6 
inches long, and weighing 50 ounces. Circumference of vertex 30 inches. 
After a normal puerperium the stenosis returned about as before, but with 
edges less sharp than at first. 
I have since that time had four analogous cases in which cicatricial ste- 
noses formed obstacles to delivery in primipara?. 
It is proper to mention in this connection the irregular ligamentous 
bridges which originate in the vagina from the adhesion of detached folds 
of vaginal or cervical mucous membrane. 
Occasionally we find pessaries which have been worn for years, and which 
have caused ulceration, more or less imbedded and fixed by granulation 
and cicatricial tissue, and by these bands above mentioned. When there 
are no such foreign bodies, the bands are important from the tension and 
injury they may be subjected to during coitus and childbirth. In one 
of my cases, there was a broad fleshy band 1.1 inches long and .4 inch 
broad, which extended from the anterior lip of the os uteri to the left side 
of the vagina. It was inserted 1.6 inches from the introitus and formed a 
serious obstacle to intercourse. It occurred in a woman twenty-two years 
old, after her first confinement. Division of the bridge, which was very 
vascular, and required a few sutures, easily relieved her. CHAPTER IV. 
DISPLACEMENTS OF THE VAGINA. 
rPIIE great distensibility and mobility of the vagina permits it to un- 
dergo both dilatation and displacement by neighboring organs to a 
very great extent, without interfering with the integrity of its attach- 
ments. Hence vaginal displacements do not possess the importance which 
attaches to dislocations of other organs. We would refer the reader to 
the ihtroductory chapter for an anatomical description of these attach- 
ments. 
Pathological dislocations of the vagina depend upon a change in the 
normal fixation of the organ, and form, as Klob ' has rightly insisted 
upon, projections of the vaginal walls into its lumen. They may affect 
the anterior or the posterior wall, or the whole circumference. In conse- 
quence of the intra-abdominal pressure and the lesser resistance anteriorly, 
they will always lead either to descensus or prolapse, in accordance with 
whether the projection remains within the vulva or protrudes from it. 
The conditions which influence vaginal dislocation are more or less 
connected with those that cause prolapsus uteri. They consist on the 
one hand of a loosening of the anatomical fixation bands, which are the 
predisposing conditions, and on the other hand of a force which acts 
either as a pressure from above or a traction from below. Pregnancy 
and childbirth especially cause loosening of the vaginal supports. The 
increase in vascularization and in mass of the vagina, the disappearance 
of fat from the peri-vaginal connective tissue, the venous stasis of the 
last month of gravidity, all these concur to affect an anatomical predis- 
position, which is immensely increased by the process of birth, with its 
acute tissue-loosening and immense vaginal dilatation. And when the 
child's head passes through the lowest portion of the vagina and the 
labia, the least mobile portion of the vagina is stretched and torn, and 
the relaxation of the perineal vaginal support is pushed to its utmost 
extent. 
In a somewhat similar way voluminous uterine polypoid fibromyomata 
1 Path. Anat. cl. Weibl. Sexual Org., p. 421. DISPLACEMENTS. 
269 
may fill the vagina and cause such a loosening of the attachments of that 
organ that descent and prolapse may be very marked after the growth 
has been extirpated. Other influences also, such as frequent tension and 
distension by coitus, persistent pressure by bladder, rectum, uterus, tumors 
of the true pelvis, or fluid accumulations, etc., may bring about the same 
result. 
In extreme old age and in marantic conditions the loosening of at- 
tachments may occur from the disappearance of the fat in the pelvic con- 
nective tissue and the atrophy of the muscular structures of the floor of 
the pelvis. 
Prolapse of vagina and uterus are extremely rare in undeveloped girls. 
Examples have, however, been seen in very early life, as the following 
two cases, which I have seen myself, will show. 
In one, which I saw at the Prague Foundling Asylum, a girl a few 
weeks old had a ring-shaped vaginal prolapse, which was easily replacea- 
ble with the finger through the exceptionally large introitus vaginae. As 
soon as the child cried it reappeared. A more minute examination was 
not at that time possible. 
But I possess more complete notes of a second case, which Prof. Ep- 
stein was good enough to send to me for examination. I have also a 
schematic sketch of the condition. It appears to me to be interesting 
enough to be reproduced. On February 28, 1881, Therese Roth, 39 
years old, from Tiskow, near Prague, who had three weeks previously had 
her fourth labor easily and quickly, brought me her infant for examina- 
tion. She had had twins the first, and triplets the third time. Immedi- 
ately after birth the child had a rectal prolapse, and a tumor situated at 
the small of the back was noticed. On the fifth day a tumor appeared at 
the genitals, and it has remained there ever since. The child was badly 
nourished, but at full term; over the sacrum was a spina bifida sacralis 
with meningocele. The pelvis was fissured, though there was no exter- 
nal cleft; a yielding spot replaced the symphysis pubis, the arch being 
formed at most by a ligamentous band. Clitoris and labia majora and 
minora were normal; the hymen formed a thin, gaping, ring-shaped 
border, especially low upon the left side. The urethral orifice was con- 
siderably dilated, and the smaller vesical mucous membrane projected 
out of it as a small tumor. Out of the introitus protruded the portio 
vag. uteri, and there was a pronounced ectropian of the os. For the 
vaginal portion of the collum was greatly lengthened; a complete eversio 
vaginae was not present, but the organ was short and prolapsed. Bi- 
manual palpation was practised with the little finger in the rectum after 
replacing the prolapse, and with the other hand applied to the abdominal 
wall. By its aid, as also with the sound, I could satisfactorily decide 
that the uterine body stood at its usual height. The rectum formed the 
largest prolapse. The succeeding sketch shows the condition. 270 
THE DISEASES OF THE VAGINA. 
Examination with the sound gave the following measurements: 
Length of uterine cavity, . . . . 1.6 inch 
Anterior vaginal wall from introitus to arch, . .7 " 
Posterior, " " " " . .8 il 
Left, " " " " . .9 " 
Right, " " " 11 . .8 " 
Especially remarkable was the relaxation and thinness of the perineum 
and the muscular floor of the pelvis. When the child cried they were bal- 
Mc.sp 
1.6 
or.ia 
prol.ves 
prdl.c.iitr 
prol.rtct' 
Fig. 20.-Mc.sp, Meningocele spin. Z.s, Lig. Svmphyseos. or.ur, Oriflc. urethrae, prol.ves, 
Prolapsus vesicae. prol.c.ut, Prolapsus colli uteri, prol.rect, Prolapsus recti. 
looned out. The child nursed well; spontaneous movements of the lower 
limbs were normal, though the reflex motions were slow. 
Unfortunately Professor Epstein's efforts to obtain permission for a 
post-mortem examination in the probable event of the child's dying were 
fruitless. 
Under these circumstances we can say but little as to the anatomical 
conditions present which had led to the prolapse of all the organs that lie 
along the floor of the pelvis. I can only surmise that an imperfect de- 
velopment, and perhaps an abnormal position of the muscular structures 
of the pelvic floor, may have caused its relaxation, and the dilatation of 
the places of exit of urethra, vagina, and rectum. The presence of fissure 
of the symphysis and of spina bifida would favor this view. DISPLACEMENTS. 
271 
There are no other anatomical investigations concerning the condition 
of the muscular and aponeurotic pelvic floor in these cases. Not only is 
this so with rare congenital anomalies such as we have been considering, 
but it is also the case with the very frequent acquired descensus and 
prolapsus. From a clinical point of view Schatz 1 and Emmet2 have called 
attention to the importance of the ruptures and contusions of the mus- 
cular structures of the pelvic floor incidental to childbirth; and Hegar 3 
has insisted upon its efficacy as the etiological agent in displacements of 
the pelvic organs. 
Billroth has recorded a case of prolapsus uteri with vesical ectopia in a 
girl eighteen years old, and has added a handsome drawing to it.4 The 
sketch shows us that the pelvis was fissured and the perineum imperfectly 
developed. 
Among the more recent literature a case of Prochownik's5 deserves men- 
tion here. The girl was a virgin, twenty years old, and had prolapsus 
septus with congenital deficiency of the perineum. Prochownik believes 
that the earlier occurrence of the prolapse in this case was prevented by 
the tension of the lateral attachments of the uterus, although a deficient 
development of the muscular structures of the pelvic floor could be recog- 
nized. I think also that the shape and breadth of the womb, in relation 
to the lumen of the vagina, had something to do with it. After the 
patient had had to do very hard work upon very poor food for seven 
months, a prolapse occurred. It was well retained by a Schatz pessary. 
CTndoubtedly dilatation and relaxation of the introit. vagina can usually 
be proven to be among the efficient causes of vaginal dislocation. Yet 
the influence of rupture of the perineum as a predisposing moment, has 
been much overestimated, since without doubt the larger number of vagi- 
nal prolapses occur without its being present. 
The loosening of the attachments which we have described explains the 
occurrence of a displacement in layers of the septum vesica and recto- 
vaginale in those cases in which the bladdex- or the rectum does not fol- 
low the dislocation. Only in exceptional instances are we unable to 
prove the anatomical reasons for predisposition of the vaginal attachments 
to be loosened; and in these the amount of pressure or of traction must 
have been enough to overcome the resistance of the normal means of 
fixation. 
As to the participation of neighboring organs, uterus, bladder, and rec- 
tum, in vaginal displacements, we must distinguish between primary and 
secondary projections. In the first case the vaginal walls sink on account 
1 Arch. f. Gyn., vol. 22, p. 298. 
2 Prine, and Pract. of Gynecology, 3d ed. 1884, p. 367. 
3 Deutsche Med. Wochenschr., 1884, No. 36. 
4 Chirurg. Klinik, Berlin, 1879. 
5 Arch. f. Gyn., 1881, vol. 17, p. 326. 272 
THE DISEASES OF THE VAGINA. 
of their loosened attachments, not being able to withstand the normal 
amount of pressure which bears upon them; and the organs attached to 
the vagina follow it. In the second case the vagina is permanently dis- 
placed by the constant pressure and tension exercised upon it by the 
neighboring organs. In advanced cases these causal relations cannot 
always be distinguished. 
The protrusion of the anterior wall (descensus or prolapsus vagin. 
anterior) may be partial, and originates now from the lower and now from 
the upper segment of the vagina; or it may be complete. In both the 
latter cases it is regularly accompanied by sinking of the collum uteri. 
Partial descent of the lower segment of the wall, sometimes prolapsing 
to a moderate extent through the vulva, is dependent upon the projection 
forwards of the lower extremity of the columna rugarum ant., (the tuber- 
culumvag. of Luschka, and the carina vag. of Kohlrausch), just below the 
urethral orifice. It occurs from swelling of the mucosa and the submu- 
cosa, and Is frequently seen in gravidity from the combination of venous 
stasis with the hyperplasia of pregnancy. Its dark livid color, and suc- 
culence, as well as the fact that it occurs in primiparse only during the 
last three months, and in multi parse, together with phlebectasi^s of vulva 
and vagina, show how much venous stasis is concerned in its development. 
Nor does it always retrogress during the puerperium; and we find it in 
women who have borne children as a dense tumor of the normal color 
of the mucous membrane, and composed of the hypertrophied mucosa and 
submucosa. If the prolapse is more extensive, the covering mucous 
membrane becomes skin-like. The direction of the urethra is not much 
changed, though its orif. ext. is usually gaping and displaced somewhat 
forwards; occasionally it is covered by the prolapsed folds which lie be- 
hind it. 
Unimportant as the prolapse may appear, it does give trouble to the 
patient, especially during pregnancy. It then becomes swollen from 
venous stasis; its surface is dry, and perhaps irritated or eroded, and there 
occur in consequence bearing-down pains and difficulty in walking and 
sitting. When the hypertrophied prolapse becomes long and comb- 
shaped, and, by dragging upon the contiguous portions of mucous mem- 
brane, displaces the sept. ves. vag., it becomes of even greater importance. 
Very frequently there occurs in connection with the above-mentioned 
partial dislocation, a displacement involving the septum ves. vag. At 
first this only occurs when the bladder is distended or the abdominal pres- 
sure exerted; later it is always seen when the patient is in the erect posi- 
tion ; and finally it is present even when the patient is lying down, as an 
egg-shaped or large prolapse. The soft tumor can always be readily re- 
placed after the bladder has been emptied. When well marked, it obli- 
terates the anterior fold of the vaginal vault, and is regularly accompanied 
by depression of the portio vag. uteri. The various layers of the sept. DISPLACEMENTS. 
273 
ves vag. are so intimately united, that the bladder, as a rule, takes part 
in the protrusion, giving us a cystocele vaginalis (Malgaigne.1) Most of 
these cases are of puerperal origin, and therefore we think that as a rule, 
the prolapse of the vaginal mucous membrane is the primary, and the 
sinking of the adjacent vesical wall the secondary phenomena. In newly 
delivered women we will often notice a slight degree of sinking of the 
vaginal wall. This is to be explained by the enormous dilatation of the 
vaginal sac, the gaping of the rima vulva, and the relaxation of the peri- 
neum, sub partu. If the sinking of the anterior wall and of the bladder 
that is connected with it, is more marked than usual, as may be the case 
after difficult labors or speedy extractions, a valve-shaped bend of the 
urethra may occur, the anterior portion of that canal, being fixed by the 
lig. triang. remaining. • 
Thus there occurs that obstacle to urination to which Mattei and Ols- 
hausen have drawn attention. It is not of very frequent occurrence, and. 
can easily be remedied by giving a proper direction to the catheter. 
A moderate protrusion may easily be increased to a prolapse, by getting 
up too early from childbed, physical exertion, or by retention of urine for 
too long periods of time. V enous stasis, swelling, and increase of weight 
then occur. Prolaps. vag. ant. with cystocele, exerts a double influence 
upon the puerperal uterus. On the one hand it tends to maintain the 
anteversion of the uterine body, the urinary bladder descending, and the 
womb following it; and on the other hand the tension exercised by 
the prolaps. vag. extends to the anterior lip of the os, and the anterior 
wall of the supra-vaginal portion of the organ. As a rule the uterus 
does not give way to this tension as a whole. The collum, relaxed and 
thinned sub partu, is distensible enough to stretch to a moderate extent. 
If the orif. ext. is so torn across that traction is not at once transferred 
from the anterior to the posterior lip, there occurs a unilateral elongation 
of the collum. The anterior wall is drawn out in gutter-shape, and the 
prolapsus vag. follows it; while the posterior lip remains stationary, or 
only sinks to a very small extent. This form of displacement is especially 
well marked when the uterine body is attached by adhesions or tumors 
to neighboring organs. Schroder has described the condition as one of 
hypertrophy of what he calls the portio media, the median segment of the 
uterine neck.2 I have observed it many times, and have invariably been 
able to prove its secondary origin. 
The habitual retention of urine by women for long periods of time, 
has been by many authorities, and especially by Scanzoni,3 regarded as the 
cause of the formation of cystocele, in contradistinction to the above de- 
scribed primary origin of the prolapsus vag. ant. This is indubitably the 
case in a certain number of cases, but not in as many as are of puerperal 
' Journ. de Chir., Nov. 1843, p. 353 2 1. c. p. 71 to 81. 3 I. c. p. 659. 274 
THE DISEASES OF THE VAGINA. 
origin. Protrusions of the anterior vaginal wall by tumors (cysts, dense 
submucous new growths, luematokolpos, and the like) are to be consid- 
ered under the heading of their special causes. And besides this, descent 
and prolapse of the anterior vaginal wall frequently occur as part of the 
total vaginal prolapse which follows descensus and prolapsus uteri. 
In a few rare cases the bladder remains in its normal place with prolap- 
sus vag. ant., the peritoneal pocket of the excavatio vesico-uterina on 
the other hand being abnormally depressed and drawn forward into the 
prolapsus. This occurrence has been supposed to be a special form of 
dislocation of the anterior vaginal wall, due to the sinking of this cavity, 
and has been called hernia vaginalis anterior.1 But the loosening of the 
bladder and urethra from the uterus and vagina, with depression of the 
anterior peritoneal pocket, as has been represented in some of the draw- 
ings, does not appear to existat all; rather the septum urethro-vaginale 
under all circumstances forms the boundary up to which the anterior 
vaginal wall may be separated from the bladder.2 Huffel's excellent 
drawing of a section of the pelvis with prolapsus ut. incompl., without 
any change of position of the urinary bladder, shows us how the separa- 
tion of the prolapsed anterior vaginal wall from the bladder is limited 
anatomically by its intimate connection with the layers of the urethro- 
vaginal septum. It shows also a relatively firm vesical attachment, the 
peritoneal covering of the organ lying above the upper edge of the sym- 
physis, and the ligamenta vesicalia being tense. On the other hand the 
connective-tissue union between the portio supra-vaginalis colli uteri, the 
upper part of the anterior vaginal wall, and the bladder, appears to be 
unusually loose and to be stretched into a thin stratum. Had the blad- 
der been depicted empty, all the conditions necessary to originate a hernia 
vaginalis anterior, might have been demonstrated in this drawing. 
Since a congenital depression of theexcav. ves. ut. has not been noticed, 
and since in the few cases of the affection which have been recorded, 
there has always been the complication of prolapsus uteri totalis or partialis 
1 The older authorities (comp. Meissner, 1. c.) include cystocele vaginalis also 
in this designation. The rarity of this form of the malady, and we have never 
seen a single case, is shown by the fact that it is not mentioned in the text books 
on pathological anatomy of Rokitansky, Forster, Klob, Klebs and others. 
2 The most striking, as well as the best described case is that of E. Martin 
(Monatschrift f. Geb., vol. 28, 1866, p. 168), which both Htiffel and Hegar and Kal- 
tenbach have copied. But we must object that the drawing, which shows a com- 
plete division of the connection between the anterior vaginal wall and the bladder 
from the sinking of the anterior peritoneal pocket, and extending almost through 
the entire urethro-vaginal septum, is not in accord with Cohnheim's record of the 
autopsy. Cohnheim expressly says that the anterior vaginal wall, together with 
the urethra, was for an inch in length in its normal position behind the pubis 
(p. 169), whilst the portion above that was markedly lengthened, thickened and 
prolapsed. DISPLACEMENTS. 
275 
present, we must regard hernia vaginalis anterior as an acquired disloca- 
tion. For its development the urinary bladder must be firmly attached 
to the anterior abdominal wall, and there must be an unusually loose 
connective-tissue layer between the supra-vaginal portion of the collum 
uteri and the bladder, and between the anterior vaginal wall and the blad- 
der; and finally the excav. vesico-uterina must be abnormally broad from 
reclination of the body of the womb, and must also be drawn down by 
the prolapsus colli uteri. When these conditions are present, the intra- 
abdominal pressure upon the excav. ante-uterina on the one hand, and 
the tension of the prolapsus upon the other, may be able to cause disloca- 
tion and separation of the layers of the septum vesico-vaginale in a degree 
such as E. Martin has described. The anatomical disposition in question 
Fig. 21.-Section through the Pelvis with Incomplete Prolapsus Uteri. (After Hiiffel.) 
is most intimately connected with the etiology of prolapsus uteri; and we 
can only look upon hernia vag. ant. as one of its consequences. We can- 
not recognize its primary occurrence from the cases thus far described. 
The diagnosis of prolapsus vag. ant. needs but little consideration after 
what has been said. It may, however, be necessary to distinguish it from 
protrusions caused by new growths in the septum ves. vag., or from con- 
genital anomalies with unilateral closure of the vag. septa and retention 
of fluid. The dilatation and separation of the layers must be especially 
considered. This is to be done by examining the vesical dilatation with 
the catheter, and by finding out the exact position of the uterus. If 
cystocele is present, the catheter will go downwards a short distance 
behind the orif. urethrae, and its point can be felt through the protruded 
wall. If the bladder does not participate in the protrusion of the wall, it 276 
THE DISEASES OF THE VAGINA. 
can easily be proven with the catheter that the viscus has not sunken, 
and thus we can ascertain whether we have to deal with a hypertrophic 
prolapse of the mucous membrane, an interstitial neoplasm, or the lateral 
half of an atresiad vagina distended with fluid. In the latter case the 
uterus will be situated at its normal height. 
The symptoms resemble in general those of descensus or prolapsus 
uteri. They consist of impediments in walking, standing, or any hard 
work, which causes increase in the size of the tumor, in irritation of the 
prolapsed mucous membrane from dessication and friction, and finally, 
in frequent desire to urinate. Only when the prolapse is very marked 
can urinary retention occur from bending of the urethra, or more rarely 
from pressure or tension upon the ureters. Some observations seem to 
show that cystocele vaginalis may form a mechanical hindrance to child- 
birth; 1 but it was in cases where, from an abnormal position of the head, 
or from absence of the proper relation between it and the pelvis, an unu- 
sual amount of compression of the full bladder against the anterior pelvic 
wall occurred. In this way the viscus was forced into an hour-glass 
shape; and the tense pelvic portion formed an obstacle to delivery which 
sometimes, as in Moor's case, could not be removed by the catheter. 
Much may be hoped from treatment, even when it is restricted to rest 
in bed, frequent emptying of the bladder, looseness of the bowels, astrin- 
gent and cooling injections, and the introduction of tampons of absorbent 
cotton of not too large size, to be changed night and morning. But fre- 
quently this treatment alone is not enough, and in old cases it is useless 
to attempt to accomplish anything with it. Thus operative narrowing of 
the vagina, kolporrhaphy, or palliative treatment with pessaries and 
bandages, need only be considered. The operative treatment of prol. 
vag. ant. must not, to be successful, be confined to the anterior wall. All 
the various methods of anterior kolporraphy do not ensure us against a 
return of the cystocele; under the influence of the abdominal pressure 
the scar gives way, and the vaginal wall comes down. Kolpoperineor- 
rhaphy must be done, or a septum-like connection between the anterior 
and posterior walls, after the methods of Neugebauer and Lefort, be made, 
to prevent the inversion and prolapse of the vaginal wall. I cured a case 
of very marked cystocele vaginalis in an elderly woman, in whom all pal- 
liative measures for the retention of the prolapse were useless, by Neuge- 
bauer's operation; and I came to the conclusion that in just such cases, 
where the cystocele was the most important part of the malady, it prom- 
ised better results than in cases of total utero-vaginal prolapse, since there 
was less pressure upon the cicatrix. It has been attempted to improve 
the patient's condition, by sustaining the organ in various ways. We 
1 Brennecke (Sudenburg-Magdeburg), Centralblatt f. Gyn., 1879, p. 80. Dick 
(Bern), Ibid. p. 154. More, Ibid. 1880, p. 212 Ref. from: Obst. Journ. of Gr. Br. 
and Ireland, January, 1880, No. 82, p. 620. DISPLACEMENTS. 
277 
will only mention a few here, the object of which is to lift up the ante- 
rior vaginal wall. Such are pessaries1 designed to raise the anteverted 
uterus, point those of Graily Hewitt and Thomas. When these instru- 
ments find a sufficient point d'appui in the vagina, so that they may be 
worn without causing too much tension, they act by sustaining the re- 
placed septum ves. vag. upon their horn-shaped convexity. Occasionally 
the instruments which Vuillet and Ke hr er have recommended for the 
retention of uterine prolapsus will be found applicable. More efficient, 
but much more irritating from the fact that their fixation point lies with- 
out the pelvis, are the stem pessaries which are fastened to a pelvic band, 
and which elevate the anterior vaginal wall either alone or together with 
the uterus. Roser's hysterophor is the best known of these arrange- 
ments, and has been modified by many surgeons, especially by Scanzoni 
and Lazarewitch. But they have all fallen into desuetude from their 
uncomfortable nature, and from the irritation they caused; and in non- 
operative cases, where the above-mentioned pessaries are not supported, 
voluminous instruments designed to sustain the uterus are employed, 
now one form and now another being recommended. Most of them are, 
however, open to the objection, that they only prevent vaginal prolapse 
by great dilatation of the channel above the introitus; they exercise con- 
siderable pressure, cause the rima vulvas to gape, and set up an intense 
catarrh of the vaginal mucous membrane. If the necessary conditions 
are present for the retention of the egg pessaries, to be mentioned later 
on, they will render the most efficient service in these cases. 
Displacements of the posterior vaginal wall (descensus and prolapsus 
vag. post.) more frequently occur without participation of the adjacent or- 
gan than do those of the anterior wall, on account of the loose connective- 
tissue union between vagina and rectum. Here also the descent may be 
partial, and affect the upper or the lower segment, or it may involve the 
entire extent of the wall. 
Partial descent of the lower division of the posterior vaginal wall is an 
everyday occurrence in its lesser degrees, in women who have borne many 
children. It appears as a prominent tubercular fold of thickened mucous 
membrane, situated at or near the median line, corresponding to the 
lower end of the columna rug. post. Its occurrence is by no means 
limited to women who have perineal scars, but is always found in con- 
junction with a wide vaginal entrance. When much developed it forms 
a prominent comb-like tumor extending an inch or more into the vaginal 
canal; it gets less in volume as it ascends, and bears some similarity to a 
rudimentary septum vag. It very rarely occurs during a first pregnancy, 
like the protrusions of the anterior wall, but is usually formed during 
1 As regards the various forms of pessaries, we must refer the reader to the 
chapter on uterine displacements. 278 
THE DISEASES OF THE VAGINA. 
labor and the puerperium. Pregnancy predisposes to it only from the 
hyperplastic development of the vaginal walls and the loosening of the 
peri-vaginal connective-tissue. The great stretching and tension upon 
this portion of the wall when the perineum is distended in labor, and the 
cicatricial traction caused by ruptures at the posterior vaginal entrance 
during healing, complete the process. Nevertheless, it is undeniable that 
in many cases of exquisite prolapse of this kind, there are no perineal 
cicatrices. The partial protrusions of the upper segment of the posterior 
wall occur only exceptionally as lax transverse folds of the mucosa, at the 
place of the normal posterior cul-de-sac of the vaginal vault; more gener- 
ally they are seen as extensive inverted depressions of the posterior vaginal 
vault. These are really secondary occurrences; since they are dependent 
upon descent of the uterus, or of Douglas's pouch, or upon excessive 
dilatation of the recto-vaginal septum from the side of the rectum.. In 
the latter case they are large from the beginning, and involve the entire 
extent of the posterior wall above the perineum.* When the rectum is 
full the sac is tense and does not fall; but when it is empty it immediately 
prolapses. 
The participation of the anterior rectal wall in the protrusion, recto- 
cele vag., occurs either to a small extent only or not at all. Only where 
there is a high degree of total prolapse does it occunto any extent. The 
tumor may then, as Freund1 has shown, reach an extreme size. 
All the partial dislocations of the posterior wall are easily increased by 
the pressure exercised upon the tumors by the uterus and intestines, and 
by the abdominal pressure. They may then form extensive prolapses, 
their lower end usually appearing free just behind the posterior commis- 
sure of the vulva. The retroflexed uterus always follows the tumor, 
when it is not fixed in the pelvis by tumors or adhesions; and the perito- 
neal excavatio retro-uterina is always drawn deeply down. 
Secondary protrusions are formed when the retroverted and enlarged 
uterine body, or tumors of the uterus or its adnexa, or encapsulated col- 
lections of fluid (hsematocele, pelvio-peritonitic abscess, hydrops saccatus) 
or an extra-uterine foetal sac, lie in and depress Douglas's cul-de-sac. Free 
fluid may also, though more rarely, do the same thing, as when there is 
much ascites. We must agree with Hegar and Kaltenbach in regarding 
hernia vag. post, or enterocele vag. as a rare cause of protuberance of 
the posterior wall without uterine prolapse being present. The reason is 
that the coils of small intestine which lie in Douglas's cul-de-sac can be 
more easily displaced from it, and forced into the abdominal cavity, than 
could the elasticity of the walls of the cul-de-sac be overcome, and the 
vaginal surface protruded. There must at all events be a relatively nar- 
row entrance to Douglas's cul-de-sac, which may of course occur from an 
1 Path and Ther. of Chronic Inversion, etc., Breslau, 1870, p. 30. DISPLACEMENTS. 
279 
increased development of the sickle-shaped connecting band of the plicae 
semilun. which Kohlrausch has figured, or from acquired pathological 
Fig. 22.-Schematic Drawing of my Case of Enterocele Vag. 
adhesions. In this case the tension of the hernial tumor may be great 
enough to cause a considerable displacement of the womb, and to hinder 
reposition. This we had occasion to see ourselves in the case shown in 
Figs. 22 and 23. Landau1 relates an interesting case which belongs here. 
A woman forty-eight years old had had nine children, and suffered from ob- 
Fig. 23.-The same Case after Reduction of the Enterocele. 
1 Report of Spiegelberg's Klinik at Breslau for 1873-75, in Berl. KI. Wochen- 
schrift, 1876, No. 48. 280 
THE DISEASES OF THE VAGINA. 
stinate constipation and meteorism. An enterocele vag. appeared, which 
protruded downwards and became tense during the pains. It formed an 
obstacle to delivery, resisted all attempts at reposition in the lateral posi- 
tion, and was only displaced when the patient was deeply anaesthetized 
and the whole hand introduced into the rectum. The diagnosis of en- 
terocele vag. is to be made in these cases by the soft elastic resistance of 
the tumor and the occasional rumbling during manipulation, and may be 
completed by percussion upon a long spool-shaped pleximeter. If repo- 
sition is even partially successful, the diagnosis is simplified; in our case 
it could not be done, though repeated attempts were made to effect it in 
the knee-elbow position. But it occurred spontaneously after a lengthy 
course of mild laxatives. Although the symptoms were not troublesome, 
they were decidedly similar in character to those of an old hernia with 
large opening. The woman was a field hand, and the tumor pained her 
when she walked or stood for long periods of time, and caused difficulty in 
defecation. We know of no case in which symptoms of strangulation 
have been observed; but we cannot deny the possibility of the occurrence 
of the accident, especially when peritonitic adhesions of the intestinal 
coils are present. 
It is much more common to see loops of intestine descend into Douglas's 
pouch, when that fold is drawn down in prolapsus uteri and inversio vagi • 
nae. But even here the intestine rarely reaches to the lower limit of the 
tumor. As a rule, we find tympanitic resonance only at the upper parts 
of such prolapsus, though Rokitansky1 and Fehling 2 have described re- 
markable cases in which rupture of the posterior wall of the prolapse and 
descent of coils of intestine through the tear occurred. 
As to treatment, we can only relieve secondary invaginations of the 
fornix and the upper portion of the vagina when we succeed in removing 
their causes. If the descent and prolapse of the lower division of the 
posterior vaginal wall is great, but little is to be hoped from the measures 
recommended foi' the relief of cystocele, even in recent cases. Retention 
by means of pessaries is only useful in those exceptional cases in which 
the vulva is not much dilated. We must here rely upon surgical proced- 
ure; and it is only because in uncomplicated cases, where there is no pro- 
lapsus uteri, the troubles caused by the condition are not great, that 
operations are so seldom done. 
Descent of the vagina in its whole circumference, inversio vaginae, so 
common in marked cases of uterine prolapse, may be due to an even dis- 
placement of the vaginal vault which drags the surrounding walls of the 
canal down with it, or to a protrusion and approximation of the anterior 
and posterior segments of the vaginal tube. (Fig. 24.) 
1 Lehrb. d. Path. Anat., 3d ed. vol. 3, p. 515. 
2 Arch. f. Gyn., vol. 6, p. 103. DISPLACEMENTS. 
281 
In the first case direct pressure is the cause of the displacement. The 
vaginal vault may be pressed upon by the uterus or the abdominal muscles, 
or, more rarely, by tumors. Relaxation of the pelvic connective tissue, 
and of the vagina and the uterine ligaments, predispose to the affection. 
Hence its frequency in the puerperium, and in old age, and hence also 
the great preponderance of cases among the working classes. An origi- 
nally low position of the uterus with a short vagina, as well as flexions of 
the womb, predispose to inversion; but T do not think that small inclina- 
tion and great width of the pelvis exercises by any means that influence 
which many authorities, and especially Kiwisch, have ascribed to it. 
Under these circumstances there usually first occur primary descent of 
the uterus and depression of the vaginal vault, from abdominal pressure, 
Fig. 34.-Inversio Vag., with Incomplete Prolapsus Uteri. (After Cruveilhier.) 
the womb itself being normal, or, if senile involution has set in, even 
sub normal as regards weight. But, of course, the enlarged uterus might 
pull down the vaginal vault by its weight, if its volume is not too great 
and it is not fixed by adhesions. Only in rare cases do we find vaginal 
descent in consequence of hypertrophy of the collum. Where we do see 
it, the hypertrophy affects the vaginal portion of the neck, and gradually 
drags the entire uterus and the fundus downwards. 
When the inversio vag. has occurred in this way, and has led to a pro- 
lapse of the whole inverted vagina, the tumor always includes the entire 
uterus. But if on the other hand the inversio vag. proceeds from pro- 
lapsus vag. ant. and post., the uterine descent is secondary, and often 
involves only the elongated collum; the corpus uteri itself taking little 
or no part in the displacement.1 
1 Virchow was the first (Coll. Works, p. 812) to claim that inversio vag. occurs 
from the hypertrophied collum pushing the vaginal vault before it in its growth. 
Althoug-h objections have been raised against it on various sides (Kiwisch, Speigel- 282 
THE DISEASES OF THE VAGINA. 
From what we have said in regard to the etiology of prolapsus vag. ant. 
and post., it will be seen that the puerperal state furnishes the chief con- 
dition necessary for the origination of inversion with prolapsus colli uteri. 
But whether vaginal inversion be primary or secondary, it always in- 
creases in size, and finally forms a prolapse of the total inverted vagina. 
At its lower portion will be seen the orif. ext. uteri, situated to one or 
other side in accordance with the relative protrusion of the anterior and 
posterior portions of the tumor. Its shape depends partly upon its con- 
tents, and partly upon the amount of thickening of mucosa and submu- 
cosa. It is usually eithei* cylindrical or pear-shaped. The walls of the 
prolapse at first are thin; but in time the hypertrophy of the dry, der- 
moid-like mucous membrane and of the submucosa, may become so great 
that the walls of the tumor nearest the portio vag. may measure from | 
to 1 inch in thickness, and the whole mass be compared, as has been 
done by Klebs, to an elephantiasis. The surface will then be smooth, 
rugosities being absent; the epithelium is thickened; and not infrequently 
erosions and fissures leal to losses of substance very like varicose ulcers. 
This is favored by the intense venous congestion of the hypertrophic tis- 
sue. In old inversions which have not been replaced for years, the thick- 
ness and rigidity of the walls is often so marked that it forms a great 
berg, Schroder and others), it is accepted by most pathologists and a large num- 
ber of gynecologists. I do not believe it to be correct, for all the peculiarities of 
the condition are more easily explicable as being due to tension of the prolapsus 
vag. than to a local hypertrophy of unknown origin. For, firstly, we only find 
such elongations of the supra-vaginal portion with prolapse of the inverted blad- 
der, under conditions in which tension cannot be excluded. That this tension 
does cause elongation of the supra-vaginal portion of the collum may be directly 
observed, as Kiwisch has suggested, by noticing the shortening which occurs 
after reposition. This can be best seen in the gutter-shaped elongations of the 
anterior wall of the collum in prolaps. ant. and cystocele. The thinness and pli- 
ability of the tissue of the supra-vaginal portion favors the idea of a secondary 
extension ; for the hypertrophied part would have to be increased both in thick- 
ness and resistance to overcome the fixation of the vagina. And it is especially to 
be noted that this form is always of puerperal origin, thus originating at a time 
when the resistance of the collum is at its least, and the conditions favoring pri- 
mary vaginal prolapse most pronounced. It is exactly the lengthening, thinning 
and relaxation of the cervix up to the int. os in childbirth which renders it conceiva- 
ble how the supra-vaginal portion can give way before the tension without dislocat- 
ing the corpus uteri. Too early rising and hard work during the puerperium will 
cause descent of the vagina, and the descent soon leads to increased tension at the 
vaginal insertion of the collum uteri. If the collum is yielding, it will be stretched 
in its supra-vaginal portion-between the internal os and the vaginal insertion ; 
its normal involution and shortening' will be hindered by the steady tension of the 
vaginal prolapse, and lengthening be caused by the gradually increasing weight 
of the growing prolapsus vag. It is readily conceivable that a certain amount of 
hypertrophic growth will accompany this elongation, but it is determined prima- 
rily by the vaginal prolapse. DISPLACEMENTS. 
283 
though, in our experience, a not impassible hindrance to reposition. 
The portio vag. uteri is blended in with the walls of the tumor. This is 
due to the hypertrophy above-mentioned, and also, if the os is ruptured 
to any great extent, to the ectropion-like eversion of its lips. These, to- 
gether with the other changes occurring in the mucous membrane of the 
portio vag. and the cervix, will be considered in connection with prolapsus 
uteri. 
The symptoms of inversio vag. will consist of those of partial displace- 
ments together with those of prolapsus uteri The diagnosis also needs 
no further elucidation. Only in rare cases is inversio to be observed in 
the stage in which the portio vag. does not occupy its lowest point. It 
then forms a prolapsed, ring-shaped vaginal tumor, in the middle of which 
Fig. 25.-Section through the Hypertrophic and Inverted Vagina in a case of Prolapsus 
Colli Uteri. (After Farre.) 
is a funnel-shaped orifice which leads to the portio vag. (Fig. 26.) This 
is the transition form between a prolapsus ant. and post, beginning at the 
lower segment of the vagina, and a complete inversion. 
Even in slight cases of circular protrusions of the vagina, treatment by 
rest in bed, and astringent injections and tampons, will usually not be 
sufficient; and in complete and old inversion, the tumor .may be so large, 
and its walls so thick, that reposition itself may be very difficult. In 
these cases we must first remove the intra-abdominal tension by empty- 
ing the bladder and placing the patient in the knee-elbow position. If 
its surface is dry and crusted, it should be covered with linen cloths soaked 
in water, oil, or glycerine. The tumor is best reduced in the knee-elbow 
position, pressure being made upon all sides of the mass, and the portio 
vag. first, then the posterior, and then the anterior wall pushed up. Oc- 
casionally the reposition of the portio vag. alone will cause the reduction 284 
THE DISEASES OF THE VAGINA. 
of the whole tumor. It is important to ascertain whether the uterus has 
prolapsed en masse, or whether only the elongated collum has come down. 
If the former is the case, it may hinder reposition by its mass and posi- 
tion. It is best replaced by pushing it up somewhat obliquely, with one 
tubal angle in advance. It is generally easier to reduce the inversion in 
prolapsus colli uteri, since the elongated collum tends to go back as soon 
as the cystocele is replaced. Freund (l.c.) has observed a quite unusual 
obstacle in the shape of a colossal rectocele filled with fasces; it took two 
weeks rest in bed, and careful emptying of bladder and rectum before he 
could replace the prolapse. Fehling's case (l.c.), in which a rude attempt 
on the patient's part to replace the mass caused rupture of its wall and 
Fig. 25.-Prolapsed Circular Tumor of the Vagina. (.After M'Clintock.) 
prolapse of coils of intestine, will serve to warn us against the use of vio- 
lence in our attempts at reduction. 
It is much more difficult to maintain the reposition, if we do not con- 
tent ourselves with palliative treatment by pessaries and bandages. 
The operative treatment of vaginal displacement is the only one which 
is reliable, and is to be recommended in all cases when the patient is not 
too decrepit to undergo it. Its purpose is, if possible, to remove the con- 
ditions which caused the displacement, or, if that cannot be done, by 
keeping the protrusion in place, to prevent its growth. Thus the opera- 
tions are very largely the same as those in vogue for the cure of prolapsus 
uteri. They all depend upon the following points: 
1. The removal of the pressure or tension which maintains the protru- 
sion. 
2. The prevention of the relaxation and protrusion of the walls of the DISPLACEMENTS. 
285 
dilated vaginal tube, and the increase of its resistance to abdominal pres- 
sure by narrowing its calibre. 
3. The reproduction of the lost fixation points of the vaginal walls by 
the production of extensive and firm cicatricial masses in the peri-vaginal 
connective tissue. 
The accomplishment of these ends will in many cases entail several 
operations; but in some cases procedures directed to fulfill the first and 
second indications alone, will accomplish our purpose. 
The reduction of the pressure of the anterior vaginal wall, when the 
protrusion is due to new growths in the septum ves. vag., may be attained 
by extirpation of the tumors. Cysts are especially to be considered, which 
we shall do later on. The pressure of a cystocele can only be averted by 
permanent retraction of the bladder, as might occur if a vesico-vaginal 
fistula were present. The production of such an abnormal orifice for this 
purpose has in point been successfully accomplished in one case by J. Ely.1 
In spite of the greater certainty with which we operate upon fistulas to- 
day, there is this objection to this method of treatment, that the elimina- 
tion of vesical pressure, while the fistula is present, does not ensure us 
against a return of the cystocele when it is cured. 
The pressure from Douglas's pouch upon the posterior vaginal wall 
may, when due to circumscribed collections of fluid, be removed for a time 
by vaginal puncture or incision. If cystomata, or dermoid cysts of the 
ovary, or fibromyomata of the uterus cause the protrusion, their removal 
by laparotomy may remedy it. If the uterus and the vaginal vault are 
depressed by hypertrophy of the cervix, amputation of the enlarged por- 
tion will relieve the condition; and in cases where the supra-vaginal por- 
tion is hypertrophically elongated, amputatio colli, especially by Hegar's 
method of funnel-shaped excision,2 occasionally cures it by elevating the 
vaginal vault. I will refer the reader to the operation for prolapsus uteri, 
and will only say that I have once cured a case in this way. It is imma- 
terial whether we consider the hypertrophic elongation as primary or sec- 
ondary to explain it. 
When the tension exercised by a hypertrophied prolapsed vaginal fold 
causes increasing displacement, the ablation of the mass will occasionally 
1 M. Sims does not object to the excising of a portion of the wall of the bladder 
together with a strip of the anterior vaginal wall. But he did not reach the blad- 
der, and contented himself with the excision of the vascular strata. He did not, 
however, state that he intended to exclude the pressure of the cystocele by per- 
manent retraction of the bladder. J. Ely (Madison) (Am. Journ. of Obst., April, 
1882, p. 434), opened the cystocele by incision, and put in a drainage tube which 
was attached to a urinal. The patient was phthisical, and 32 years old. Her 
urine, formerly ammoniacal, became normal, and her difficulties disappeared. In 
4 weeks, the cystocele is said to have disappeared, and the urine flowed per ureth- 
rum. After the drainage tube was removed, the fistula closed spontaneously. 
2 Hegar and Kaltenbach, 1. c. 286 
THE DISEASES OF THE VAGINA. 
suffice. I once cured a case by the extirpation of an oval protrusion of 
the posterior vaginal wall, which was 2.4 inches long and as thick as a 
finger. 
It has been attempted to effect vaginal constriction for the cure of vagi- 
nal and uterine prolapsus by operation, and by bloodless methods. For 
the latter purpose cauterization and the ligature have been employed. 
Various cauterizing agents have been recommended; but no one of 
them, not even the red-hot iron, has turned out to be trustworthy. 
Meding used nitrate of silver; Philipps nitric acid;1 Degranger chloride 
of zinc;2 Langier,* Evory Kennedy,4 Dieffenbach,6 ferrum candens. 
Longitudinal or ring-shaped cauterization cannbt be applied thoroughly 
enough to form deep eschars, from the danger of injuring peritoneum, 
bladder, or rectum. The resulting cicatricial contraction is therefore in- 
sufficient, and the method has been abandoned in spite of Dieffenbach's " 
encouraging remarks. 
The tying of the prolapsus tumor or the hypertrophied portion of the 
vaginal wall was recommended by Richter,7 and first successfully done 
by Hedrich 8 in a patient forty-four years old with an irreducible pro- 
lapse, the size of a child's head. The mass of the prolapse weighed one 
pound, and was removed in eighty-two hours without much bleeding or 
pain. Bellini9 has described a modification of this process under the 
name of kolpodesmorrhapia. It consists of a submucous application of 
the ligating threads. Naturally it has found few adherents. The same 
may be said of the method employed by Blasius,10 who gradually tightened 
a number of ligatures passed circularly through the vagina, so as to ob- 
tain a ring-shaped, constricting scar. Most recently Carl v. Braun 11 and 
C. von Rokitansky jr.,12 have again employed the elastic ligature. But 
Braun noticed that the time of treatment even for small hypertrophies was 
longer than that required by excision, and that fever occurred once in 
twelve cases. 
1 Lond. Med. Gaz., vol. 24, p. 494. 
2 Dresd. Zeitschrift f. Nat. und Heilk., 1830, New Series, vol. 1, part 2. Gaz. 
M6d. de Paris, 1853, Nos. 5 and 25. 
3 Lecture in the Acad, de M6d., Paris, Aug. 1835. 
4 Lancet, 1839, vol. 2, No. 12. 
5 Op. Chir. 
• 6 Chippendale has even proposed to inoculate the vaginal mucous membrane 
with gonorrhoeal virus. 
1 Loder's Journal, vol. 7, p. 59. 
8 Neue Dresdener Zeitschrift f. Nat. u. Heilk., 1829, part 1, p. 179. 
9 Bulletino della Scienze Med., Bologna, 1836, November and December. 
10 Med. Ztg. d. Ver. f. Heilk. in Preussen, 1884 ; Dissert, von Stephan, Halle, 
1884, and Beitr. z. prakt. Chir., p. 310. 
nLehrb. d. ges. Gyn., Wien, 1881, p. 322. 
12 Aertzl. Bericht des Maria-Theresa-Frauenspitales in Wien, 1877, Verlag von 
Urban u. Schwari zenberg. DISPLACEMENTS. 
287 
The combination of cauterization with mechanical procedures, the 
pincement du vagin of Degranges with a toothed forceps armed with 
chloride of zinc,1 and the extensive cauterization with lapis, with subse- 
quent suture of the wounded surfaces recommended by Joubert,2 are only 
of historical interest. 
Mende3 was the first to theoretically recommend, and Fricke,4 inde- 
pendently of him, the first to execute an operation for the retention of 
these prolapses. Since their time this method of treatment has constantly 
grown in popularity. 
Fricke's episiorraphy consists of a freshening and union of a part of the 
labia majora and a strip of mucous membrane between these points at the 
posterior commissure, thus constricting the vulva. But the pressure of 
the tumor was found to be too great for the weakened and thinned-out 
perineum, and the operation itself was not much more valuable than 
Dommes' plan of uniting the labia majora by means of a gold ring. Yet 
it has formed the groundwork for all subsequent improvements. Mal- 
gaigne6 soon gave greater breadth to the median band which united the 
denuded labial surfaces; and Credo," Keiller,' Baker Brown,8 Kiichler,' 
and Linhart have worked in the same direction. But as Hegar rightly 
says, all these modifications are only to be looked upon as improved 
episiorrhapies having for their chief aim the constriction of the vulva. 
On the othei' hand attempts were made to freshen and unite the vaginal 
walls themselves, so as to narrow the vagina and at the same time to form 
a high column which would leave no room for a prolapse above it and 
would oppose aily further descent of the uterus and the upper part of the 
vagina. B. Gerardin10 seems to have been the first to do kolporraphy or 
elytrorraphy. Occasional excisions of the prolapsed tumor had been done 
before by Stalpart van der Wiel, Medren, and others; but only the hyper- 
trophied mucous membrane was operated upon, and the operation was 
not methodically developed. The successful operations of Heming,11 and 
1 M6m. sur le traitement de la chute de 1'uterus par le pincement du vagin 
(Gaz. Med. de Paris, 1853, Nos. 5 and 25). 
2 Gaz. M6d. de Paris, 1840, No. 5. 
3 Geschlechts-krankheiten des Weibes, published by A. Balling, Gottingen, 
1834, part 2, p. 51. 
4 Annalen der Chir. Abth. d. Allg., Krankenhauses in Hamburg, 1833, p. 142. 
5 Man. de M6d. Operatoire, 1837, p. 728. 
6 Casper's Wochenschrift f. d. Ges., Heilk. 1851, Nos. 14, 15, 16. 
1 On the radical treatment of perineal laceration. Lecture delivered before the 
Edinb. Med. Chir. Soc. 
8 On Surg. Dis. of Women, p. 99. 
9 The double or perineo-vulvo-vaginal suture, Erlangen, 1863. 
10 Harles, Rhein-Westphal. Jahrbiicher fur Med. u. Chir., Hamm. 1825, vol. 
10, pt. 1. 
11 Heming first operated in consequence of a suggestion made by Marshall-Hall 
in 1831 (Eng. translation of " Boivin and Duges," by Heming, 1834, p.3). 288 
THE DISEASES OF THE VAGINA. 
of Ireland 1 first brought kolporraphy into general notice. The former 
freshened up the anterior wall of the prolapsus tumor; and the latter cut 
out a strip inches wide from the entire length of the vagina, and 
united it with sutures. Dieffenbach excised from each side of the pro- 
lapsed vagina oval flaps the size of a hen's egg, and united the wounded 
surfaces with sutures.2 Later he advised the excision of elliptical and 
pointed areas 3 inches long by 2 inches wide; and when there was great 
laxity of the vagina a small segment of the anterior wall was to be remov- 
ed also. He also recommended another method: the mucous membrane 
was to be denuded to the breadth of half an inch or more, and the 
strip to extend from the vaginal entrance to the collum uteri No 
sutures were to be used, but the vagina was to be tamponed. These 
operations are for large vaginal inversions complicated with uterine pro- 
lapse. If the vagina alone is involved, I), recommends that the tumor be 
seized with a toothed forceps, a strong ligature applied in front of it, and 
then the tissues divided between the two. As many sutures as may be 
needed are applied to the surface of the wound. Though we would pre- 
fer to excise longitudinal areas, Dieffenbach says we will more commonly 
have to excise transverse folds. 
There is often considerable venous hemorrhage when Ave ablate pro- 
lapsed vaginal folds, and a few small twigs of the art. vag. may spurt. 
When the whole base of the fold can be grasped by the toothed forceps, 
that instrument will be very useful; nevertheless we prefer to pass a 
number of silver-wire sutures instead of the silk ligatures above the 
forceps at once, so as to check the hemorrhage. C.V. Braun (1. c. p. 320) 
has recently recommended this procedure. 
G. Simon3 and A. Hegar4 have done more than any others in Germany 
to introduce and systematize operative procedure for prolapse of vagina and 
uterus. After them many modifications and variations have been propos- 
ed, especially by Bischoff5 and L. Neugebauer.6 
As to the details of the prolapsus operation, they are fully considered 
by Fritsch in the part of this work dealing with uterine displacements, to 
which we refer the reader. 
For the palliative treatment by retention of vaginal inversion, any of 
the ordinary pessaries and bandages used for uterine prolapse may be 
1 Dubl. Journ. of Med. Science, January, 1835, p. 3. 
2 Med, Zietung- d. Ver. fur Heilk. in Preussen, Berlin, 1836, No. 31, and Die 
Operative Chirurgie, vol. 1, p. 642. 
3 Prager Vierteljahrsschrift f. pr. Heilk., 1867, vol. 95 ; and Engelhardt, Die 
retention des Gebarmuttervorfalles, Heidelberg, 1871. 
4 Hegar und Kaltenbach, 1. c., und Huff el, 1. c. 
5 H. Banga, Die Kolpoperineo-plastik nach Bischoff, Diss.-Basel, 1875, and 
Egli-Sinclair, Corr.-Bl. f. Schweizer Aerzte, Year, 1877. 
6 Centralblatt f. Gyn., 1881, p. 3. DISPLACEMENTS. 
289 
employed. We will not attempt to describe their innumerable varieties, 
since their choice depends largely upon the physician's prejudice or habit. 
Every one of them has some disadvantage. If the structure of the introi- 
tus vag. and the muscular floor of the pelvis allows the retention of pes- 
saries within the vagina, they are always to be preferred to instruments 
which are in part worn externally; the latter being less convenient and 
being liable to cause great irritation of the vaginal entrance. And also 
they retain the vagina in place by maintaining it in a state of tension 
above the diaphragma pelvis. If the introitus is so dilated by relaxa- 
tion, diastasis or loss of substance of the muscular and aponeurotic base 
of the pelvis, that a pessary can find no vaginal support, they may still 
be retained if certain conditions are present. Thus peculiarities in the 
shape and width of the pelvis (funnel-shaped pelvis), or of the form of 
the pessary (large lateral wings), may enable the instrument to rest against 
the bony walls of the pelvic canal. It is very well known that under these 
conditions of continuous localized compression of the soft parts between a 
hard instrument and the bone, evil consequences will soon ensue; and it 
does not seem proper to me that we should continue to gather renewed 
experience upon the subject. 
But in any case the maintenance of the replaced vagina above the 
diaphragma pelvis necessitates an amount of tension of the vaginal walls 
which cannot be attained with most pessaries without a deleterious amount 
of local pressure. The more irregular these instruments are in their 
shape, the more certainly will they cause uneven pressure at certain 
places. Often we find that pessaries which have been introduced whilst 
the pelvic organs were in a state of rest, have assumed a different position 
shortly after being placed. Elongated and winged instruments readily 
get into crooked positions, and cause contusion and friction; and these 
lead in time, if carelessly left to themselves, to ulcerations and deeper 
pressure-necroses, and even to perforations 
Yet, though these accidents have occurred time and time again, they 
have not been sufficiently noticed in medical circles; and even yet the intro- 
duction of a "womb-ring" is oftentimes looked upon as a trivial matter, 
to be relegated to the midwife. I have seen so much evil result from 
neglect of this kind that I do not deem it superfluous to say a word of 
warning in regard to the introduction of pessaries. In addition to the 
ordinary treatment of the complicating erosions and ulcers, the following 
precautions should be observed: 
1. The pessary should be chosen in accordance with the width of the 
vagina. It should be introduced in the knee-elbow position, and after 
the prolapse has been thoroughly reduced, and the vagina filled with air. 
It slips easily into the dilated sac, when it finds plenty of room. Now, 
with its opening encircling the portio vag., it is kept pressed against the 
posterior vaginal wall, and against the fornix, whilst the patient gradually 290 
THE DISEASES OF THE VAGINA. 
raises herself into a kneeling position. The stretching of the posterior 
vaginal wall at the moment of rising prevents the sinking forwards of the 
collum, and the descent of the movable adnexa and the intestines into 
Douglas's cul-de-sac. Very often we thus effect an anteversion of the 
uterus; a position most favorable for retention; and we will frequently 
prevent painful pressure upon an ovary which may be lying in Douglas's 
cul-de-sac. 
2. We should never rest satisfied only with an immediate examination as 
to whether the pessary remains in place well when walking, standing, 
and bearing-down; we should always examine the patient again next day, 
after she has been moving around for some time, and has had a passage. 
3. Vaginal injections of lukewarm water, either plain or containing 
antiseptic agents, must be used twice daily, so as to prevent stagnation of 
the catarrhal secretion which the presence of the foreign body will always 
occasion. 
4. A soft rubber ring should never be worn longer than eight weeks; 
and one of hard rubber should be removed and cleansed at least once in 
that period of time, though it may be worn much longer. 
I know of but a single case in which a pessary was worn continuously 
for years without any evil consequences ensuing, though the patient did 
not trouble herself about it at all. I was asked to remove it for a trouble 
in no way connected with that of the womb, and was told to replace it 
again. 1 removed with difficulty, on account of its size, a yellow ball of 
wax as big as a large orange with the help of a polypus forceps. It had 
exerted a moderate and even tension upon the vaginal walls; and, from 
its smooth surface and indifferent nature, as well as from the complete 
exclusion of air from the vagina which it ensured, there was so little 
irritation that although the portio vag. was softened and injected, there 
was neither erosion nor any other tension.1 The case led me to re- 
mark in 1879, in the 1st edition of this -work: "The hard rubber balls 
which Bozemann uses for the preparatory dilatation of the cicatricial 
vagina, before operating for vesico-vaginal fistula, seem to rank next to 
those of v'ax in respect to the small amount of irritation they occasion. 
My experience with them is as dilators, not as pessaries; but 1 think they 
might well be occasionally used as such. ' ' 
Of late years I have made great use of the so-called egg pessaries for the 
palliative retention of vaginal and uterine prolapsus, especially when they 
are of long standing, and in women who have passed the climacterium.2 
'They consist of light hollow7 pessaries of hard rubber, of various sizes 
and egg-shaped. 
1 Gbckel (Miscell. Nat. Cur. du II. den V. obs. LIV.) relates a case where a 
woman carried a wax ball over 6 ounces in weight, and a copper ball 2 ounces in 
weight for 27 years as a uterine support (from Voigtelle, 1. c.). 
2 Prager Med. Wochenschrift, 1884, No. 33. DISPLACEMENTS. 
291 
The even and moderate tension of the vaginal walls which they occa- 
sion, the stability with which they maintain their position over the mus- 
cular pelvic floor, the exclusion of air, combined with their smooth surface 
and indifferent material, render these pessaries the most desirable of all, 
and the ones which entail in the least degree the evil consequences due 
to the presence of a foreign body. 
For their removal I use a small pair of forceps made especially for the 
purpose, if they are so firmly seated that they cannot be expressed by ab- 
dominal tension. I would refer the reader for fuller particulars in 
regard to these pessaries to the communication referred to above, and will 
only state here that I have several times had occasion to use them in 
women who were still menstruating, and have had abundant proof that 
they in no way interfere with that process. Nevertheless this form of 
pessary puts a stop to sexual intercourse, and it is applicable especially to 
women at the ages at which involution of the sexual organs has occurred. 
When there is not sufficient support for pessaries, bandages may be 
used. They should press upon and irritate the parts as little as possible, 
should not interfere with the motions of the body, and should be readily 
introduced and easily cleansed. And withal they must not be too 
expensive; for not only must they be within the means of the working 
classes, but the intra-vaginal part, at least, must be frequently changed. 
I will not describe these appliances in detail, since that will be done 
under the heading of prolapsus uteri. I will only say that I myself 
employ a simple T-bandage with elastic insertion, to the middle piece of 
which a smooth, hard, rubber, pear-shaped pessary is attached by means of 
a stout gutta-percha stalk. " 1 
1 Aerztl. Benefit. des Allg. Krankenhauses, zu Prag. 1876. CHAPTER V. 
RUPTURES OF THE VAGINA. 
~DUPTURES of the vagina may be due to traumata, or may occur spon- 
taneously. Usually there is tension and stretching of the walls of 
the canal up to the limit of distensibility; or sharp or pointed bodies may 
penetrate from without. 
Among the traumatic causes of the accident are falls upon the genitals 
and the entrance of foreign bodies (see under that head). Rockwitz saw 
a vagina that had been ruptured by the horn of a bull, and Curran records 
a recto-vaginal tear from penetration of the horn of a goat. I have seen 
2 cases of complete perineal rupture into the rectum in young girls; the 
one was caused by the breaking of a wooden sled upon which she was 
straddling and sliding down hill; and the other was caused by the horn 
of a cow. It may well be doubted if violent coitus can cause a fatal rup- 
ture when the vagina is in normal condition, although Diemerbroeck, 
Colombat, and Meissner record such cases. If senile involution, and 
pathological changes such as stenoses, etc., are present, rupture might 
occur from intercourse; I have myself seen such a case, which, however, 
recovered. Hymenal ruptures of some depth, which may bleed consider- 
ably, are often made by defloration, and are not to be looked upon as 
vaginal ruptures. It has lately been denied by E. Hofmann 1 that the 
severe vaginal lesions which have been seen in certain cases of rape upon 
children have been caused by attempts at coitus; he claiming justly that 
they were more probably due to rude manipulation. Maschka2 expresses 
a similar opinion Finally, instruments, and even the hand of the phy- 
sician or the midwife, may tear and even rupture the vagina, most often 
during childbirth. More rarely this has occurred during violent attempts 
at the reposition of chronic inversio uteri, the extraction of large utero- 
fibromata, etc. 
The location and extent of the ruptures vary greatly, in accordance with 
their cause. As in all wounds which do not immediately destroy organs 
necessary for life, the two chief factors of hemorrhage and infection will 
decide the result. Fatal hemorrhage is comparatively rare in vaginal 
rupture; when it has occurred it has been in pregnant women, and has 
1 Lehrb. d. Ger. Med., Wien, 1877. 
2 Handb. der Gerichtl. Med. 1882, vol. 3, p. 164. RUPTURES. 
293 
been near the introitus and involved the erectile tissues. Complications, 
such as the opening into neighboring organs or the peritoneum, always 
make the wound a dangerous one, but are not necessarily fatal unless 
very considerable hemorrhage or septic infection occur. We can nowa- 
days better understand the isolated and apparently wonderful cases of 
recovery after' such injuries; though there are some in which infection 
did not occur, although the patient was most unfavorably situated. Thus, 
Reckwitz had a case in which the lower portion of the vagina, one inch 
above the introitus, was torn in three places, and the patient recovered 
after the wounds were sutured. Colombat1 relates a case of recovery 
after the posterior vaginal wall of a young girl had been pierced by 
an iron pitchfork, in jumping from a hay-stack; and Rey records the 
recovery, after fourteen days, of a case where a long wooden rake had 
penetrated the peritoneum through the wall of the vagina. Ruhfus2 
saw the intestines protrude through the wound after withdrawing a pitch- 
fork which had penetrated the posterior vaginal vault. He replaced them, 
although they had already become cold, and held them in situ with a 
sponge soaked in oil. The patient was kept upon her back with the pel- 
vis elevated, and antiphlogistic treatment " ordered; and she recovered. 
Fleury3 records a more recent case in which a fall from a grain wagon 
against a piece of wood caused rupture of the anterior vaginal wall and 
the bladder, and which healed of itself. The cases to be related later, in 
which large ruptures of the posterior vaginal vault occurred post-partum, 
are still more remarkable. 
The spontaneous ruptures of the vaginal walls occur almost exclusively 
during childbirth, although a few cases have been observed under other 
conditions. Thus Grenser4 reports that in a pregnant woman with ascites 
the first-sized retroverted uterus prolapsed through a spontaneous rupture 
of the posterior wall of the vagina, and appeared at the vulva. The fatal 
result was hastened by the attempts made by a surgeon who was called in 
to remove the prolapsed body, which he took to be a mole. Samples (l.c.) 
reports a case of spontaneous rupture of the posterior vaginal vault in a 
woman who violently exerted herself some three months post partum. 
The finger could be passed into a cavity which had no connection with 
the peritoneal sac. Fallen closed the rupture with a few sutures, and the 
patient got well. The physician suspected, probably correctly, that the 
rupture had been caused by the bursting of a haematoma. 
Fehling's 5 remarkable case is probably partly traumatic in its origin. 
The woman was sixty-three years old, and had had eleven deliveries and 
1 Trait, d. Malad. d. Femmes, Tome II., p. 424. 
2 Grafe u. Walther's Journ. f. d. Chir., vol. 5, part 3. 
3 Annales de Gynecol., 1877, Tome VIII. p. 457. 
4 Naturforscher Vers, in Wien, 1856 (Monatschrift f. Gebwctsh. vol. 9, p. 73). 
5 Arch. f. Gyn., vol. 6, p. 103. 294 
THE DISEASES OF THE VAGINA. 
one abortion. For fifteen years she had had a prolapsus which had been 
left to itself. One day, after going up to the fourth floor with a pail of 
water, it protruded very greatly, and she attempted to replace it forcibly 
with her hands. A fatal rupture of the posterior vaginal wall, with pro- 
lapsed coils of intestine, occurred. The history of this case furnishes us 
with a key to a similar condition, which Rokitansky1 once found post- 
mortem. 
In these cases the traumatic influences were slight, and they may be 
placed by the side of the spontaneous cases. They presuppose an exces- 
sive friability of the vaginal walls from a pathological process of some 
kind, together with a sudden increase in vaginal tension from ascites, 
retroversio uteri, or hernia post, vag., etc. 
Now as to vaginal ruptures which occur sub partu. 
They occur both with natural and with artificial deliveries. If we do 
not include the very frequent fissures of the mucous membrane at the 
hymenal insertion, which occur in most first deliveries, vaginal ruptures 
are rare accidents in childbirth. In 108 cases of rupture M'Clintock 
counts 35 as affecting the vagina especially.3 
We can easily appreciate the conditions which predispose to vaginal 
rupture in childbirth. The excessive tension and stretching of the walls 
is the prime factor, especially when there is any disproportion between 
the advancing part and the vaginal tube. An unequal amount of ten- 
sion is therefore exerted; sometimes spontaneously by abnormal positions 
of the head, but much more frequently from a faulty direction of the for- 
ceps in extraction. As a rule the posterior wall, being the one most sub- 
ject to tension, is the one that is ruptured. The rapidity with which 
the vagina is dilated is a factor, as is also the condition of the vaginal 
tissue as regards extensibility. Deep fissures at the upper and lower 
segments of the tube generally involve the neighboring organs. Thus 
ruptures of the vaginal vault usually involve that of the cervix uteri; those 
near the vaginal entrance are continuous with perineal rents. But we 
do see uncomplicated fissures at both places. Those of the vaginal vault 
then often form transverse tears, and sometimes spread so far in a circular 
form as to completely separate the uterus from the vagina. Hugenberger, 
who has described this variety of rupture minutely under the name of 
kolpoporrhexis,3 has collected 39 cases, the 40th occurring in his own 
practice. Seventeen of them were anterior, 17 posterior, and 6 more or 
less complete separation of vagina and uterus. Like uterine ruptures, 
they occurred most frequently in multipart, in whom there was marked 
disproportion between pelvis and foetus. In either case the essential 
cause of spontaneous rupture is the enormous stretching and tension of 
1 Lehrb. d. Pathol. Anat., 3d ed. vol. 3, p. 515. 
2 Comp. Speigelberg, Lehrb. d. Geburtsh., p. 619. 
3 L. c. RUPTURES. 
295 
the cervical and vaginal walls, which occurs when there is an impassable 
obstacle, and the internal os is behind the head or other prominent part 
of the child. This mode of origin was described by Crantz, though G. 
A. Michaelis was the first to thoroughly study it.1 
Michaelis found in eight cases of rupture which he observed, that the 
vagina was always solely or especially the part involved. Bandl2 has 
proven the same origin for the more frequent cervical ruptures of the 
uterus, though he improperly denies the validity of the generally accepted 
explanation of vaginal rupture. Next to this the commonest cause is the 
exceptionally great extension of the vagina above an unyielding steno- 
sis; this we have already mentioned when considering vaginal stenoses. 
(E. Kennedy, Doherty.) Ruptures from pressure of the soft parts be- 
tween the child's head and pelvic prominences can probably only occur 
when the vagina has been enormously stretched and there are exostoses 
springing from the promontory or the sharp edge of the pecten pubis 
(Lehmann), or most commonly, the symphysis. It might also occur from 
too great prominence of the ischial spines, or from badly united fractures 
of the pubis, with displacement and a large amount of callus. 
We do not set any very high value upon spasmodic uterine contractions, 
or the influence of ergot as causes of rupture, though they have been 
much dwelt upon by the older authorities. We cannot in any of these 
older cases exclude the possibility of a want of proper mechanical rela- 
tionship between the pelvis and the foetus; and more recent confirmatory 
observations are wanting. 
Finally, pathological changes in the vaginal walls themselves may give 
rise to spontaneous ruptures sub partu. Hugenberger found two suCh 
among his forty cases; there being in one case stenosis and in another case 
large cicatrices from antecedent and successfully operated upon fistula 
ves. vag. 
Ruptures of the vaginal vault are frequently penetrating. Hugenberger 
found thirty-four of them so; while in two cases the peritoneum was 
preserved and only elevated by extravasations. 
The symptoms are very like those of cervical ruptures of the uterus. 
There is sudden pain, distinctly localized hypogastric tenderness on pres- 
sure, increasing abdominal distension, collapse even with but slight ex- 
ternal hemorrhage, sometimes cessation of the pains, change of shape of 
the lower abdomen from partial or complete extrusion of the foetus through 
the rent, and the occasional formation of a hsematoma. These are the 
symptoms which are common to both affections. Vaginal ruptures can 
often be directly reached with the fingers; if they affect the anterior 
wall, the entrance of air will occasionally cause emphysematous crepita- 
tion above the symphysis. (M'Clintock, Hugenberger.) Protrusion of 
1 The Contracted Pelvis, Leipzig, 1851, p. 208. 
2 On ruptures of the uterus and their mechanism, Vienna, 1875. 296 
THE DISEASES OF THE VAGINA. 
the presenting part of the child does not follow vaginal as frequently as 
it does uterine ruptures. Thus in Hugenberger's cases the head remained 
seventeen times and the breech once in the pelvic canal, even when, as 
sometimes occurred, other parts of the child were already within the ab- 
dominal cavity. Hence it happens that the external hemorrhage is some- 
times very slight, the parts of the child preventing outflow. Nevertheless, 
all these signs are not sufficient to enable us to make a diagnosis of vagi- 
nal rupture before the child is born. Feeling the lower border of the 
rupture will only enable us to decide that the vagina is involved. We 
can only ascertain the facts after the uterus is empty. 
As regards their course and termination, vaginal ruptures occurring 
high up sub part'll in most cases terminate fatally from hemorrhage, 
shock, or peritonitis septica, like similar ruptures of the neck of the 
uterus. It is usually not in our power to control the conditions necessary 
for an aseptic course. Yet the prognosis is better than that of uterine 
rupture. Hugenberger calculates from the reports of the large Euro- 
pean lying-in institutions, that the mortality of the latter class of cases is 
95 per cent., while in 40 cases of kolpoporrhexis 11 recovered, although 9 
of them were penetrating ruptures. 
Deep ruptures during labor of the median segment of the vagina proba- 
bly only occur spontaneously when stenosis is present. Traumatic rup- 
tures, also, are rare, though as elsewhere they may occur from the use of 
instruments or from pieces of bone in difficult extractions. Spiegelberg 
mentions a case in which a large fold of the anterior vaginal wall was 
seized with the part, and an opening torn into the vesico-vaginal septum. 
'As to ruptures at the introitus, the passage of the child's head is most 
likely to cause it at the tensest part, the posterior wall. They regularly 
begin at the narrowest part, where the hymen is inserted, and run to the 
entrance of the vagina. (Kiwisch.) They therefore occur most com- 
monly in primiparae. The mucous membrane first gives way, on account 
of the excessive circular distension, in a longitudinal direction. The 
tear then continues, boring into the deeper strata, either upwards as a 
longitudinal fissure, or, combined with a transverse rupture, it attains a 
Y or W-shape, depending upon whether it is continued in the direction 
of the raphe perin. or not. As a rule longitudinal ruptures at the 
vaginal entrance do not run exactly in the median line; they always go 
to one or the other side, since the columna rugarum post, is always more 
resistant than other parts. The columna also limits the transverse rup- 
tures of the introitus. But apart from these features, due to the anatomi- 
cal peculiarities of the parts, the ruptures may vary much in shape, es- 
pecially when the tissues have been contused and are sugillated. We then 
often find the ruptures continued into the perineum. Transverse fissures 
of the introitus may also be continued into the depths of the perineal 
tissue, without there being any longitudinal rupture of that structure. RUPTURES. 
297 
I do not know of any prolongation of transverse ruptures of the vaginal 
entrance into the rectum; but I do not doubt that they do occur, espe- 
cially when they are met by a rupture of the rectal mucous membrane. 
For when the perineal portion of the vagina is greatly distended, a primary 
longitudinal rupture of the anterior rectal mucous membrane occasionally 
occurs. In two such cases of fissures 1.2 inches long of the rectal mucous 
membrane, which I saw not long ago, I was able to prevent deeper 
vaginal rupture by free lateral incision of the vulva, and by relieving the 
perineum by lifting up the head per rectum. The rectal lesion healed 
quickly after suturing. 
Fissures of the anterior parts of the introitus are never so extensive or 
so deep as those of the posterior portions. This is to be explained by 
the fact that when the head is passing, the longitudinal extension of the 
anterior wall is less than that of the posterior wall; and the fixation of 
the urethro-vaginal septum to the pelvic fascia is such as to admit of but 
little movement; and finally, that the arch of the pubis protects the 
anterior vaginal wall from hyper-distension. Thus the greater part of 
the tension falls upon the more yielding posterior segment. But in spite 
of this there do occur longitudinal ruptures of the anterior wall, which 
may be continued to the vestibule, or more rarely, to the nymphae. 
They may be of exceptional importance on account of the dangerous 
hemorrhage which may occur from the tearing of tissues so near the ure- 
thra and clitoris. They will be considered elsewhere. A narrow vulva, 
a rigid perineum, and a hindrance of the descent of the occiput will es- 
pecially favor their occurrence. 
If the vaginal tube is small, and the pains severe, longitudinal ruptures 
of the vaginal mucosa may occur which may involve the entire length of 
the organ, and yet not invade the deeper strata. I myself saw in a peas- 
ant girl, who had just been delivered of her first child under very insuffi- 
cient care in the country, and who desired to become a wet-nurse, a fresh 
linear scar running from the posterior vaginal vault to the commissura 
post. This spontaneous cure was an excellent recommendation for her 
as wet-nurse, and she did her duty well. 
In regard to the prognosis of vaginal ruptures, the following points are 
to be considered: 
1. The hemorrhage. 2. Complication with injuries of neighboring 
organs. 3. Infection. These will decide as to the dangers to life, as 
well as to the possibility of a restitutio ad integrum in case of cure. In 
complicated injuries the latter will only exceptionally be attained. Fis- 
tula of rectum and of bladder, deforming scars, atresias and stenoses, de- 
scents and fixations of the uterus, are often left behind. 
Infection is of the greatest importance for the prognosis, since occa- 
sionally, and very especially in childbed, slight traumatic losses of tissue 
may prove fatal. Foi- in addition to the possibility in all vaginal rup- 298 
THE DISEASES OF THE VAGINA. 
tures of the access of septic material from without at the moment of in- 
jury and later, we have here two additional dangers-traumata during 
childbirth often cause extensive losses of tissue from contusion, and the 
wound is inevitably kept bathed in the decomposing lochial secretion. 
The treatment may be prophylactic in a certain number of vaginal 
ruptures, mainly in those occurring sub partu. This presupposes that 
symptoms of the approaching danger of rupture are recognized; which 
has been found possible in many cases. Since spontaneous ruptures high 
up in the vaginal vault occur under precisely similar conditions as do 
cervical ruptures, the prophylactic treatment of the two are identical. 
When in cases of disproportion between the pelvic entrance and the ad- 
vancing head, that contraction of the region of the uterine tumor corre- 
sponding to the internal os over the child's head, to which Bandl has 
drawn attention, has formed, the vagina itself will be markedly stretched, 
and is, with the cervix, in danger of rupture. But even when on account 
of an abnormal presentation, the constriction of the orif. int. is not 
plainly marked, or when the contraction of the orif. ext. has gone so far 
that the cervix has safely passed the point of greatest tension, the stretch- 
ing of the vagina over the advancing part may yet show that there is 
danger of rupture 
And prophylaxis would here consist not only of the avoidance of all 
procedures which would increase the tension, and in the combating of 
very violent pains by narcotics, but also in the relief of tension by opera- 
tive procedure. 
In cases of stenosis, the incisions of which we have already spoken are 
available to prevent rupture. When the obstacle is situated at the vagi- 
nal entrance, we may endeavor to enlarge the vulva by lateral incisions, 
at the same time endeavoring to guide the head and shoulders through 
the introitus in the most favorable way. When the head is in its nor- 
mal position, this latter indication will depend chiefly upon the complete 
descent of the occiput and on the slow advance of the head during this 
movement of flexion. In my experience this can be most successfully 
done by the method of bi-manual protection of the perineum, the one 
hand taking care of the descent of the occiput, while the other by pres- 
sing against the perineum during the pains, prevents the too rapid passage 
of the head. During the remissions of the pains the tips of the fingers 
should be pressed against the ischial regions, so as to favor the rotation 
of the head. I have abandoned Ritgen's method of guiding the face from 
the rectum for antiseptic reasons. 
If rupture has already occurred, we must endeavor to control the hem- 
orrhage; and, after thoroughly cleaning the wound, try to unite its edges 
with sutures. If this cannot be done, we must simply dress the wound 
and put it in as favorable a condition as possible. 
If the injury has been caused by a foreign body, it must be removed RUPTURES. 
299 
with the precautions I have described. Under all circumstances a careful 
cleansing of the wound and a minute examination is necessary. Irriga- 
tion is our best method of cleansing in non-penetrating wounds, and it 
alone will often stop the hemorrhage. If larger vessels have been injured, 
they are almost always veins; cold and pressure will usually control the 
hemorrhage. But sometimes it will not do so. Then it will depend upon 
the nature and the accessibility of the wound whether the hemorrhage can 
be stopped by union of the edges of the wound, or whether temporary pres-, 
sure-sutures should be passed. In any case compression by sutures is not 
only the surest way of controlling hemorrhage, but it is also the one which 
interferes least with primary union of the wound. If the rupture can be 
closed with sutures, irregular edges are to be trimmed off and the edges 
of the wound carefully united with wire or thread. Then complete rest 
should be enjoined, with cold cloths to the genitals and hypogastrium, a 
diet that does not give much faecal residue, and the use of the catheter. 
If there is much vaginal discharge, lukewarm vaginal injections should 
be taken several times a day, (alum. acet, with addition of spir. lavand., 
or one of the various antiseptic solutions), always under very slight pres- 
sure, and without the injection tube immediately touching the wound. 
Sutural union can occasionally be done even when there are severe com- 
plicating injuries, and is then always indicated. Naturally it must be 
carefully effected, though in an emergency operation; the couch, instru- 
ments and assistants must be specially prepared, the wound being meantime 
provisionally attended to. Without doubt much will depend upon ex- 
ternal circumstances, and much upon the energy of the physician. 
If sutures cannot be applied, tampons soaked in an antiseptic fluid, or 
better, compresses of iodoform gauze, must be applied after the hemorrhage 
has been controlled, and the whole fixed with a T-bandage. The length 
of time which the tampon is permitted to remain in situ depends partly 
upon the material of which it is composed, and partly upon the amount 
of vaginal distension which it occasions. If it causes much distension it 
must not be left in place many hours; iodoform tampons remain aseptic 
longest. In penetrating ruptures with prolapse of the internal organs 
(uterus, adnexa, coils of intestine), the latter must be carefully cleansed, 
and replaced, even when they have become cold, since several cases of 
this kind have recovered. In these cases the collapse and the gaping of 
the wound usually prevent suture. The prime indication after replace 
ment is to prevent intestinal protrusion by suitable tampons. The re- 
markable case which Breslau has described, where a midwife and a bath- 
man succeeded in removing the uterus, tubes, and ovaries of a recently 
delivered woman with their fingers and nails, show that recovery may take 
1 De totius uteri extirpatione, Dissert, inaug., Monachii, 1852. Even this case 
is not unparalleled. 300 
THE DISEASES OF THE VAGINA. 
place in high cervico-vaginal ruptures, and the intestines be retained even 
when the entire uterine body has been taken away. 
And now as to the best method of completing delivery in large and high- 
seated vaginal ruptures occurring sub partu. Our choice between lapa- 
rotomy and extraction will depend upon the amount of disproportion 
between the foetus and the pelvis or soft parts (stenoses, tumors, etc.), 
and also upon the extent of foetal prolapse through the rupture. In a 
general way we can refer to the rules laid down for uterine ruptures, which 
are mostly applicable here. 
If there is not too great a want of proportion between the foetus and 
the pelvic canal, and if the rupture is large and the child is wholly or 
mostly within the abdominal cavity, turning and manual extraction may 
be done. If the rupture is small, and the foetus wedged in the uterus, 
perforation and cranioclasis may be employed. The after-birth is to be 
removed immediately after the foetus, so as to put an end to hemorrhage 
and give rest to the injured parts as soon as possible. Coils of intestine 
are to be replaced, and a bandage employed as directed above. Since 
union by suture is but rarely practicable, hemorrhage and displacement 
must be combatted by externally applied cold (ice-bags), a suitable posi- 
tion, and as complete an immobilization of the wound as is possible by 
means of the dressing. If the uterus is well contracted, and the hemor- 
rhage still persists, the bleeding point must be searched for as soon as it 
can be reached, and ligatured. In order to prevent lochial stagnation 
over the wounded region we must not allow the first tampons to remain 
in situ over twenty-four hours. It is desirable, in order to secure as com- 
plete rest for the wound as is possible, to limit our vaginal antiseptic in- 
jections as much as possible. Where, from septic changes, they become 
necessary, they should be done without employing too great pressure and 
without disturbing the patient too much. 
As we have said, general treatment consists chiefly in the exhibition of 
analeptics. Alcohol in small doses.may be indicated, and considerable 
quantities of opiates may be necessary for the pain and restlessness. 
There can be not the slightest doubt that delivery per vias naturales 
under all circumstances enlarges the rupture and renders the prospect of 
recovery very faint. But unfortunately our experience so far does not 
seem to render it probable that laparotomy, which Trask 1 has so sturdily 
advocated for uterine ruptures, will do much better. For we never suc- 
ceed by laparotomy in controlling the rapidly advancing septic infection. 
Our best prospects lie in putting the wound in such a condition that its 
secretions can flow off undisturbed. This is to be accomplished by the 
position of the patient, drainage and local antisepsis, with complete rest, 
immobilization of the uterus and light compression of the abdomen by 
1 Amer. Journ. of Med. Science, January-April, 1848. RUPTURES. 
301 
means of a suitable bandage, with counteraction of the collapse by wine, 
etc. Ruptures of the middle and lower segments of the vagina are al- 
ways accessible, and can be sutured if they are not situated behind ste- 
nosed areas. They can be well exposed in the dorsal position, with the hips 
elevated, or on the side, with the duck-billed speculum and depressor, 
aided by sharp hooks. The sutures should be begun at the posterior 
angle. Many operators employ carbolized silk, or catgut, which need 
not be removed later. There is no objection, however, to wire su- 
tures; they are to be removed in fourteen days, and though this may 
be difficult to do, it can always be accomplished. If the rupture is situ- 
ated behind a stenosed tract, and cannot be seen, the hemorrhage must 
be stopped by injections through the double catheter, or by the introduc- 
tion of small pieces of ice. If we must use tampons, those of iodoform 
gauze are the best. Liq. ferr. sesquichlor. is occasionally useful, but 
should only be employed after other methods have failed. For the special 
considerations in regard to ruptures at the vaginal entrance and peri- 
neum, we must refer the reader to the section upon diseases of the ex- 
ternal genitals. CHAPTER IV. 
HAEMATOMA OF THE VAGINA. 
i F JEMATOMA (thrombus) of the vagina is of rare occurrence. In 
J-L the recorded cases of the affection there is no distinction made 
between vaginal and vulvar haematomata. But haematoma of the genitals 
in general is very rare; and Winckel, calculating on the basis of 50,000 
births, says that there occurs only one in every 1600 cases. Bidder and 
Sutugin found only one haematoma limited to the vagina in 3285 child- 
births. In my clinic in Prague there has been one case of haematoma 
vag. in 2126 births. Spath saw in two years at the clinic four cases of 
thrombus vag. in 6000 deliveries. (Wucher.) They do not differ in 
regard to their mode of origin from haematoma of the external genitals. 
Both probably occur but very rarely save in pregnancy, and then only 
in consequence of direct traumata. All the cases of which I have a his- 
tory were primiparae, and several of them were old ones. The posterior 
wall was usually affected, though sometimes the tumor was seated on the 
anterior wall. . Once only did I see the entire length of the vagina 
affected. 
The hyperplasia, loosening of tissue, and vascularization which accom- 
pany pregnancy, furnish the predisposing causes. Varices are not neces- 
sarily present. Marked and suddenly increased venous stasis from ab- 
dominal pressure will sometimes alone cause extravasation in pregnant 
women; but traumata are often the cause in spontaneous or artificial 
deliveries. This may be due, like the haematomata of pregnancy, to 
increase of pressure in the veins of the vaginal wall involved; or from so 
great a local contusion of the vessels that pressure-necrosis and subsequent 
hemorrhage occurs; or, probably most frequently, from direct rupture 
of the vessels from tension and displacement.1 In the latter case the dis- 
placement and compression of the vaginal walls by the child's head ex- 
plains how it is that the blood-tumor only developes post partuni. 
There have been too few investigations made as to the immediate 
' Perrot (These 1864, cited by Charpentier, 1. c.) long ago recognized the im- 
portance of displacement of the vaginal walls upon the sub-mucous recto-vaginal 
connective tissue in the formation of haematoma. Freund, by his explanation of 
the behavior of the various sections of the vagina during the birth of the head in 
his treatise upon ruptures of the vagina, has recently thrown much light upon 
the subject. HEMATOMA. 
303 
origin of the hemorrhage for us to decide as to their anatomical relations. 
In any case the veins will be more exposed to pressure and subsequent 
stasis than will the more elastic arteries. The hemorrhage is usually freer 
than would come from capillaries, and has no systolic impulse; hence it is 
most probably venous. Of course, however, smaller arterial twigs may 
be involved. 
The tumor always forms rapidly. In pregnant women, if there has 
been no traumatism, it appears after exertion, a fit of coughing, or other' 
action which involves a sudden abdominal pressure. During childbirth 
it only exceptionally appears before delivery is complete; as a rule it forms 
either immediately thereafter, or in a few hours or days, exactly as does 
haematoma vulvae. The symptoms depend upon its seat and extent. A 
part of the tumor usually appears as a bluish-black or bluish translucent 
tumor; it will not be seen, of course, when the haematoma is small, or is 
confined to the upper segment of the vagina. Occasionally there is 
oedema of the vulva. As a rule there is sudden hypogastric pain, a feel- 
ing of bearing-down, and, when the tumor is large and affects the poste- 
rior wall, painful attempts at defecation. Symptoms of acute anaemia, 
fainting, and collapse have been observed a number of times, especially 
when the haematoma formed while external hemorrhage was in progress. 
If in addition to these symptoms there are those of tension and separa- 
tion of the walls of the septum recto-vag., with elevation and anteflexion 
of the uterus and dragging upon the walls of the rectum, the trouble may 
become very great, and the pain far exceed that which attended the pre- 
cedent delivery. The course of vaginal haematoma is usually to a sponta- 
neous rupture, and, with appropriate treatment, generally terminates in 
recovery. But repeated hemorrhages, and suppuration of the contents 
of the sac, with septic infection, may occur. The dangers of vaginal 
haematomata are greater than those of the vulvar form, inasmuch as the 
tumor spreads more rapidly to the parametrium and thus causes pelvic 
thromboses and recto-vaginal fistulae. 
There is no difficulty in the diagnosis of vaginal haematomata. Even 
if the tumor remains hidden in tiie vagina, it is easily accessible to the 
finger and can be well exposed with the Sims speculum. Once exposed 
to view, its smoothness, softness, and hemorrhagic discoloration are char- 
acteristic. As a rule the tumor is broad-based; but Fehling, Reich, and 
Anderson, as well as I, have seen some which were provided with a kind 
of pedicle; the columna rugarum, or a rudimentary septum vaginale, 
being the seat of the tumor. The sudden, origin of the mass, and the 
presence of the above-mentioned characteristics, will complete the diag- 
nosis, if that be necessary. Not infrequently the nature of the tumor is 
rendered plain by certain parts of its walls being thin, or even being rup- 
tured, so that the contained blood can be easily seen. 
In regard to treatment, we will be careful to follow here also the gene- 304 
THE DISEASES OF THE VAGINA. 
ral rules laid down for haematomata of the genitals. Incision should not 
be done unless necessary, and any openings which may exist are to be 
used for the removal of coagula. This can often be accomplished by sim- 
ply compressing the mass between vagina and rectum. But incision may 
become necessary. If the tumor forms an obstacle to delivery, or if the 
tension it causes gives rise to too much pain, it should be done; as also 
when the tumor is no longer increasing in size, and the coagula are under- 
going septic decomposition from infection through the ruptured places 
or in some other way, and the orifices present are not sufficiently large to 
permit free outflow. 
The danger of setting up renewed hemorrhage is greater, of course, the 
earlier an incision is made; and is not entirely absent even in cases several 
days old. If, as will in very exceptional cases be the fact, a spot in the 
ruptured tissue can be seen with the speculum, on compression of which 
the hemorrhage stops, it should be at once ligated. Usually, however, 
we must rely upon compression of the sac after it has been thoroughly 
washed out and disinfected. It is to be remembered, however, that a 
too firm tamponing may stretch the vagina too much; and that, besides 
being unreliable, it will not be borne by the patient. If the opening into 
the sac is large, small pledgets of absorbent cotton attached to strings, 
and steeped in styptic solutions (liquor ferri), or strips of iodoform gauze 
may be introduced directly into the sac; and they can be retained in situ 
by vaginal tampons, while a T-bandage with a hypogastric compress may 
help to fix the uterus. When the hemorrhage has definitely ceased, we 
must turn our attention to the prevention of the stagnation of the accu- 
mulated secretion in the vagina and the blood sac. For this purpose 
antiseptic injections are best, with antiseptic tamponade between times, 
to favor contact and union of the walls of the sac. CHAPTER VIL 
THE INFLAMMATORY AFFECTIONS OF THE VAGINA. 
"TDRELIMINARY Remarks.-The task of giving a satisfactory deserip- 
tion of the inflammatory and infectious disorders of the vagina is 
rendered difficult by the fact that our pathologico-anatomical knowledge 
of these affections is still too incomplete for us to have a certain anatomi- 
cal basis for all the clinical forms. Various circumstances, which have 
been, and still are, active, suffice to explain our slow rate of progress in 
this field. Even the minuter structure of the healthy vagina, and the 
occurrence of glands and lymphatic follicles in it, are subjects which yet 
occupy anatomical investigation. In addition to this, suitable material is 
difficult to obtain, and portions of tissue excised during life, such as C. 
Ruge used so much and so successfully, are at the disposal of but very few 
investigators. Hence but very few anatomists have worked upon this sub- 
ject; and all the more recent and exhaustive work in it has been done by 
C. Ruge and H. Eppinger. 
Since their time, however, our knowledge of several infectious diseases 
has been much extended by Neisser, Fehleisen, and others upon the 
basis of Koch's method; and histological investigation has been enriched 
by many technical discoveries. Hence the task of the anatomical inves- 
tigation of vaginal diseases has been enlarged, and the material at our 
disposal needs revision in more than one respect. For one of the most 
important of the infectious diseases of the female vagina, gonorrhoeal 
catarrh, this has been done by E. Bumm in his studies upon the gonococcus. 
H. Chiari also has investigated the relations of vaginal air-cysts with the 
improved methods, and has reached new results. But a number of very 
important questions still remain unanswered in this field; and we are not 
in the possession of an undisputed anatomical basis for inflammatory and 
infectious vaginal diseases. Therefore in their description and classifica- 
tion w7e will for the present adopt a clinical standard, and consider the 
pathologico-anatomical data separately. 
The inflammatory diseases of the vagina usually affect the mucous 
membrane (vaginitis), the deeper layers of the vaginal walls being but 
infrequently and subordinately involved. In exceptional cases they 
chiefly affect the peri-vaginal connective-tissue layers (peri-vaginitis.) 
Vaginitis most commonly appears as a catarrhal inflammation. It is 
seen in various forms according to its cause, to the extent and duration 306 
THE DISEASES OF THE VAGINA. 
of the process, and to the condition of the vaginal mucous membrane as 
regards evolution or involution (gravidity, puerperium, senility); but it 
may also be exudative, croupous, diphtheritic, etc. 
Since Rokitansky* this has been the usual division of vaginal inflamma- 
tions. It is not quite an accurate one, since transition-forms occur, and 
there is an etiological relationship between the two. But we have retained 
it because it enables us to classify the different forms of inflammation, 
and because there are clinically a number of important differences between 
the groups. 
In general the first includes the milder, and the second the severer in- 
flammations. In catarrhal vaginitis we do not have the coagulable exu- 
dation and the superficial tissue necrosis which is the rule in the exudative 
form. The latter are regularly the more severe, and are usually found 
conjointly with infective diseases springing from other organs. The 
exudative inflammations much more commonly than the catarrhal lead to 
ulceration, and the ulceration may affect an extent of surface and reach a 
depth such as is never seen in the catarrhal forms. 
The catarrhal inflammations include all those forms in which there is 
secreted a pathological, pus-containing mucoid fluid, and in which the 
inflammatory tissue changes (small-celled infiltration and proliferation) 
are confined to the superficial layer of the mucous membrane (the papil- 
lary bodies and their neighborhood, with the glands and follicles). Thus 
not only do the simple and virulent catarrhs in sensu strictori, but also 
the forms described as vaginitis glandularis, follicularis, miliaris, and 
papillaris, belong here. 
Remarks.-In several recent treatises upon vaginal inflammations there 
is no mention made of catarrh, but only of the changes of vaginitis. 
(Ruge, Schroeder.) Much stress is laid upon the similarity in structure 
of the vaginal mucous membrane and the integument; it being claimed 
that from its want of glandular structures, its papillary surface, and its 
layers of epithelium, it resembles the skin much more than the mucous 
membranes. Bumm has lately reached the same conclusion, as have 
Eppinger and Fritsch. I hold that in spite of this analogy, we cannot 
clinically dispense with the idea of catarrh. It marks, as Virchow in an- 
other connection has again reminded us,a as its etymology (zarapew) 
shows, the chief symptom, the flow, and enables us to group together the 
various forms of inflammation known as vaginal leucorrhoea, blenorrhoea, 
and pyorrhoea. 
Pathological Anatomy.-While most authorities agree in their descrip- 
tion of the anatomy of the catarrhal changes in the vagina as regards their 
macroscopic relations, and the clinical pictures correspond, there are but 
1 Lehrb., 3d ed., vol. 3, p. 516. 
9 Berl. Klin. Wochenschr., 1883, No. 8. INFLAMMATORY AFFECTIONS 
307 
few and those varying reports as to the microscopic findings. We will 
refer at length to C. Ruge's important work, which is the first detailed 
anatomical investigation of vaginal inflammation. 
Ruge divides vaginal inflammation into three forms: 
1. Kolpitis granularis, which he takes as the type of vaginal inflamma- 
tion; 2, simple kolpitis; and, 3, the kolpitis of old women. The first two 
vary as they occur as acute or as chronic processes. Ruge thus describes 
the development of the changes of kolpitis granularis 
In consequence of the irritant which causes the inflammation, the 
entire epithelial layer is thickened, the increase being especially marked 
in the deeper layers. The proliferating layer, which in carmine stained 
sections colors more deeply than does the older tissue, may equal half 
Fig. 27.-Kolpitis Granularis. (After Ruge.) 
the entire thickness of the stratum, and more. The papillae are enlarged, 
the broader and higher ones often reaching up almost to the surface. In 
the epithelium there form pretty distinctly limited groups of small-celled 
elements, which wedge themselves in between the straight ascending ves- 
sels. This gives the tissue an adenoid appearance. Over these inflamma- 
tory infiltrations of the sub-papillary tissue, the epithelium is thinned 
out. Two processes can be noted in the papillae: 
1. At one place the papillae are larger and broader, and approach nearer 
the surface, and the epithelial processes which originally separated them 
become thinner. The papillae themselves become thicker, but less promi- 
nent; finally, the papillae coalesce, and the granulum consists only of a 
thin epithelial coating with inflammatory and infiltrated tissue lying 
below it. 
2. As the tissue stretches the papillae become larger and broader; the 
epithelial processes do not disappear; but they become thin and look like 
arcades supporting the epithelial layer. The epithelium over the granu- 308 
THE DISEASES OF THE VAGINA. 
lum is changed also. The larger epithelial cells become smaller, the thin 
epithelial covering over the granula looks like granulation tissue, and can 
hardly be distinguished from the structures lying beneath it. The ves- 
sels of the subjacent tissues are turgid with blood, and are increased in 
number. The appearance of follicle formation is deceptive; kolpitis 
granularis is not k. follicularis, nor k. papillaris. There is simply a sub- 
papillary, or sub-epidermoidal inflammation, accompanied by change in 
the epithelium and the papillae. 
A similar state of things prevails in the chronic form of kolpitis granu- 
laris, in a case which occurred from the long-continued wearing of a 
pessary. There were the same alterations, but the epithelium over the 
granular layer was less changed and thinned, and the tissue below it con- 
tained comparatively few nuclei. The thickened stratum of epithelium 
Fig. 28.-Kolpitis Granularis. (After Ruge.) 
between the projections was pigmented, and of a sepia color in its lower 
strata. 
During the healing process the changes occur in the reverse order. As 
the swelling of the sub-epithelial tissue and the inflammatory infiltration 
disappear, the epithelial processes grow larger and broader, until papillae 
and processes attain their original size. 
In simple kolpitis the surface of the layer of pavement epithelium is 
smooth, but it is irregularly thick in various places. Where it is thinner 
the papillae are enlarged, and the tissue beneath it shows a small-celled 
infiltration. The proliferation is confined to the epithelial layer, and 
thus kolpitis granularis is only distinguished from kolpitis simplex by the 
extent of the process. 
In the chronic form the proliferation is small in amount, and there is 
pigmentation of the lowest layers. Here again there is no question of 
follicular or papillary kolpitis, nor of erosions, ulcerations, etc. 
In the vaginal inflammation of old women there are seen larger or 
smaller confluent spots, which often project above the surface. There 309 
INFLAMMATORY AFFECTIONS. 
occur many transitional forms, from simple ecchymoses to flat elevations, 
which often contain a central softened, eroded, or ulcerated defect. The 
color of the spots is never so vivid as in kolpitis granularis; there are often 
adhesions of the vaginal walls, which, however, are easily broken through 
with the finger. The entire epithelial layer is thinned out. The spots 
correspond to circumscribed and often extensive and deep cellular infiltra- 
Fig. 29.-Kolpitis Simplex. (After Ruge.) 
tions, which appear to lie directly on the surface. There is no trace of 
epithelium. Leaving out the changes incidental to old age, this corre- 
sponds in general to the anatomy of kolpitis granularis, save as to the 
great tendency to adhesion, and even to obliteration of the vagina. 
Eppingerhas also made a series of careful investigations into the patho- 
Fig. 30.-Kolpitis Vetularum. (After Ruge.) 
logical anatomy of vaginal affections, and describes as kolpitis miliaris and 
vesiculosa forms which belong here. 
Both are characterized by the occurrence of multiple, round, sharply 
limited exudation masses, which in certain stages of retrogression become 
ulcers, and appear as grayish spots to the naked eye.1 The difference 
consists in that in kolpitis miliaris the exudate is cellular and partly inter- 
stitial; while in kolpitis vesiculosa it is serous, and collects between the 
1 Zeitschrift f. Heilkunde, vol. 3, p. 177. 310 
THE DISEASES OF THE VAGINA. 
epithelium and the sub-epithelial tissue to form a vesicle.1 In both forms 
Eppinger noticed vertical and strongly injected vessels at the base of the 
inflammation, which were surrounded by a large number of proliferated 
cells. Eppinger did not observe that the papilla? participated much in 
the inflammatory changes; but for the rest his description coincides in all 
essentials with that of Huge. 
We may here mention the connection which Eppinger has proven be- 
tween the sub-epithelial inflammatory infiltration and the pigmented gray 
spots in the vaginal mucous membrane. These latter were first described 
by Haller,2 and have since been repeatedly supposed to be glandular struc- 
tures.3 But they are pathological in their origin, and begin as promi- 
nent, knot-like, superficial, cellular centres of infiltration (milia, granula), 
whose protruded epithelial covering often gives way, and forms the well- 
known central opening which has been so often supposed to be the duct 
of the gland; the surrounding pigmentary layer being supposed to depend 
upon circulatory disturbances. The conception of the Hallerian spots 
as sub-epithelial round-celled infiltrations is one which approaches the idea 
of the granula being a lymphatic follicle-like body, and the process a folli- 
cular vaginitis. This is important for our understanding of other condi- 
tions, such as the formation of gas cysts. 
Etiology of Catarrhal Inflammation. As Klebs correctly claims, we 
must first learn to distinguish the physiological changes which the vaginal 
mucous membrane undergoes in menstruation and gestation, and in the 
puerperal period, from those which are due to catarrh. They are appar- 
ently alike. We must do the same with simple hypersecretion, occur- 
ring either from mechanical disturbances of circulation (stasis) or from 
general disturbances of nutrition, (chronic anaemia, chlorosis, etc.) 
In the first set the clinical symptoms are not always sufficient for differ- 
entiation; and we must then decide from the connection between them 
and certain phases of the physiological function. Simple hypersecretion 
has only a few characters in common with catarrhal inflammation of the 
vaginal canal, such as increase of secretion, swelling of the mucous mem- 
brane, and blood stasis. So long as there is no qualitative changes in the 
secretion, and none of the alterations in the surface of the mucous mem- 
brane, which are characteristic of inflammation, have occurred, we must 
1 We cannot follow Eppinger in his differentiation of his kolpitis miliaris from 
the vesiculosa, and of both from the granulosa and vesicularis of the authors, 
since he bases it only upon some differences of detail in the histological findings. 
There exists a clinical necessity for a single conception of these forms, which 
should be united. We can thus obtain a basis which will enable us to understand 
the connection between the various phenomena which mark inflammation of the 
vaginal mucous membrane. 
2 Elem. phys. corp, hum., Tome vi. lib. 28, p. 26. 
3 Comp. Mandt. Anatomy of the female vagina (Zeitschrift f. rat. Med., vol. 
7, part 1, p. 12). INFLAMMATORY AFFECTIONS. 
311 
divide the two. But both the physiological changes and the hyper-secre- 
tion predispose to catarrh, since they seem to lead to diminish resisting 
power of the mucous membrane to irritants. 
Bumm's observation is of interest in this connection. He found that 
the puerperium caused an extremely abundant proliferation of gonococci, 
even in cases where the phenomena of gonorrhoea had sunk quite into 
the background. Bumm also ascertained the astonishing fact, that gonor- 
rhoea practically never occurs primarily in the vagina, but usually spreads 
thence from the cervix, or more rarely from the urethra. He claims 
that the stratified pavement epithelium forms so good a protecting tissue 
that the gonococci cannot affect an entrance unless changes which render 
the more delicate layers accessible, have first occurred. On the other 
hand the mucous membranes covered with cylindrical epithelium, such 
as that of the cervix, are not so resistant. 
It may be said in general of catarrhal inflammations of the vagina, that 
they are all caused by irritants which either come from without, or from 
neighboring organs. Such are mechanical irritants (injuries, foreign 
bodies), thermic irritants (burns, cold), chemical irritants (cauterization), 
and infectious irritants (gonorrhoeal contagion). 
By one or other of these irritants, in the last case by the passage of the 
pathogenic coccus into the sub-epithelial tissue at points of less resistance, 
reactive circulatory disturbances with increased secretion and abundant 
leucocytic emigration are set up. The effect is in all cases at first one 
and the same. The circulatory disturbances, however, soon subside, 
unless the source of irritation continues active. 
This does seem to occur as a rule because decomposition processes go 
on at the primarily injured spot or in the secretions. We do not know 
the exact nature of the irritants which are thus produced; but we think 
that those of an infectious nature take the greater part in the process, 
penetrating into the tissue of the mucous membrane in various places, 
and keeping up circulatory disturbances by their presence and prolifera- 
tion. This is proven by the fact that when decomposition processes are 
prevented by disinfection and the removal of the stagnating secretion, 
the effects of moderately severe traumata soon pass away, foreign bodies 
become healed in, or, as we see with pessaries, cause no catarrh; and cau- 
terization with ferrum candens, the most violent thermic irritant, only 
causes an eschar and a very temporary swelling of the neighboring tissues, 
just as does a localized chemical cauterization. On the other hand, vagi- 
nitis catarrhalis occurs with certainty in all these cases where the neglect 
of antiseptic precautions leads to the decomposition of injured portions of 
tissue and of the stagnating secretions. 
And the various decomposable foreign bodies which reach the vagina 
from the uterus, as well as stagnating vaginal secretions, blood-clots, 
etc., all lead to vaginitis, since contact with the external air offers specially 312 
THE DISEASES OF THE VAGINA. 
favorable conditions for the reception and proliferation of the micro- 
organisms concerned in decomposition. Hence the frequent connection 
between catarrhs and menstruation and the puerperium. 
As to the point of origin of the inflammatory process, the vaginal 
mucous membrane may be primarily affected, or it may originate from 
neighboring organs or tissues. The function of the vagina, as the organ 
of conception, gives rise to many occasions for the action of inflammatory 
irritants; while its communication with the open vulva, even apart from 
the chances of sexual intercourse, exposes it to the influence of external 
irritants, which it is especially prone to react against when circulatory 
disturbances (stasis, status menstrualis or puerperalis, descensus) are 
present. Gaping of the introitus is of importance. Primary ulceration, 
and disintegrating vaginal new growths, may also form the starting-points 
of catarrh, as may finally the various therapeutic measures which expose 
the vaginal mucous membrane to irritation. 
The influence of neighboring organs is of much importance for the 
etiology of catarrhal vaginitis. From the uterus especially may come the 
cause of the catarrh process. Decomposing or infectious secretions may 
flow out of it (in endometritis, carcinoma, and cervical gonorrhoea), as 
may blood, lochial and menstrual discharges. Schultze has correctly 
claimed that the decomposition of the stagnating scanty menstrual blood, 
mixed with vaginal mucus, which occurs behind the narrow hymenal ring 
in chlorotic girls, is not infrequently the cause of vaginal catarrh. Then 
again polypoid tumors originating from the uterus may lie partially in 
the vagina, and cause retention of secretion; or the uterine tumor may 
disintegrate superficially, and lead thus to decomposition of the secretions. 
Finally, inflammatory processes which were primary in the cervical canal 
or the portio vag. may spread to the vaginal mucosa. 
In contradistinction to the last-mentioned descending catarrhs, there 
are others which ascend from the primarily affected vulva. The vulvo- 
vaginitis of children, with cases of gonorrhoea of vestibule and urethra, 
and those due to labial exanthemata, belong here. 
In the rectum also, and in the bladder, may the conditions causing 
vaginitis originate. The rectal contents may reach the vagina through 
fistulae and perineal ruptures. And without any solution of continuity, 
oxyurides may reach the vagina by traversing perineum and labia, and 
infiltrations of the septum recto -vaginale may set up inflammatory 
changes in the vaginal mucous membrane. The same is true of the blad- 
der, though the passage of undecomposed urine through the vagina is far 
less irritating than the passage of rectal contents. Fistulous communica- 
tions of the vagina with abscesses of the pelvic connective tissue, with 
extra-uterine foetal sacs, with incised or punctured pelvic cysts, lead the 
more regularly to catarrhal vaginitis the more putrid the secretion and 
the less care is bestowed upon its removal and upon vaginal disinfection. INFLAMMATORY AFFECTIONS. 
313 
Clinical Features.-The condition of the mucous membrane which is 
affected with the catarrh has much influence upon this. The changes 
incidental to advanced life, to the hyperplasia of gravidity, to pathological 
processes which have become stationary, may modify the picture greatly. 
Apart from these latter, the usual appearances in the adult non-pregnant 
woman are as follows: 
In acute catarrh congestive swelling prevails. The diffuse redness, re- 
laxation, and tumefaction may affect the entire vagina, or may be limited 
to its upper or lower segments. The rugosities are less prominent, and 
the redness is most intense at their summits. With the naked eye, or 
more plainly with a magnifying glass,1 we can see that the papillae are 
somewhat swollen and injected, causing a fine roughness and a dark punc- 
tation of the vividly red surface of the mucous membrane. Here and 
there minute extravasations are visible, and sometimes eroded strips 
or spots. The mucosa bleeds easily when touched, and is immediately 
recovered with secretion after its removal. The vagina often feels 
warmer than usual, and in acute catarrh the introitus is always sensitive. 
This tenderness is more marked when the catarrh has spread to parts in 
the neighborhood of the introitus; in which cases the swelling of the 
columna rugarum is always more marked, and the hymen participates in 
the swelling and redness. There are then frequently eroded spots on 
that membrane. If the catarrh affects especially the upper portion of the 
vaginal tube, the vaginal covering of the portio will participate in the 
process. Upon its surface the papillae will appear as injected protru- 
berances, and we will frequently see erosions of the os uteri and neigh- 
boring structures. 
While at the very beginning the secretion is scanty and serous, it is 
usually abundant, muco-purulent, and yellow in color by the time we ex- 
amine the patient. Its reaction is generally faintly acid;2 it contains 
desquamated epithelium cells, numerous leucocytes, cell detritus and 
various cocci and bacteria. These latter, which are found in the healthy 
vagina also, become important when pathogenic forms prevail. The 
gonococcus of Neisser has been the most carefully studied of these organ- 
isms, and the proof of its existence in any given case furnishes perhaps our 
best criterion as to the existence of gonorrhoea; since the clinical pictures 
presented by catarrhs of various origin are entirely alike, and the other 
1 I have used for several years a 6 inch g-lass, constructed on the principle of 
the Briicke loup, for the exact examination of the vagina and portio through the 
speculum. 
2 Martineau (Ann. d. Gyn., 1885, Tome xxiv. p. 51), claims that Neisser's gono- 
coccus can only flourish in a sour fluid, and believes that primary gonorrhoeal 
affection of the cervix is extremely rare. In the Hopital Lourcine he saw it only 
10 times in 4,000 cases. 314 
THE DISEASES OF THE VAGINA. 
criteria, such as the involvement of the urethra, are not always present.1 
Naturally we must be cautious and not take cervical for vaginal secretion. 
The cervix should be closed with a small tampon, and the vagina first 
cleansed of the mixed secretion, before collecting the vaginal fluid for ex- 
amination. 
In chronic catarrh there are certain symptoms which show the long 
continuance of the affection, and especially the following: 
1. The swelling and relaxation for a long period of time has caused an 
increase in the mass of the mucous membrane, in consequence of which 
the relaxed wall is folded upon itself, with furrows containing the patho- 
logical secretion between the folds. 
2. The mucosa is no longer evenly injected. Upon the grayish (pig- 
mented) surface there appear circumscribed, red, vascular areas and spots, 
corresponding to the apices of the rugosities; and here and there we will 
see eroded places. 
3. The papillae are no longer so diffusely swollen, though to a greater 
degree than in acute catarrh. But it is especially in chronic gonorrhoeal 
catarrh that the hypertrophy of the papillae becomes very marked, even 
in non-pregnant women. It is seen in three forms. There may be 
papillary hypertrophy over large areas, giving the mucous membrane an 
even sandy appearance of a pale grayish color; or the papillae may grow in 
circumscribed spots to form papillomata and pointed condylomata; or 
finally there may be a moderate and general papillary hypertrophy, giv- 
ing rise to club-shaped protrusions, each one of which corresponds to a 
group of hypertrophic and swollen papillae. These papillary granulae 
cannot be microscopically distinguished from the granulae which we will 
describe further on, in which the papillae are not involved. Only the 
extent and the evidences of other changes enable us to decide as to the 
latter form. 
The secretion in chronic vaginal catarrh may vary very much. Some- 
1 Compare esp. E. Bumm, 1. c. The figure of 8 or dumb-bell figure of the 
gonococcus of Neisser, which Bumm compares to two coffee-beans with their flat 
sides in opposition, is not of itself sufficiently characteristic ; a number of similar 
diplococci are present in the secretion, some of which are not pathogenic at all, 
and others of which are indeed pathogenic, but are both in their relations and 
their actions upon the mucous membrane entirely different from the gonococcus. 
We must be able to demonstrate that they are mainly located upon the pus cells, 
into the protoplasm of which they apparently penetrate; and there must also be 
the heaps of cocci upon which Neisser has laid so much stress. Bumm recom- 
mends the following as a convenient method of examining the secretion for gono- 
cocci; it is the method employed at the Wurtzburg Clinic, and takes but 2 to 3 
minutes. The secretion is spread out thinly upon an object-glass with the blade 
of a knife, dried in the flame, exposed for from a half to one minute to a concen- 
trated watery solution of fuchsin, washed, again dried in the flame, and exam- 
ined at once, without cover-glass, in oil, with a homogeneous immersion lens. INFLAMMATORY AFFECTIONS. 
315 
times it is abundant, cheesy, or purulent; at other times it is grayish white 
and mucoid. Even in the latter case it may contain many gonococci. 
The amount of epithelium present in the fluid is usually very great; there 
are leucocytes in varying quantity; in fact acute and chronic catarrh 
contain the same formed elements, their amount and relative proportion 
varying with the consistency and color of the secretion. In the cheesy 
yellow secretion of chronic catarrh, we not infrequently find the tri- 
chomonas vaginalis which Donne has described, and Kblliker and Scan- 
zoni have investigated; but we do not know that the occurrence of this 
infusorium bears any relation to the composition of the secretion. 
Follicular Vaginitis.-In exceptional cases of chronic catarrh we find 
as the most striking change of the mucous membrane the development of 
those round granula or noduli, whose origin is still a matter of dispute. 
Some authorities consider them to be lymphatic follicles (Birch-Hirschfeld, 
Winckel); others, mucous glands (Thomas, Heitzmann); others again, 
papillary structures (Rokitansky, Bois de Loury, Costilhes, Kiwisch, 
Huge); and still others, circumscribed sub-epithelial inflammatory foci 
(Eppinger, Huge). Clinically we must separate this form from the 
catarrhs accompanied by the usual papillary changes. Deville first 
characterized it as vaginite granuleuse; but it has been known as vagini- 
tis granularis, follicularis, miliaris, psorelytrie, etc. 
For the affection shows a number of peculiar and characteristic symp- 
toms. 
a. It occurs most frequently during gravidity, and often disappears 
spontaneously during the puerperium, even during pregnancy if antisep- 
sis is thoroughly carried out. It has only been observed in non-pregnant 
women in extremely rare cases, so far as I know, and then solely in per- 
sons of middle or advanced life. 
b. Its usual seat is at the fornix vaginae and the adjacent mucous mem- 
brane, especially of the posterior wall; only exceptionally does it affect 
the greater part of the vagina. 
c. The granule or noduli itself may be distinguished by the touch from 
the ordinary papillary hypertrophies. Whilst the lattei' feel hard and 
rough, the former are smooth, round, soft, lentil-shaped prominences. 
Where closely aggregated in the fornix, the mucous membrane may feel 
as if it were filled with closely-packed small varices. Through -the 
speculum they appeal' as round, smooth, isolated or grouped, broad-based 
protuberances, of a bright reddish or paler grayish color, which show 
very distinctly upon the swollen and vascular membrane. Occasionally 
they are surrounded by a vividly injected, red, seam-like border, and 
show here and there a central groove or opening. Whilst the other 
catarrhal changes of the mucous membrane are never absent, the com- 
plication of extensive papillary hypertrophy may often be absent. 
d. We cannot deny that this affection stands in relationship to the de- 316 
THE DISEASES OF THE VAGINA. 
velopment of vaginal gas-cysts. We regularly find in kolpohyperplasia- 
cystica transition forms between granulis with the central depression and 
the gas-containing prominences. The common location at the fornix, and 
the common chronically inflamed base, also point in the same direction. 
e. Finally, as Eppinger has proved, where disintegration of the cir- 
cumscribed cellular infiltrate which forms the granula or milia occurs, a 
central opening appears; and with the retrogressive changes at the in- 
flamed spot there begins the floccular pigmentation of the mucous mem- 
brane so frequently seen in elderly individuals, though sometimes observed 
in young persons. We must therefore regard the rounder, sharply limited 
and grouped spots of pigmentary deposit, even when no infiltration or 
loss of substance is discoverable, as the remains left by this form of 
vaginitis. 
f. Though papillary hypertrophy is chiefly caused by virulent catarrh, 
we cannot prove any causal relationship between the granular form and 
gonorrhoea. 
Heitzmann,1 who gives a good specular picture of a follicular vaginitis, 
recently claims that he has observed it not only in pregnant women, but 
also in young girls suffering from virulent and non-virulent catarrhs. But 
he refers this form to the participation of glands in the inflammation, 
which are not regularly found there; and he gives a drawing of a micro- 
scopical preparation, which does show marked and partly dilated gland- 
like depressions.2 
His idea is that the central cavities of the granulis in vaginitis follicu- 
laris are nothing more than the dilated excretory ducts of the swollen and 
inflamed glands. Only after the glands have been destroyed by suppura- 
tion are their places taken by the lymph-follicle-like arrangements which 
Birch-Hirschfeld mentions. 
Although the concensus of opinion of other investigators is that the 
relation claimed by Heitzmann between true vaginal glands and the 
nodules with disintegrating centres of follicular vaginitis is not proven, 
his drawings show that he has really seen ectatic glandular structures in 
catarrhal vaginitis, and that in cases where glands are present, true re- 
tention follicles may occur. 
We will accordingly entirely discard the term granular vaginitis, since 
both the papillary and the above-mentioned form are included under it; 
and we will call the latter follicular vaginitis, for the analogy between the 
circumscribed small-celled accumulations in the superficial layers of 
the mucosa, and lymphatic follicles, has been dwelt upon by several ob- 
servers, and is supported most recently by H. Chiari's observations.8 
1 Specular pictures of the healthy and diseased vaginal portion and vagina, 
Wien, 1883 (W. Braumiiller), p. 165, Taf. xiii. fig. 2.) 
« L. c., p. 166. 
3 Zeitschrift f. Heilkunde, Prag. 1885, vol. 6. p. 99. INFLAMMATORY AFFECTIONS. 
317 
I intend to consider here two changes of the catarrhally inflamed mucous 
membrane, for I believe them to be only modifications of follicular vagi- 
nitis; I refer to the formation of vesicles containing serum and gas. 
Vesicular Vaginitis.-Eppinger first investigated this form of the mal- 
ady, which he called vaginitis vesiculosa or herpetiformis. It is formed 
by the epithelium of the infiltrated area being raised over a vesicle by the 
serous exudation. If the vesicles rupture, they have superficial, circular, 
sharp-edged erosions behind, which when large much resemble ruptured 
pemphigus blebs. Kleinwachter,' however, is the only one who has ob- 
served these erosions in connection with pemphigus, his patient being 
thirty years old, and having had pemphigus of the lower limbs for three 
years. Apart from the vesiculation, all the other appearances, as well as 
the termination in the Hallerian pigment spots, are in exact accordance 
with the variety called miliaris by Eppinger, here termed follicularis; and 
we can only regard it as a modification of that form. 
Emphysematous Vaginitis.-This second modification appears as mul- 
tiple cysts of the vaginal mucous membrane with gaseous contents. To 
E. Winckel belongs the credit of having first minutely investigated it in 
the cases of some pregnant women. He called it kolpohyperplasia cystica.2 
In his communication he reviewed the observations of Eppinger,3 Schro- 
der,4 myself,5 Nacke,6 Schmolling,7 Cheneviere,8 Zweifel,9 and Ruge. 
Since that time there have appeared researches upon the subject by 
Klauser and Welponer,11 Eppinger,12 Lebedeff,13 Zweifel,14 Hiickel15 
and H. Chiari.16 It is true that occasional and very excellent observations 
upon such cases had been made by Ritgen and C. Braun before Winckel; 
but the latter was the first to thoroughly investigate the subject. 
In the vaginae of pregnant women, exceptionally in those of puerperal 
and non-pregnant women, there are found hemispherical prominences with 
soft smooth surfaces, in some few cases of which an emphysematous 
crackling can be recognized even with the finger. They usually occur in 
1 Prager Med. Wochenschrift, 1878, No. 6. 
2 Archf. f. Gyn., 1871, vol. 2, p. 383. 
3 Prager Med. Vierteljahrsschrift, vol. 120, p. 32. 
4 Deutsches Archiv. f. Klin. Med., vol. 13, p. 538. 
5 Corr.-Bl. f. Schweizer Aerzte, 1875, vol. 5, p. 430. 
6 Archiv. f. Gyn., 1876, vol. 9, p. 461. 
2 Dissert., Berlin, 1875. 
8 Archiv. f. Gyn., 1877, vol. 11, p. 351. 
9 Ibid., 1877, vol. 12, p. 39. 
40 Zeitschrift f. Geb. u. Gyn., 1878, vol. 2, p. 29. 
11 Centralblatt f. Gyn., 1879, No. 14. 
12 Zeitschrift f. Hei Ik., 1880, vol. 1, p. 369. 
13 Archiv. f. Gyn., 1881, vol. 18, p. 132. 
11 Ibid., vol. 18, p. 359. 
15 Virchow's Archiv., 1883, vol. 93, p. 204. 
16 Zeitschrift f. Heilk., 1885, vol. 6, p. 81. 318 
THE DISEASES OF THE VAGINA. 
the upper third of the vagina, and may affect the portio vag. Through 
the speculum they appear as grayish translucent vesicles of from corn 
grain to grape size, occurring in irregular and often crowded groups. 
Many vesicles appear sunken, or have a central depression. They all 
spring from a swollen, bright-red surface; when pricked they collapse 
without any fluid exuding, and we can often hear the noise made by 
the escaping gas. At the utmost they may exceptionally contain a few 
drops of serous fluid. 
There is usually also an abundant dirty-yellow mucoid discharge. A 
very correct picture of the portio vag. and the neighboring tissues in this 
condition accompanies Cheneviere's communication. 
Microscopic examination of the dead and living tissues has as yet given 
us no certain information as to the condition. Winckel, Zenker (in 
Schroder's case) and Hiickel found the inner wall of the cyst distinctly 
lined with epithelium. Lebedeff found it. absent in part. Klebs, Eppin- 
ger, Ruge, and Chiari coujd never demonstrate it. And the latter ob- 
servers unite in asserting that they found a number of communicating 
cavities in each round cyst, which, being entirely devoid of epithelium, 
could only correspond to clefts in the tissues. Klebs believed that they 
were caused by micro-organisms in the lymphatic spaces. Eppinger sums 
up his six cases thus: " Emphysema of the vagina is distinguished by 
the appearance of very numerous grouped air vesicles in the lymphatic 
channels of the interstitial connective tissue, especially along the vessels; 
and its occurrence is greatly favored by oedematous loosening of the in- 
terstitial connective tissue in consequence of venous stasis/' In all his 
cases there were circulatory disturbances; but vaginal catarrh or other in- 
flammation Eppinger does not consider necessary for the occurrence of 
emphysema. Lebedeff also considers passive hypenemia to be the effi- 
cient cause, but claims that the air cysts are due to extravasations in the 
interstitial connective tissue. The latest monograph upon the subject 
is that of Chiari. Celloidin, embedding of alcoholic preparations, and 
staining with alum-cochineal enabled Chiari to reach some new and re- 
markable conclusions. He used two new cases and five of Eppinger's 
which had been preserved in the pathologico-anatomical museum at 
Prague. In both of. his own and in the three best preserved of the other 
specimens he found " that the gas-cysts are always without a proper wall; 
and that their internal surfaces are characteristically lined in part by 
flattened or rounded giant cells. In every case these giant cells were 
also found in the lymphatic capillaries, being evidently derived from 
their epithelium; and in every case lymph-follicle-like heaps of round 
cells and lymph capillaries filled with lymph cells, could be demonstrated 
in the mucosa vaginas." In two cases of Chiari's and two of Eppinger's 
the round erosions present were found to be due to the opening of gas 
cysts. Very commonly, as Eppinger has noted, the cysts follow the INFLAMMATORY AFFECTIONS. 
319 
blood-vessels in their course. Nor was venous stasis absent in Chiari's 
cases; both patients had heart lesions. Chiari concludes that the condi- 
tion is connected with a pathological change of the lymphatic apparatus; 
and that the gas-cysts develop in preformed pathological spaces in the 
lymphatic system, which are filled with a mass of epithelial cells, part of 
which have been changed to giant cells. Chiari found by careful exami- 
nation post .mortem of the vaginal mucous membrane of many subjects, 
Fig. 31.-Smallest Gas Cysts, and Fissures containing Lymphoid Cells. Giant cells and 
proliferated epithelium. (After Chiari.) 
that lymph-follicle-like structures are fairly frequently found both in old 
and young individuals. He could generally recognize them as grayish 
points with the naked eye, and usually found them in the upper part of 
the vagina, especially along the posterior wall. They appeared almost 
always to be combined with a catarrh, and always gave him the impression 
of a new growth. The small punctate central openings, into several of 
which a bristle could be passed, were the orifices of ectatic lymphatic 
spaces. These structures were histologically exactly like the gas-cysts, 
and were traversed and surrounded by capillary passages filled with 
lymphoid cells. In a small percentage of these cases Chiari found giant 
cells in the lymphatic capillaries. 
These investigations of Chiari show the connection between the lymph- 
follicle-like round cell accumulation and the gas-cysts, and the relations 
of both of them to dilated lymphatic vessels. 
Fig. 33.-Giant Cells, flattened in Part. (After Chiari.) 320 
THE DISEASES OF THE VAGINA. 
Hence it is very probable that the not papillary but follicular nodules 
seen in catarrhal vaginal inflammation really are connected with the lym- 
phatic follicles; and that the formation of gas is simply a change which 
occurs under certain circumstances in the lymph follicles and the neigh- 
boring canals. Hence the extent of gas accumulation in the deeper 
layers of the vaginal walls, though the original follicular change affected 
only the mucosa, and chiefly its more superficial layer 
Chiari is inclined to believe that the development of gas and of the 
giant cells may have a common cause in some bacterial activity. It is 
true that we only have a somewhat far-fetched experimental proof of 
this connection. L. A. Niigeli1 found, when experimenting upon the 
formation of extravasations in doves, that out of seventeen cases where 
infection occurred with the wound, eleven had micrococci in the extrava- 
sation and giant cells upon the outer surface of the clot. The giant 
cells were absent in twenty out of twenty-one cases in which the process 
was carried on with perfect antisepsis. 
It is true that cocci have not yet been demonstrated in the gas-cysts, 
and Lebedeff is the only one who has as yet brought the extravasation 
formation into connection with the formation of gas-cysts. Nevertheless 
Niigeli's observation deserves further investigation in its relation to gas- 
cysts, especially as venous stasis has been proven by Lebedeff, Chiari, and 
Eppinger to be the usual predisposing moment for the condition. 
Nor has the question as to the origin of the gas in the cysts found a 
decisive answer. Schroder first demonstrated its nature by puncturing 
the cysts under water; but its composition has not been ascertained. 
Eppinger concludes from a case which Lerch examined, that it is atmos- 
pheric air; and this seems to be confirmed by a case of Klauser and Wel- 
poner. Zweifel believes it to be trimethylamin, and finds confirmatory 
evidence in the fact that Hilger has lately proved that trimethylamin is 
present in the vaginal secretions of healthy pregnant women. At all events 
it is very probable that it is not simply atmospheric air; and Klebs is I 
think right when he says that germs present in the vaginal secretions get 
into the affected cavities, and give rise to the development of gas. 
The constant presence of swelling and hypersecretion, as also the micro- 
scopic appearances which most observers have found, entitle us to place 
the affection among the chronic inflammatory ones of the vagina, and have 
led to the designations kolpohyperplasia cystica (Winckel), kolpitis vesi- 
culosa (Schmolling), or k. emphysematosa (Huge, Zweifel). It certainly 
occurs less frequently in non-pregnant women. I have seen it over twenty 
times developed to a varying degree in gravid women, and only twice in 
others. I can sustain WinckeFs assertion that kolpohyperplasia cystica 
1 On the influence of bacteria upon the development of giant-cells with lateral 
nuclei. (From the Path. Inst, of Langhans in Bern.) Arch. f. Exper. Pathol., 
vol. 19, p. 101. INFLAMMATORY AFFECTIONS. 
321 
causes no serious symptoms, and lias in most cases disappeared by the ninth 
or tenth day of the puerperium. 
It is evident that since most of the cysts are superficially located in the 
sub-epithelial connective tissue, their disappearance is due to the stretch- 
ing and compression of the vaginal wall during labor, and the abundant 
secretion and desquamation during childbed. Air-cysts which are deeper 
seated persist much longer. Schroder saw them well-marked upon the 
tenth day; and in a case described by Cheneviere and which we ob- 
served, the cysts were most developed on the thirtieth day post partiim, 
and some were still present even upon the forty-sixth day. 
Special treatment would hardly be required did not the affection always 
occur in connection with a catarrhal vaginal flow. Disinfecting injec- 
tions are indicated; carbolic acid or corrosive sublimate may be used, or, 
as Zweifel recommends, water acidified with hydrochloric acid. 
Gravidity exercises an influence upon the catarrhally diseased mucous 
membrane on account of the increased vascularization and hyperplastic 
tissue increase which occurs in the vagina of pregnant women; and also 
by the venous stasis which is so early caused by phlebectasus in multiparas. 
Hence the swelling, relaxation, and diffuse injection of the mucous mem- 
brane, as well as the papillary hypertrophy, reach a high grade in the 
vaginal catarrh of gravid women. It occurs in them more often than in 
non-pregnant women without any gonorrhoea being present. As we have 
already said, gravidity offers the most favorable conditions for the de- 
velopment of the nodular hyperplasias. And for the same reasons the 
secretion is more abundant, and the whole course of the disease a more 
obstinate one. 
A certain influence is also exerted by age. The mucous membrane at 
the time of senile involution, possesses anatomical peculiarities so marked 
as to give a different picture when attacked by catarrh than does the 
mucous membrane of the adult vagina. Hence there occur changes rather 
in spots than diffuse; and hence also the tendency of circumscribed 
sub-epithelial extravasations to undergo ulcerative degeneration with 
consecutive adhesion, which Huge has so well described. Sharply cir- 
cumscribed purulent and easily bleeding erosions of the vaginal mucous 
membrane often occur in senile vaginitis; but papillary swellings are 
not so common. On account of the frequency of adhesions, especially in 
the atrophied fornix, Hildebrandt1 has been led to erect this into a separate 
form, which he calls vaginitis chronica adhesiva. They can usually be 
easily broken down with the finger; but where they cannot some caution 
is necessary, since from the friability of the atrophic mucosa false pas- 
sages into the peri-vaginal connective tissue may readily be made by 
attempts at division. 
Much more rarely the infantile vaginal mucous membrane is said to 
1 Monatschrift f. Geb., vol. 32, p. 128. 322 
THE DISEASES OF THE VAGINA. 
be disposed to form adhesions when attacked by vaginitis. Such cases 
have been described by J. Y. Simpson.1 They are said to cause close of 
the introitus by the union of excoriated surfaces without suppuration. 
Simpson remarks that want of cleanliness cannot be the cause of these 
inflammations, since he has seen it in two children in spite of the most 
careful attention. It is difficult to prevent adhesion, which we must 
endeavor to do by means of pledgets soaked in oil or glycerine. Save 
for a little pain in urination, there are no symptoms. Inspection reveals 
the fact that the vaginal entrance is closed by a grayish, non-vascular 
membrane, which does not bleed when torn. Simpson considers the 
affection to be a special form of adhesive inflammation. I cannot decide 
from Simpson's short and indefinite description whether we are not deal- 
ing with retro-hymenal epithelial adhesions, and not with any inflamma- 
tions at all. Or there might have been simple adhesion of the labia. 
For the former speaks the non-vascular membrane at the introitus, for 
the latter the treatment which Simpson recommends. 
Subjective symptoms are never absent in acute catarrhs, and depend 
upon the cause and the seat of the affection. Most commonly there is a 
feeling of heat and burning in the pelvis with difficulty in urination. 
This latter may consist in difficulty in voiding water, but is more com- 
monly seen, especially in catarrhs affecting the introitus, as a feeling of 
burning on micturition, even when no urethritis can be proven. Often 
the patient complains of troublesome itching around the genitals and of 
burning of the portions of skin which are bathed by the secretions. 
More rarely disturbances of the general health appear; there is anorexia, 
lassitude, nausea, or nervous excitation. Acute gonorrhoeal catarrh, 
affecting the introitus, causes the most violent symptoms. We hardly 
evei' see fever. In chronic cases we get very varied symptoms. 
As a rule, complaints of illness, weakness, want of appetite, and ner- 
vousness predominate, which we can easily understand from the long- 
continued loss of fluid. But, as Schroder remarks, there are women 
who have no trouble at all. The local difficulties also are not so marked 
as in acute catarrhs, and are chiefly confined to burning and itching 
sensations about the genitals. 
The prognosis of catarrhal inflammation, if left to itself, is not a good 
one. If treated, it is usually good, though relapses often occur. Acute 
catarrh has a great tendency to become chronic, since the causes which 
originate it, do not tend to subside of themselves. The continuance or 
recrudescence of the catarrh is favored by the unevenness of the surface 
of the mucous membrane, which lead to the retention of secretion in its 
furrows and in the crypts of the introitus; and also by the periodic 
1 Sir J. Y. Simpson, Clinical Lectures, &c., ed. by A. R. Simpson, Edinburgh, 
1872, p. 259. INFLAMMATORY AFFECTIONS. 
323 
fluxions of menstruation, and those of gravidity and the puerperal period. 
In children and virgins the hymenal ring hinders the outflow of secre- 
tions; and in old women there is the tendency to ulceration of the inflam- 
matory focus. And although the catarrh does not cause any danger to 
life, it does depress the general health both by the albuminous waste, the 
changes in the vaginal mucosa itself, and the abnormal nervous excita- 
tion caused by extension of the process to neighboring organs. Besides, 
in its acute stages it prevents coitus, even if in general it does not influ- 
ence the capability of conception. During childbirth it may easily cause 
infection of traumata; and the gonorrhoeal form is always liable to cause 
infection in wounded surfaces or predisposed mucous membranes which 
come in contact with the secretion. 
The treatment of catarrhal inflammation of the vagina demands above 
all things the removal of its cause. Then we must reestablish favorable 
conditions for the relief of the circulatory disturbances, thus limiting the 
secretion and promoting retrogression of the inflammatory changes. The 
local is therefore the most important part of the treatment, which may 
be helped by a suitable general treatment. The latter consists essentially 
of a suitable regimen dieteticum, rest, care of the bowels, etc. 
Especially to be avoided are alcoholic and aromatic drinks. Sedatives 
are only indicated occasionally in very sensitive patients. Lukewarm, 
indifferent or slightly stimulating sitz and general baths do good by les- 
sening the sensibility of the parts, preventing irritation of the skin of the 
external genitals, adhesion of the labia by dried-up secretion and other 
consequences of uncleanliness. Chronic cases do not require such strict 
general treatment, though a careful regimen is undoubtedly useful, and 
the use of alkaline and stimulating baths are of service in complicated 
cases. Even in the chronic form it is important to prevent exascerba- 
tions by a careful regulation of exercise, food, cleanliness (especially at 
the menstrual epoch), and the avoidance of coitus. The physiological 
complication of pregnancy requires the same care as does menstruation; 
while during the puerperal period the necessary regimen is in any case 
carried out. 
If pathological complications influence the catarrh, they must be com- 
batted at the same time. It may be necessary to treat uterine affec- 
tions; and the case of any chlorotic or chronic anaemic condition which 
may be present is an essential condition for the success of the local 
treatment. 
Sometimes the simplest methods suffice to control the catarrhal condi- 
tion, in cases where we know the cause, as for instance, the removal of 
foreign bodies (frequently pessaries), or of stagnant secretion. Ordinarily, 
however, the treatment must be directed towards overcoming infection, 
that is nullifying the life and development of the bacteria which are in 
the secretion, and we must here disinfect without at the same time irri- 324 
THE DISEASES OF THE VAGINA 
tating. After neutralizing the infectious action on the mucous mem- 
brane, the after-treatment does not amount to much, since the inflam- 
matory swelling, the circulatory disturbances and the abnormal secretion 
will disappear largely of themselves. Nevertheless we should not too 
strictly abstain from local treatment, particularly in chronic cases where 
there exist papillary excrescences, erosions, etc. 
In order to disinfect properly it is necessary that: 
1. The secretion be rendered harmless, and its stagnation prevented. 
2. The entire superficies of the mucous membrane must be brought 
into contact with the disinfectant, and contact of diseased parts with one 
another must be prevented. 
3. The disinfectant should be of the proper strength. 
In order to wash away the secretion, it is preferable to use an irrigator 
holding at least two quarts, and which should be refilled two to three 
times in succession. The patient should be informed carefully how to 
use it. In order to avoid unpleasant sequelae, which ordinarily follow on 
the injected fluid entering the uterus, attention must be paid to a num- 
ber of rules, even as in case of uterine irrigations. The irrigator should 
not be hung too high (about three feet above the genitals will suffice); 
the patient should occupy such a position that the pressure in the pelvis 
does not become negative, that is to say, she should ordinarily assume 
the sitting or the half-sitting posture. The injection tube should not be 
inserted too deeply towards the cervix, and in order to bring the fluid in 
contact with every part of the canal, it should be moved from side to side, 
and forwards and backwards. The free outflow of the fluid should be 
assured, and where the introitus is narrow, this is done by lateral pres- 
sure with the injection tube. A simple tube with central opening, of 
glass or hard rubber, so that it may be readily cleansed, can be used. 
The water should be lukewarm (24° to 26°) in order to avoid the irri- 
tating effect of heat, and the irrigation must, according to circumstances, 
be repeated twice to four times daily. 
If it could be expected that simple cleansing by these irrigators would 
suffice, as they occasionally do in uncomplicated cases, then we might use 
water or some indifferent fluids, such as were formally used for the pre- 
vention of the irritant action of an acute catarrh. But recent investiga- 
tions have clearly taught us that the irritant effects remain even after the 
use of disinfectants, although they control directly the most infectious 
causes of the inflammation. Injections of flax-seed infusions, of althaea, 
etc., are, therefore, no longer resorted to. 
The mechanical effect of the irrigation will, however, be only partially 
obtained when it is administered in the way we have outlined, since thus 
the entire mucous membrane is not cleansed. If the injection is admin- 
istered by the physician, there is greater chance of the aim being fulfilled, 
for the vaginal walls may be held apart by depressors or specula. This INFLAAEMATOKY AFFECTIONS. 
325 
separation of the vaginal walls fulfills also the second condition, which 
is, that the mucous membrane, in its entirety, must be exposed to the 
action of the disinfectant. It is, therefore, essential after disinfection to 
insert an antiseptic, slightly absorbent tampon in the vagina, in order to 
keep the walls separated, and to smooth out the rugse. We use for this 
purpose soft dry tampons which may be impregnated with one or an- 
other disinfectant. In case the vagina is not to be thoroughly tamponed, 
in which event the physician must himself attend to it, the patient should 
be taught to insert a tampon herself after each injection, and she can do 
this most readily by means of a simple tampon carrier, which I use very 
frequently, for I find that while oiled tampons may be inserted by the 
finger alone, dry tampons by soaking up the secretion in the introitus 
are apt to become painful as they are inserted. 
An essential point for the carrying out of these manipulations, and also 
for the success of the local treatment, is that the introitus vaginas be not 
too narrow. In children and in virgins treatment is rendered very diffi- 
cult by this narrowness, since it leads to retention of secretion. In obsti- 
nate cases we must resort to dilatation or to discission of the hymen, even 
as in case of stenosis vaginae it is necessary to overcome the condition 
before treating the catarrh. 
When disinfecting agents are used they should be as dilute as possible, 
and yet be effective. The experiments in regard to the minimum amount 
of various agents which are of use in diminishing the signs of life in 
certain bacteria, give us approximate data as to what we should use in 
cases of known infection, such as sepsis, gonorrhoea. These results, how- 
ever, are not purely applicable to practice in that the microbes are differ- 
ently situated on the mucous membrane than in culture solutions, and 
so the work of the antiseptic must finally depend on the therapeutic 
results which it yields. The possibility that disinfection, aside from 
direct action on the infection-carriers, may act indirectly on them by 
changes in the tissue in which they lodge, is not, as Oppenheimer rightly 
remarks, excluded. 
The following table recapitulates the results obtained by Oppenheimer 
in his experiments in regard to the action of agents on gonococci. The 
best agents proved to be sublimate and creosote. The former was effect- 
ive in solutions of l>:20,000, and the latter in the strength of one drop in 
20 cm. of water. The cocci were killed: 
By alum acet, in minimum solutions of . . 5:100 
" zinc sulph. " " . . 5:100 
" copper " " ' 5:100 
" zinc chlorat. " " . . 4:100 
" sesquichlor ferri il " . . 1:10 
" argent nitr. 11 " . 2:100 326 
THE DISEASES OF THE VAGINA. 
By hydrarg bi-chlor in minimum solutions of . 1:20,000 
44 hydrarg nitrat. " li . . 1:10,000 
44 hydrarg sulph. 44 " 1:10,000 
44 potass permangan. 44 4 4 . .5:100 
4 aq. chlorat. 44 44 . .1:2 
" aq. bromata 
" aq. iodat. 
" alcohol absolut. 
" aether sulph. 
" glycerin 
" chloroform 
not diluted. 
" " 1:0 
" " 1:0 
" " 1:0 
" " 1:0 
" " 1:0 
" " . . 1:0 
li acid carbol. 44 " . . 4 TOO 
44 acid salicyl. 44 44 5:100 
44 thymol " 44 5:100 
44 carbolized oil 11 11 . .10:100 
44 carbolized glycerin 44 44 5:100 
Copaiva balsam and cubebs, although detected in the urine, acet, of 
lead, bismuth subnitrate, chloride of potass, chloride of calcium, resorcin, 
tannin, etc.,were worthless. 
In regard to the strength of the disinfecting solution it is to be remem- 
bered that the first copious irrigation must be relatively concentrated, 
and it will depend on the stage and quality of the infectious inflammation 
as to whether it must be repeated in similar strength. Experience proves 
that in many instances, where we are not dealing with gonorrhoea, pro- 
tracted irrigation with weak solutions accomplishes the aim by preventing 
the extension of the bacteria. In case of gonorrhoea, however, strong 
solutions must be used on account of the chronicity of the affection. 
At the first irrigation we use sublimate solution of 1:1000 to 2000, or 
carbolic 5:100, and repeat in the strength of 1:5000 sublimate, | to 100 
carbolic, in other instances using even weaker solutions. Only later do 
we use permanganate of potass, or astringents (copper, zinc, etc.). 
Disinfectants may also be brushed over the vagina or poured through a 
speculum. A tubular speculum is inserted into the vagina, the vaginal 
walls being thus held apart, and they are bathed in the fluid. Here 
strong slightly caustic solutions are useful, such as nitrate of silver (2 per 
cent.), wood-vinegar (Schroeder), tincture of iodine, etc. The canal 
should be irrigated and wiped out before pouring in these agents. In 
case superficial sloughs are thus caused, iodoform should be insufflated 
after the excess of solution has run out. 
We now pass to the use of agents in powder form and to the dry intra- 
vaginal packing. We have already spoken of the advisability of inserting 
a disinfecting tampon into the vagina in the intervals of the irrigations, in 
order to keep its wall apart and to disinfect any stagnant secretion. Sanger INFLAMMATORY AFFECTIONS. 
327 
has especially advocated the dry disinfecting tamponade of the vagina in 
the surgical treatment of the genital canal, and he prefers iodoform gauze. 
He advocates this method even in case of inflammatory affections of the 
vagina, since it has the advantage of preventing decomposition of the 
secretions, and of sparing the patient the painful manipulation with the 
irrigator. I do not know whether Sanger or anyone else has ever method- 
ically followed this plan in the treatment of catarrh of the vagina; I have 
never tried it, although I have satisfied myself of the value of iodoform 
packing in other cases. My experience with the dry and aseptic treat- 
ment of catarrhal disease of the vagina has as yet been entirely limited to 
tampons of absorbent cotton, formerly salicylated, but latterly largely 
sublimated, and occasionally iodoform cotton. Although by changing 
these tampons twice daily, good results were obtained, the iodoform 
alone could remain in the vagina one to three days without causing odor. 
Only very exceptionally, however, have I left them in so long, since at 
the end of one day the cotton becomes coated with mucus and it loses, 
in a measure, its absorbability. Since gauze is more absorbable than 
cotton I believe that Sanger's suggestion is worthy of trial, and on account 
of its antiseptic principle (something else than iodoform might be used) 
it differs from the old methods of application of astringents which were 
recommended by Scanzoni, Gautier, and latterly, again, by Gougenheim. 
Aside from iodoform, other antiseptics have been tested but little in the 
dry protracted tamponing of the vagina, and I can only cite II. Schmid's 
practice of filling the vagina with salicylic powder and letting it remain 
there one to four weeks. Schmid has not tested this method in case of 
vaginitis since it irritated the vagina. Dry salicyl powder has, however, 
been inserted into the vagina, during the puerperium, in particular, by 
Crede, Fehling, Gusserow, Fritsch, and others. 
In case of catarrhal vaginitis the use of tampons covered with one or 
another ointment is favored by many. Hildebrandt advocates, in case 
of chronic catarrh, tampons covered with an ointment composed of five 
parts of alum and thirty parts of lard, and also the glycerin tampon; 
Terillon and Auvard inject directly a salve composed of vaseline, 150 
parts, starch, 150 parts, tannin, 30 parts. Suppositories are also recom- 
mended, generally made from butyr-cacao mixed with equal parts of ung. 
emolliens to render them less brittle. Iodoform is used in capsules with 
a few drops of glycerin. Where salves and suppositories are not held 
in situ by tampons, they readily fall out and necessitate rest on the part 
of the patient. They are especially valuable where the tampon and irri- 
gation cannot be used, as where the introitus is very narrow and sensitive 
(in children and in virgins.) 
While we have spoken of the disinfecting methods which are of the 
greatest value in the treatment of vaginal catarrh, we have often noticed 
the therapeutic effect on the tissues, whereby, in a measure, disinfection 328 
THE DISEASES OF THE VAGINA. 
is accomplished through changes in the abode of the carriers of infection. 
Aside from this latter action, it may be necessary to expedite the cure by 
applications which lead to regeneration of the epithelium, which increase 
the muscular tone, and which control the circulatory and secretory dis- 
turbances. Local changes in the mucous membrane affected by chronic 
catarrh require such treatment. Thus papillary excrescences can not 
always be caused to disappear without excision and cauterization, although 
they often yield to the dry treatment, thus also do erosions of great ex- 
tent heal more quickly by applications of wood vinegar, which, as Hoff- 
meier has pointed out in case of erosions of the cervix, favors the regener- 
ation of the epithelium; further still, astringents of various sorts, when 
not used too long, unquestionably exert a good effect on the relaxation 
and hypersecretion of the mucous membrane. 
Thus then, if we do not at the outset grant that these agents combined 
with the former have an anti-bacterial action, do we pass from the disin- 
fectants to the astringents. 
Vaginitis Exfoliativa.-In connection with the catarrhal inflammations 
we will speak of the rare affection, vaginitis exfoliativa, where, periodi- 
cally, accompanied by dysmenorrhaea, epithelial membranes are cast from 
the vagina. Since Arthur Farre recorded the first instance of this affec- 
tion, many writers have noted the simultaneous expulsion of dysmenor- 
rhaeal membranes from the uterus. In the last recorded case, the 
membrane was also expelled at longer or shorter intervals in the inter- 
menstrual periods, although most frequently coincidently with menstru- 
ation. (Tyler Smith.) The vaginal mucous membrane generally shows 
catarrhal changes, such as congestion, loosening, and hypersecretion, 
which, true enough, cannot always be differentiated from similar 
menstrual phenomena. Cohnstein witnessed an instance, and, from a 
study of the literature, came to the conclusion that exfoliative vaginitis 
was etiologically connected with uterine membranous dysmenorrhaea, and 
found that both processes were generally excited by general, rather than 
by local, disturbances, that is to say, by hysteria. Since local treatment 
is unavailing, Cohnstein recommended agents directed towards hysteria, 
in particular, the bromide of potass. In regard to diagnosis, we must 
differentiate from epithelial membranes the result of sloughing not infre- 
quently following the use of alum. Other superficial sloughs, like those 
caused by nitrate of silver, sesquichloride of iron, etc., may be more 
readily distinguished. 
I have never had an opportunity to see a case of exfoliative vaginitis, 
but I can prove the causal connection between hysteria and severe 
vascular disturbances in the mucous membrane, which Cohnstein claims 
is the factor in vaginitis exfoliativa, by the relation of the following case: 
Since 1878, that is to say, for seven years, I have known a woman, of 
middle age, who from childhood up has been subject to varied hysterical INFLAMMATORY AFFECTIONS. 
329 
manifestations. Since her last delivery, the fourth, she has suffered from 
leucorrhcea and profuse menstruation. The hysterical symptoms were 
more marked, and she complained in addition of nervous dyspepsia, 
cardialgia, and supra-orbital neuralgia. She was inclirted to corpulency, 
was anaemic, and had a tendency to diarrhoea. The thoracic and abdomi- 
nal organs were sound, the kidneys, as well. The uterus was slightly 
enlarged, relaxed, retroposed and anteflexed, movable; the anterior lip 
of the cervix was hypertrophic. On the vaginal surface reaching to the 
external os, was an atonic, sharply-demarcated, grayish-white erosion, 
and the cervix secreted a profuse white mucus. The vagina and the pos- 
terior lip of the cervix, beyond slight injection, were normal. The uterine 
adnexa w'ere not enlarged. The erosion did not yield to the ordinary 
method of treatment. In 1879 I excised the eroded lip and closed the 
wound with silver sutures. Union by first intention occurred, and for 
awhile the general symptoms were bettered. But soon the erosion recurred 
on the posterior lip, and although it was immediately excised, the former 
result was not obtained. Dr. Wilhelm Fischel examined the excised 
portion and pronounced it to be an ordinary ulcer. The erosion thence 
quickly spread over the posterior vaginal wall, and in addition there were 
present isolated, sharply circumscribed white spots on the mucous mem- 
brane, very vascular. These spots were dry and smooth; they felt soft, 
and their neighborhood was no more swollen or injected than the rest of 
the vaginal mucous membrane. There existed profuse secretion and 
great hyperaesthesia on examination. Menstruation was more profuse and 
irregular, and the anaemia was, in consequence, intensified. The appe- 
tite failed, the diarrhoea increased, the spasms recurred more frequently. 
The woman suffered from attacks of oppression and from fainting fits, 
from great muscular weakness; later the inguinal glands enlarged and 
became painful, and a crop of furuncles broke out. Frequently ephemeral 
fever was noted, which was not always associated with the appearance of 
the furuncles. 
The vaginal erosion, which was the only constant pathological local 
finding, resisted all treatment, antiseptics, astringents, aromatics, caustics, 
alterants, heat and cold, dry, wet, and ointment tampons, permanent ir- 
rigation, without more than transient effect. At the same time, the in- 
terior of the uterus was treated. The white erosion simply extended. 
The general hysterical treatment, which Cohnstein advocated in case of 
exfoliative vaginitis, was not neglected, with the precaution, during its 
administration, to intermit the local treatment. All sorts of cures, baths, 
electricity, etc., were without effect. Frequently carcinoma and rodent 
ulcer were suggested by my consultants, but I could never detect any- 
thing but superficial changes, there being no infiltration or deep exten- 
sion of the process. I am able to explain the case purely on the associa- 330 
THE DISEASES OF THE VAGINA. 
tion of changes in the circulation and local nourishment accompanying 
hysteria. 
Owing to the great tendency and the ability of the hysterical to simu- 
late everything, it is very difficult to explain marked symptoms from the 
side of the circulatory and secretory organs, such as haemoptysis, rapid 
discharge of unchanged fluids, as milk, per rectum, and the like, on the 
score of perverted innervation, although there is no ground for doubting 
the action of abnormal innervation on the secretions, and on the contrac- 
tion of the blood-vessels. The protracted constipation which is witnessed 
in the hysterical without appreciable disease of organs, the marked de- 
crease in the amount of urine secreted and in its concentration, these 
must be accounted as sequelae of the hysterical neurosis. In our case the 
conditions find their explanation in chronic hysteria of high grade which 
had existed for a number of years. 
A peculiar membranous exfoliation of the superficial layer of the mu- 
cous membrane has been described by Winckel under the name colpitis 
gummosa. In a twenty-eight year old nullipara, who since her six- 
teenthyear had had molimena every four weeks, and since her seventeenth 
had suffered from leucorrhoea, who at twenty-two began to menstruate 
every six months, and had never had any ulceration on her genitals, 
Winckel found the following: The vulva was reddened to the mons veneris, 
the labia not swollen and dry, the rima closed. On separating the nym- 
phae, a gray, partially adherent, partially desquamating membranous layer 
was seen, which began above the urethra, and spread over the anterior 
vaginal wall, along the inner surface of the nymphae, down to the pos- 
terior commissure and thence over the entire vagina. Externally it 
terminated sharply at the frenulum, and above at the vaginal vault; on 
one occasion alone, a portion the size of a pea was found adherent to the 
posterior lip of the cervix. The external os was entirely smooth; there 
was no cervical discharge. The membranous layer, a number of lines 
thick, could be removed with the forceps, and the mucous membrane 
beneath it was pale red. The insertion of the finger and the speculum 
was difficult and painful, although there was no hemorrhage. The con- 
dition had lasted for about three months. A year previously she had 
been treated for the leucorrhoea and for pain in the back and abdomen. 
The patient had no fever. 
The reaction of the secretion was highly acid. On microscopic exami- 
nation the layer was found to consist in numerous fat corpuscles, like 
cells, partially containing crystals in the shape of needles; these bodies 
dissolved in ether. There existed also a thick layer of partially cornified 
epithelium. 
Birch-Hirschfeld examined a portion excised from the neighborhood 
of the introitus and reported that the epithelium was markedly thickened, 
the upper layers |)eing partially converted into membranous lamellae; the INFLAMMATORY AFFECTIONS. 
331 
rete malpighi contained large cells, and was much thickened; the papillae 
were hypertrophied, the sub-mucosa greatly thickened and filled with many 
thick-walled vessels; the tissue was infiltrated with round and spindle- 
form cells, so that the appearance was similar to that obtained from fresh 
sections of a gumma. 
Winckel watched the patient for four and a half weeks. Withiii two 
to three days, on the parts whence large pieces of membrane had been 
removed, nodules the size of a pin's head formed anew, grayish in color, 
which quickly coalesced into membrane. For two days she lost a slight 
amount of blood (menses), and on the third day Winckel found the en- 
tire vagina filled with a boggy, black mass which was shed, and then the 
previous membranous formation recurred. 
It is interesting to note that the case was complicated with a chronic 
affection of the left eye, which had existed since her nineteenth year, and 
had been repeatedly treated. At the time Winckel examined her, the 
conjunctiva was covered by a layer very similar to that in the vagina, the 
cornea being partially cloudy and the pupils prominent. In addition 
the patient had had an eruption on the face and arms, which had yielded 
to inunction with some ointment. She did not cohabit till afterwards. 
Examination revealed no sign of syphilis, and the affection was neither 
cured nor bettered by protracted use of anti-syphilitic remedies. 
Far more infrequent than the catarrhal are the exudative inflamma- 
tions of the vagina. 
Vaginitis Diphtheritica.-Croupous and diphtheritic changes in the 
vaginal mucous membrane have been frequently noticed since Rokitansky 
called attention to them, although the identity of the process with chat 
in the pharynx and the larynx, has only been settled in the minority of 
cases. 
Klebs, who admits the occurrence of true croup in intense inflammations 
of the vaginal mucous membrane, describes further, as diphtheritic, the 
changes which are seen in lacerations at the introitus in puerperae; the 
dirty yellow, adherent layer, which frequently remains unchanged for 
some time, and again is said to give way to purulent and granulation 
changes, or else becomes the seat of suppuration. In secondary diphthe- 
ria, which developes in the course of acute infectious diseases, cholera, 
variola, scarlatina, measles, the vaginal mucous membrane, according to 
Klebs, is reddened,' ecchymosed, and on its surface there are generally, 
in groups, small elevations, grayish-yellow in color; the superficial layer 
necroses, and is shed in patches, or later in large pieces, and is then usu- 
ally described as croup. Schroeder calls attention to the fact, that in 
addition to the extensive croupous and diphtheritic processes seen in 
puerperal women, and also after gonorrhoea and in the course of acute 
infectious diseases, we often find whitish, more or less adherent layers 
as the result of some local traumatism (irritation by purulent secretion, 332 
THE DISEASES OF THE VAGINA. 
fistula?, etc.) In case of the general diphtheria accompanying acute in- 
fectious diseases, the swelling in the vagina attains the highest grade, so 
that, as in a case seen by Schroeder, the recto-vaginal septum may form a 
thick tumor, and the vaginal folds and the cervix may be so swollen that 
the finger cannot reach beyond the cervix. On the mucous membrane 
are found white and green diphtheritic membranes, and there exists a 
foul, purulent discharge. Occasionally the cervix is implicated, extension 
taking place to the cervical mucous membrane which is greatly swollen. 
Vaginitis Dysenterica.-Klebs describes similar dysenteric changes 
as occur in chronic dysentery. Eppinger, later, examined twelve cases, 
and described the affection as a dysentery of the vagina (kolpitis dysen- 
terica). In all the cases there existed dysentery of the large intestine, 
and the process was supposed to extend into the vagina owing to patency 
of its orifice, or narrowness of the perineum. 
The microscopic changes were most marked at the introitus, that is to 
say, at the end of the ant. and post, columna. Flat, or irregularly formed 
ulcers, or spots of superficial necrosis with greatly injected base are found 
in various places. Loose, flocculent masses of exudation are on the ulcers. 
Spread out over the folds small yellowish spots are found which are par- 
tially adherent, and, again, may readily be removed. Eppinger considers 
these spots as the beginning of the disease, the catarrhal stage, and in 
the further development they change into necrotic patches, grayish-yellow 
in color, of varying depth, with sharp hemorrhagic demarcation. Through 
partial shedding of the slough there results loss of substance, extensive 
ulcers, between which are islets of mucous membrane. Microscopically, 
the patches are seen to consist of broken-down portions of the epithelial 
layer. Between the patches are colonies of micrococci in connection 
with similar ones in the sub-epithelial layer. It regularly happens that 
large portions of the epithelium in their entire thickness are lifted up by 
these masses of cocci, and there remain ulcerated patches entirely de- 
prived of epithelium, from the base of which the denuded papillae pro- 
ject, which are also covered with micrococci. In certain parts Eppinger 
was also able to detect the extension of the micrococci deeply down along 
the papillae. These micrococci were not carefully examined by culture 
experiments; but Eppinger states that they were never grouped together 
in cylinders, but were irregularly distributed, and that they were larger 
and paler than septic cocci, single individuals possessing the power of 
motion. 
Whilst the patches and the superficial erosions depended on mycotic 
epithelial necrosis, the process appeared to extend more deeply where the 
circumscribed yellowish dry scabs existed. The structure was not recog- 
nizable, only the thrombosed vessels were prominent. At the line of 
demarcation the vessels were widened, and the tissue infiltrated with small 
cells. The micrococci were only exceptionally found. In the stage of INFLAMMATORY AFFECTIONS. 
333 
ulceration, in one marked case, the borders were formed of overhanging 
epithelium the lower surface of which was covered with a thin layer of 
pus in which projected stumps of vessels, filled with coloring matter. 
Underneath the pus layer there was granulation tissue, and in places the 
suppuration extended into the depths. 
As regards the method of infection, Eppinger concluded that the 
micrococci caused a loosening and a separation of the epithelial layer, 
even as Bumm has latterly shown occurs in case of gonococci, and that 
contact with the dysenteric dejecta caused extension to the vaginal mucosa. 
In favor of this view, the frequently observed patent vulva and site of 
election at the introitus speak. 
Vaginitis Erysipelatosa.-Eppinger has also described an erysipelatous 
inflammation of the vagina: On the body of a woman of thirty-five, who 
had died of erysipelas on the twelfth day of the disease (which began in 
the face, disappeared from there, and on the tenth day, was seated on the 
left thigh and hip), Eppinger found reddening and swelling of the nym- 
phae, especially on the left side, where also on the inner surface of the 
labium ma jus, the epidermis formed bullae the size of a bean. The mu- 
cous membrane of'the vagina, as far as the fornix, was swollen and red- 
dened, and in places, wrinkled. On the posterior wall, three-quarters 
of an inch above the commissure and as far as the middle of the vagina, 
there was loss of substance for a space the breadth of the little finger, 
which was covered with swollen epithelium, in places elevated in blebs, 
and the base of which was formed by a greatly reddened, thin, whitish 
exudation. Similar small patches were found laterally and on the anterior 
wall. Where the epithelium was intact it could be readily separated. 
The sub-epithelial and.sub-mucous tissue was softened, moist, reddened. 
The fluid from one of the small blebs by the side of the ulcer contained 
the pale, movable, monadinencocci (Klebs). Similar cocci were found 
in the epithelium from the foot; in the deeper tissue-layers and in the 
blood they were not detected. Where the epithelium was intact, it was 
swollen, and the cells contained vacuoles. The papillae were broadened, 
and the vessels were injected. The cellular infiltration extended in por- 
tions down to the muscular layer. The epithelial and sub-epithelial 
layers intercommunicated. The deep vessels of the vagina were much 
widened; the muscular layer was unchanged, and the mucous membrane 
of the cervix and the uterus, as well. 
Eppinger's case, which was seen before the appearance of Fehleisen's 
work, is, as far as I know, the only one in which erysipelas extended to 
the vaginal mucous membrane. 
Vaginitis Septica.-Of the septic changes in the vagina, the slough and 
ulceration on infected wounds in puerperae, which Klebs has called 
wound diphtheria, are best known. Less attention, anatomically, as well 
as clinically, has been paid to the septic changes in the intact mucous 334 
THE DISEASES OF THE VAGINA. 
membrane, although they are of not infrequent occurrence on the nym- 
ph®, in the vagina and on the cervix, as the result of the action of septic 
secretion. W. Fischel has often spoken of epithelial necrosis in septic 
puerper®, without going into a detailed description, Eppinger states in 
regard to the differential diagnosis between dysenteric and septic necrosis, 
that the former invades by preference the lower extremity of the column®. 
These changes are most frequently found in puerper®. On intact por- 
tions of the mucous membrane, as, for instance, on the borders of the 
nymph®, on the cervix, on top of the vaginal rug®, and in particular on 
the edge of the column®,'are found dry, yellow spots, isolated, on the 
level of the mucous membrane, which can only be removed with the 
epithelial layer. In extreme cases they may extend over the entire vagina, 
and resemble a diphtheritic exudation. Although these spots are not 
particularly injected, the mucous membrane under them is swollen and 
inflamed, especially on the apices of the rug® and column®, and it is 
reddened. Without doubt, the inflammatory processes, as well as the 
epithelial necrosis are due, in general, to secretion from the uterus con- 
taining septi cocci, and in proof of this we have seen a marked instance 
where there could be no question of extension from an ulcer. In a case 
of atresia hymenalis, to which we have referred, where, after a small per- 
foration; there occurred purulent degeneration of the retained blood, 
there formed a septic colpitis which spread over the entire vagina with 
yellow adherent deposit on top of the thickened rug®. During the course 
of antiseptic treatment these deposits remained unchanged for days, and 
the epithelium reformed without there being at any time an erosion; in 
other cases, on the contrary, where antisepsis was not attended to, there 
remained after .separation of the deposit, flat, yellowish ulcers, which 
spread irregularly in depth and in width. Such ulcers have been noted 
by Eppinger at the extremities of the column®. 
Symptoms and Course.-All exudative inflammations of the vagina, 
whether they are diphtheritic, due to sepsis, or else complications of in- 
fectious diseases localized elsewhere, such as cholera, typhus, the acute 
exanthemata, erysipelas, dysentery, are associated with high fever. The 
local symptoms are generally slight. When the patients have not a pro- 
fuse purulent discharge with necrosed masses, they complain of ischuria 
and of burning in the region of the pubes. In case of diphtheria of the 
vagina, Schroeder mentions pain in the pelvis, bearing down pains, vagi- 
nismus and painful defecation, as the symptoms, and he has exceptionally 
noted more marked symptoms in case of more intense and extensive in- 
flammatory swelling. 
The less marked the local symptoms the less likely is the physician to 
make a vaginal examination whereby the diagnosis can alone be reached. 
This is probably the reason why the number of clinical observations of 
these affections, where the anatomical changes are described, are few. INFLAMMATORY AFFECTIONS. 
335 
ODD 
Even in case of puerperal sepsis the vagina in general practice is rarely 
examined with the speculum, although it is essential to seek for the 
source of the infection in the genital tract. The more likely hence that 
an exudative inflammation of the vagina, dependent on some other infec- 
tious process, should be frequently overlooked. 
The course and the prognosis of these complications may be modified, 
however, in cases of medium severity by appropriate treatment, and 
overlooking the inflammatory process may inflict much damage on the 
patient. When the process is left to itself, it changes into more or less 
extensive ulceration, which may lead to atresia and union of the vaginal 
walls. Under bad local conditions the tissue may necrose, and abscesses 
in the pelvic celltdar tissue may form, which may seriously imperil life. 
The treatment of all these forms consists especially in the use of disin- 
fectants. The more deeply the infectious agent has penetrated into the 
tissues, the more essential it is that the disinfection should not alone 
consist in occasional injections, but that agents should be used which will 
thoroughly change the ulcerated surfaces, and prevent the growth and 
the extension of the infectious agent. Strong caustics are not appropri- 
ate, since they themselves act as strong irritants. Our results in cases of 
septic vaginitis lead us to favor tincture of iodine, which we either paint 
over the surfaces, or else in severe septic vaginitis pour through a specu- 
lum. The stronger solutions of permanganate of potass have also proved 
serviceable. 
It is of advantage, especially in septic inflammations, to insufflate iodo- 
form in order to guard against, for as long as possible, decomposition of 
the secretion. As to whether one or another disinfectant is preferable 
in the treatment of diphtheria and other forms, has not been as yet es- 
tablished. 
Perivaginitis Phlegmonosa. 
A third group of inflammatory affections of the vagina is formed by 
phlegmonous perivaginitis (dissecans), where, in contra-distinction to 
vaginitis, not the mucous membrane, but the perivaginal connective tis- 
sue is the chief seat of the process, the extension of which sequestrates 
the vagina, so that eventually, together with the vaginal covering of the 
cervix, it is thrown off. In the majority of cases both the mucous mem- 
brane and muscular layers are affected. This rare affection was first de- 
scribed by Marconnet, who saw two cases in young women, both of whom 
recovered. As regards etiology there are no data. Although Minkie- 
vfitsch's patient died of typhoid fever, as also Tschernuschew's, in the 
second case of the last observer there existed a febrile affection of three 
weeks' duration where no diagnosis was reached. Bizzozero's patient died 
of pneumonia. In the case recorded by Syromiatnikoff, and seen by Zirkun- 336 
THE DISEASES OF THE VAGINA. 
henko, gonorrhoea may have been the cause. At least, she stated that two 
weeks before the onset of her disease, her husband complained of great 
pain on micturition, and that her disease began with leucorrhoea, and two 
days afterwards severe pain on micturition and fever set in. In the re- 
maining cases (Marconnet, Wiegandt) no definite etiological factor was 
determined although all three cases appeared at the menstrual period. 
In all the cases there was fever; in Marconnet's, Bizzozero's, Tscher- 
nuschew's cases there was slight hemorrhage; in the remaining cases there 
was only a purulent discharge. Great pain was present in all the cases; 
the labia were always swollen, and occasionally ulcerated. The vaginal 
mucous membrane was swollen, pale, and, except in Marconnet's cases, 
where the blood supply was not entirely cut off, it was discolored and 
necrotic. The expulsion usually occurred spontaneously, often at stool. 
Bizzozero removed the sequestrated skin by slight traction. With the 
exception of Minkiewitsch's case of severe typhoid, all recovered after 
suppuration and granulation. (Syromiatnikoff's case is not counted 
among the fatal, since she was discharged cured, and died a few months 
later from rupture of a pelvic abscess into the peritoneal cavity.) 
It is of interest that as much atresia and union of the granulating sur- 
faces did not occur in all the cases as was to be expected. 
In both of Marconnet's cases the vaginae remained patent, although 
he only kept them a short time under observation. Tschernuschew's 
cases give us no data except that they were discharged cured. In the re- 
maining cases great stenosis resulted in consequence of the peri-vaginitis; 
nevertheless in Wiegandt's case pregnancy ensued within a year. 
The treatment aims, of course, at modifying the complications, and 
until the expulsion of the membrane it consists in the strictest possible 
antisepsis, camphor, iodoform, careful cleansing of the genitals. As soon 
as the separated parts can be removed without injury this should be done. 
After expulsion the canal should be irrigated with carbolized water, and 
the like, and tampons smeared with some ointment should be inserted, 
or else iodoform gauze, to control the tendency to shrinkage. 
In addition to peri-vaginitis phlegmonosa, there occur phlegmonous 
inflammations in the peri-vaginal connective tissue as the result of gravita- 
tion of pus from pelvic abscesses. They are far more frequent, and or- 
dinarily affect the posterior vaginal wall, although their seat depends on 
that of the primary affection, and hence may be met with elsewfliere. 
These peri-vaginal inflammations lead rather to fistulous communications 
than to undermining of the mucous membrane. In the recto-vaginal 
septum perforation rather occurs towards the rectum than towards the 
vagina, in the median division; in the upper and lower division, on the 
contrary, they more frequently perforate into the vagina. The incom- 
plete evacuation of the pus through the fistulous opening is the reason for 
the extension and chronicity of the process, and the treatment should aim INFLAMMATORY AFFECTIONS. 
337 
at making a free outlet. Finally, we must refer here to the chronic peri- 
vaginal inflammations which develop as the result of syphilitic ulceration 
in the rectum and from periproktitis, and which are characterized by 
cicatricial contraction of the cellular tissue, there existing fistulous com- 
munication with the rectum. 
Of the remaining infectious processes in the vagina we must still speak of: 
Syphilis. 
It is not possible to state how often the vagina is the seat of syphilis, 
since often in the recorded cases the presence of the disease in the vagina 
and on the cervix are confounded. For both together E. Klink, from 
his personal observation and from a search through French and German 
literature, concludes that the ratio of chancre is here to that in other 
localities as 8:322. According to Kaposi soft chancre is rarely met with, 
although more frequently than hard; Kaposi saw two cases within three 
months. Of 249 hard chancres of the female genitals Fournier only found 
one on the vaginal mucous membrane. Klebs also states that the primary 
lesions in the vagina often lack induration. 
Heitzmann gives an excellent description of the specular appearances. 
The peculiarities of the soft chancre he states to be the following: Sharply 
reddened, slightly elevated borders, sinuated and uneven base, and speckled 
purulent layer. The peculiarities of these ulcers in the vagina are: the 
destructive process extends more on the surface than in the depths, 
whence the shallow base, great tendency to unite with others, and hence 
there results an extensive ulceration surface with sinuous indented edges, 
the surface being covered with profuse secretion and necrosed masses. In 
this locality their progress is slow. The usual seat of the chancre is at 
the introitus: in the vagina, it is almost always found in the anterior 
third and most frequently in the anterior wall.. Exceptionally, Heitz- 
mann found it in the posterior fornix, whence it had extended on to the 
posterior lip. In healing, the slough separates from the borders and is 
shed after profuse suppuration; the epithelium is regenerated from the 
periphery towards the centre. When the process has not extended deeply, 
no cicatrix remains, and when one does, it is pale, smooth, shiny. Hard 
chancres, according to Heitzmann, are ordinarily found at the introitus, 
next to the posterior commissure. He was never able to detect charac- 
teristic induration higher up. 
Secondary syphilitic changes are relatively more frequent, although, as 
regards the vagina, there are but few recorded instances. Heitzmann de- 
scribes erythema syphilitica, and also a form analagous to psoriasis, and the 
mucous papules (broad condylomata.) In case of erythema there exists a 
more or less circumscribed catarrhal inflammation of peculiar nature and 
course. At first the mucous membrane is only diffusely reddened, with- 338 
THE DISEASES OF THE VAGINA. 
out marked swelling: soon at certain portions a more intense redness 
appears. Ordinarily the anterior third of the vagina is the seat of such 
circular erythema. At the same time a similar change is sometimes seen 
on the cervix. These reddened portions, in certain instances a few small, 
separate sppts, are very sensitive and vulnerable, slight touch causing 
them to bleed. 
Either the erythema disappears in a short time (8 to 10 days) sponta- 
neously, or else a peculiar cloudiness affects the diseased portions, or 
finally papules form on the erythematous base. The erythema recurs 
rapidly, and the secretion is not purulent like that of gonorrhea, but 
more watery and milky; complication with virulent catarrh is, however, 
met with. With regeneration of the epithelium, young fungous epithelial 
cells are sometimes formed, which, arranged in thick layers, cause the red 
spots to look white and opaque, as though they had been touched with 
lunar caustic. The process, according to Heitzmann, is analogous to 
psoriasis linguae and psoriasis syph. cut., only that, in consequence of the 
bathing of the parts by the increased secretion, the upper layers do not 
become dry, and therefore no desquamation is noticeable. 
Of French authors Courty speaks of changes which belong here. " Es- 
pecially under the influence of syphilis, we see in the vagina (particularly 
on the cervix) circumscribed, round, coin-like thickenings of the epithe- 
lium, which look like drops of wax, and which are differentiated by their 
pale white color from the red surrounding parts. These are a species of 
psoriasis, plaques, which are surrounded by a red surface, occasionally 
ulcerate, yield to specific agents, and yet may remain unchanged for a 
long time. In other instances they increase in thickness and consistency, 
and form either broad condylomata, or else small hard elevations. ' ' 
The mucous papules, described by Heitzmann as generally rising from 
the erythema, are always markedly elevated, although in comparison with 
the same efflorescence on the external skin of the genitals they do not 
form such characteristic nodules. According to Zeissl they only are 
typically papillar when they are seated on mucous papillae. They are 
ordinarily more characteristic on the cervix than in the vagina. 
At the outset we see red, slightly elevated, flat surfaces the size of a 
pea, generally arranged in groups and quickly running together, thus 
making large plaques. In case of accompanying virulent catarrh, the 
papules swell quickly. The surface becomes eroded and bleeds readily. 
Occasionally, from changes in the epithelial layers, they become cloudy 
and look like mother of pearl {plaques opalines of the French). The 
papules do not then disappear as quickly, and after atrophy there remain 
milk-white patches. If instead of thickening there has occurred shedding 
of the epithelium, then the denuded papillae swell into papillary nodules. 
A second metamorphosis of the papules consists in their molecular de- 
generation. In the beginning the condylomata seem to be covered with a INFLAMMATORY AFFECTIONS. 
339 
thin diphtheritic membrane. They are dirty gray, their convexity is 
rough. The breaking down begins in the centre ai!d is there far ad- 
vanced, whilst the periphery is still intact. The papules then resemble 
very much specific ulcers, especially when the borders are not very elevated. 
In the diagnosis of syphilitic affections of the vagina, the characteristic 
marks will answer in the majority of cases, particularly since ordinarily 
there are present at the same time changes due to the same disease on 
the external genitals, skin, etc. Still, in case of isolated ulcers, the diag- 
nosis may be so difficult that it is only reached on the appearance of 
secondary symptoms. 
The local treatment is similar to that which we have laid stress upon 
under the subject of catarrh. The general treatment is the usual one. 
Tuberculosis of the Vagina. 
Tuberculosis of the vagina is of peculiar interest, not so much on ac- 
count of its rarity as because of the fact that it has been usually noted as 
secondary to advanced tubercular processes elsewhere. I find but a single 
brief reported case (H. Thompson) in which the reporter found cheesy 
masses in the vagina, which he considered the starting-point of general 
tuberculosis. Although I do not consider the fact proved in the case, it 
is still worthy of record: A previously healthy girl of 15, who had never 
menstruated, died of an obscure affection of five days' duration, charac- 
terized by elevation of temperature, anxiety, livid coloration. At the 
autopsy miliary nodules were found in the lungs, on the diaphragm, and 
in the capsule of the liver. In the liver, spleen, and kidneys were large 
nodules, partially caseous, and the same at the base of the bladder and 
in the fossa sylvii. The hymen entirely closed the vagina, which was 
dilated into a sack in which was about 14 pounds of semi-fluid, grumous, 
foul substance, consisting of retained, decomposed menstrual blood. The 
cervix and the os uteri were covered with numerous miliary tubercles. 
Tuberculosis of the vagina is not always, as Klebs has claimed, the result 
of extension of tubercle from the uterus. In Virchow's, Weigert's, 
Klob's, and Kasewarowa's cases the uterus was not affected. In such in- 
stances tuberculosis of some other of the pelvic organs is never lacking; 
the urinary organs, the intestines, £he peritoneum, are more or less af- 
fected. In a case of cheesy degeneration of an ovarian cyst in an old 
woman, I personally saw a tubercular ulcer on the posterior wall of the 
vagina in the fornix. Tubercles in the vagina appear as small gray 
nodules arranged in groups on a reddened base, thickest in the middle of 
the vagina and in the fornices (Virchow), or else as larger elevated patches 
with cheesy, eaten-out base and steep edges (Weigert). In all the cases 
since Koch's discovery the tubercle bacilli were found. 
In so far as treatment is to be effective further observations must show. 
Iodoform should at the present head the list of agents. 340 
THE DISEASES OF THE VAGINA. 
Gangrene of the Vagina. 
Gangrene of the vagina, when not the result of pressure by a foreign 
body or of the fetal head, appears as noma. According to Klebs it is not 
infrequently consecutive to noma of the cheek, and as diffuse gangrene, 
following, in general, on diphtheritic processes of the mucous membrane. 
Frequently the etiology is obscure, as in Obre's case, which Klebs con- 
sidered an instance of diffuse primary gangrene. 
In such extensive processes the entire vaginal mucous membrane, with 
the exception of the covering of the cervix, appears black, pulpy, and 
there are present superficial necroses in the vestibule or on the labia. 
Pain, dysuria, inability to walk, result. Fever is not constant; in a case 
which I saw, where the gangrene was consecutive to the wearing for seven 
years of a round pessary by a woman of fifty-seven, fever was entirely 
lacking. In certain instances there is profuse hemorrhage; in Obre's case, 
a girl of fourteen, the hemorrhage was fatal. 
The treatment is by antiseptics. In the cases we have seen, frequent 
irrigation followed by insufflation of iodoform gave good results. The 
use of camphor is to be commended. 
Round Ulcer. 
Under the term ulcus rotundum simplex AV. Zahn describes a round 
ulcer with sharp border and red base which he found in the posterior 
fornix of a woman of seventy-six. The borders, like the rest of the 
mucous membrane, were pale, there was no induration, the base was 
hyperaemic and covered with a layer of pus. The connective tissue 
was infiltrated with small cells, and the borders contained smooth 
muscular fibres in a state of fatty degeneration. Colonies of micrococci 
were present. The uterine artery and its branch, the vaginal artery, were 
stenosed to a high degree, so that the lumina were reduced to the mini- 
mum, and a branch of the latter, leading to the ulcer, was completely 
obliterated. 
The ulcer resembled, according to Zahn, the round ulcer of the stomach, 
and he states that this unique ulcer depended on the cutting off of the 
blood supply and the lack of a collateral circulation. CHAPTER VIII. 
NEW GROWTHS OF THE VAGINA. 
A. Cysts. 
/^lYSTS of the vagina are rarities, although during the past few years 
the recorded instances have increased. They are found, ordinarily, 
as isolated tumors in the mucous membrane or sub-mucosa of the vagina, 
at times two to three in number, rarely more; Schroeder on one occasion 
extirpated six at a sitting. 
The site is a trifle more frequent on the anterior than on the posterior 
wall, more rarely on the lateral walls. In one case (Bastelberger) the 
hymen was implicated. The size varies between that of a pea and a hen's 
egg, although it may, as in J Veit's case, attain that of a child's head. 
Very large cysts may implicate the entire length of the vagina, as Nelaton 
saw on the posterior wall, Crede (Herder's report) on the anterior and 
J. Veit on the lateral. The contents are at times serous, then gummy, 
slimy, or emulsion-like, similar to lime (from admixture with cholestea- 
tomatous material), and occasionally blood. 
Microscopically, epithelium, granular cells, fat-drops, at times crystals 
of cholesterine, pus and blood, are found. Exceptionally the clear fluid 
contains no morphological elements. 
In the majority of cases the inner wall of the cyst is lined with cylinder 
epithelium (Ruge), although laminated epithelium is also found in the 
same cyst near the cylindrical (Mayer, Lebedeff, Ruge). 
The epithelial cyst-wall consists, in superficial cysts, of a thin layer of 
finely fibrillated connective tissue; in thicker wall cysts there is often a 
mucous membrane. (Muscular and connective tissue layers, rarely well 
developed papillae. Ruge, Garrigues.) 
A cyst, described by Kaltenbach and examined by Mayer, had a very 
unusual complicated structure. It resembled a cystoma, a section of 
which was papillary, and another was glandular in characteristics. In a 
few instances the epithelial lining was totally wanting (Huguier, Ladreit, 
Verneuil, Lebedeff). 
The anatomical origin of vaginal cysts has not, as yet, been entirely 
settled; still, the examinations which have been made point to variations 
in the local origin. Aside from cysts arising from other sources and 342 
THE DISEASES OF THE VAGINA. 
growing towards the vaginal wall, the deeper cysts covered by mucous 
membrane originate from persistent parts of Muller's and Wolff's 
ducts: the superficial cysts, with simple connective tissue walls covered 
with cylindrical or laminated epithelium, like those described by von 
Preusen, although exceptionally, yet they originate from vaginal glands. 
In all these instances vaginal cysts have the importance of retention 
cysts. Klebs has described them as lymphatic cysts in the connective tis- 
sue, lined with endothelium, and possibly formed from dilated lymphatics. 
The case of Freund (hsematokolpos) and Cullingworth's blood cyst, 
Smolsky's and Kleinwfichter's cases of pyokolpos unilateralis, and the 
case of Grafe (from Schroeder's practice), where six cysts lay below one 
another, the lowest of which projected into the vagina, and were arranged 
spirally from the right backwards to the left, from the introitus to the for- 
nix, these are instances of development from a remnant of Muller's ducts. 
Although the contents of these cysts were varied, serous, slimy, clear and 
brown, still the wall, a few lines thick, was muscular, and the inner sur- 
face was covered with papilla? and cylinder epithelium. Of the same 
origin, I believe, are two vaginal cysts in new-born infants, the one seen 
by Winckel and the other by myself. 
Winckel saw in a new-born, strongly built infant, a vaginal cyst the 
size of a cherry, which interfered with micturition. When the child 
cried a tumor with vascular wall projected through the hymen, between 
the nympha?. The tumor proved to be a cyst occupying the left side of 
the anterior vaginal wall, and adherent to the neighboring part of the 
hymen. He was able to penetrate into the vagina to the right of the 
tumor. The orifice of the urethra was occluded by the tumor, and 
the urine was directed to the right and posteriorly over the hymen; the 
rectum was normal. An incision let out a teaspoonful of a milky cheesy 
fluid in which were numerous laminated epithelial cells, fat, but no 
cholesterine. After puncture the urine was passed without difficulty. 
The meatus urinarius was in its usual place. The cyst shrivelled, and 
after the twelfth day only a small elevated linear cicatrix was apparent. 
In April, 1873, I saw an analogous case in a healthy seven weeks old, 
breast-reared infant. A cyst, the size of a hazel-nut, with relaxed walls 
and furrowed surface, spreading from the anterior vaginal wall backward 
and to the left of the meatus urethrae, was prolapsed through the widely 
dilated hymeneal orifice. The little finger could be passed into the vagina 
behind the tumor, and the attachment of the cyst as well as the normal 
state of the posterior vaginal wall and of the cervix could be determined. 
There was no disturbance of micturition, and the cyst did not trouble the 
patient. Artificial opening was not allowed by the parents. It probably 
broke spontaneously, since the family physician reported later that it had 
shrunk. 
In neither of these cases was there an anatomical examination, and NEW GROWTHS. 
343 
therefore no definite statement can be made in regard to the source. The 
site, the thickness, the vascular wall, and the nature of the contents in 
Winckel's case, speak for theii' having been due to a closure of a rudi- 
mentary segment of the anterior vaginal wall. This is more likely than 
the belief in their origin from a crypt near the meatus urinarius, since in 
the new-born, when they are developed at all, these crypts are very shallow. 
In favor of the derivation of these cysts from rudiments of Muller's 
duct, the following points speak: They are simple or multiple cysts, 
arranged longitudinally, and never extending above the fornix towards 
the broad ligament, they are usually in the axis of the vagina, in the mid- 
dle or to one side; the base of the cyst wall consists of developed mucous 
membrane (muscularis, papilla?, with pavement epithelium); the wall is 
thick; there is no connection with the urethra; there is occasionally also 
present a uterus unicornis (Freund). 
As regards the bloody and the purulent contents of such vaginal rudi- 
ments, Kleinwachter points, with reason, to the influence of pregnancy 
and of labor, and even in Freund's case traumatism of labor must be 
considered the cause of the blood in the cyst, although he thought it was 
dependent on menstrual separation of the vaginal mucosa. Such rudi- 
ments may exist for years without symptoms, until the appearance of 
hypersecretion or hemorrhage, or else of prolapse. 
In regard to the origin from persistent remnants of Wolff's or Gartner's 
ducts, to which G. Veit first called attention, two instances have recently 
been recorded where this seemed to be the case. 
In one case (Robert Watts) the woman was forty-one years old, had 
borne eight children, and for three years a cyst, the size of a hen's egg, 
attached to the anterior vaginal wall, had prolapsed, and it spread upwards 
into a slender duct, in which a sound could be passed without difficulty 
towards the left side for a number of inches, so that the point of the 
sound could be felt through the abdominal wall at the level of the umbi- 
licus, between it and the ant. sup. spine of the ilium. Only the lower 
cystic portion could be loosened from its bed, and it was removed after 
ligature of the upper and neck-like extension. The point of removal was 
just above the reflexion of the vagina from the cervix, and the lower end 
of the cyst was about one half an inch behind the urinary meatus. Fre- 
quent examinations with the catheter proved that it had no connection 
with the bladder. The contents of the cyst was about two ounces of a 
sero-purulent fluid. 
Garrigues examined the extirpated cyst and found the smooth inner 
surface covered with pavement epithelium, and about a dozen recesses, 
the smaller of which were round, while the larger were transverse. Un- 
derneath the epithelium of the thick wall there was a thin layer of con- 
nective tissue containing round cells and many capillaries, and externally 
there was a normal muscularis. 344 
THE DISEASES OF THE VAGINA. 
During and after the operation there was hemorrhage from the upper 
part of the wound which required the tamponade. During two days the 
urine was bloody, but it then became clear, and the cavity gradually 
closed. Watts states that analogically the site was that of the vas deferens, 
and he finally reaches the conclusion that it was a cyst of Gartner's duct. 
If his supposition be correct, then the bloody urine must be considered 
the result of excoriation of the mucous membrane of the bladder by the 
repeated catheterization. 
A second very uncommon case is considered by the reporter, J. Veit, 
to be an instance of cystic development of a persistent Wolffian duct. In 
a woman of forty-seven, who had borne a number of children, there had 
existed a prolapse for a number of years, which it was difficult to rectify 
and, which caused retention of urine. Veit found the prolapse only from 
the right side of the vagina, and the size of a child's head. The urethra 
was entirely dislocated downwards; the left wall of the urethral projection 
was normal; to the right, where there was no cul-de-sac, the urethra 
spread over the prolapse. To the left the finger penetrated into the 
compressed vagina, and reached the cervix, which was unchanged, as also 
the anteriorly flexed uterus. The uterine adnexa could not be felt with- 
out anaesthesia, but the uterus was greatly pushed to the left by a swelling 
in the right broad ligament. There was no rectocele. The catheter 
could not be inserted into the prolapse. Examination under anaesthesia 
revealed a tense tumor in the broad ligament, which was in connection 
with the cyst in the vagina. Above the tumor the ovary could be felt, 
and on the left side the adnexa were normal. Veit incised the prolapsed 
portion as freely as he could without injury to the vessels, and then sewed 
the edges to the vaginal mucous membrane. 
The fluid contents were exactly like those found in dermoid cysts, al- 
though neither hair nor teeth were present. The wall of the cyst was 
covered with pavement epithelium. After emptying the cyst the finger 
could be passed above the pelvic inlet and could feel the upper end of the 
ovary. The cyst quickly shrunk. There is no statement in regard to 
the texture of the cyst. 
The reasons for the belief in the development of vaginal cysts from 
remnants of Gartner's duct are their deep seat more to one side, and their 
mucous covering with an epithelial layer, which from the method of devel- 
opment of the epithelium need not necessarily be simply cylindrical. Not 
much can be said in regard to difference in structure between cysts from 
Muller's and from Wolff's ducts. Presumably the cysts from Muller's 
ducts should show greater development of the papillae of the mucous 
membrane. The only valuable differential diagnostic point is the fact 
that cysts from Wolff's ducts may extend above the fornix vaginae into 
the- broad liagment up to the neighborhood of the ovary, and this can 
never happen in case of those from Muller's ducts. The difficulty in NEW GROWTHS. 
345 
differentiation is, however, still great, and we mnst await further obser- 
vations. 
As regards the origin of the vaginal cysts from the vaginal glands (von 
Preusen), although exceptional, it has been proved by a number of ob- 
servers. C. Huge determined this in a case of hsematocolpos internally 
to the hymen; Huckel and Heitzmann have observed cases exactly like 
von Preusen's. These cysts may be recognized by their structure, that 
is to say, as C. Ruge has shown, they are regularly lined with cylinder 
epithelium, and are better explained on the assumption that they are re- 
tention cysts of the glands, than in any other way. 
Winckel's suggestion that these cysts result from obstruction of the 
mucous follicles of the vagina, or the belief that they are due to dilated 
lymph vessels (Klebs), cannot be excluded; the present results of exami- 
nation, however, do not point to such conclusions. 
More readily explainable are the cystic tumors which partially develop 
from the peri-vaginal connective tissue, and the contents of which are at 
times hemorrhagic, at times pale, watery or slimy. The first are the result 
of trauma-hematoma after a fall, after labor (Sanson, Winckel); the latter, 
as Verneuil has shown, result from the collection of serum in the loose 
cellular tissue between the rectum and vagina, the cause of which is re- 
laxation of the vaginal wall from traction or pressure. When there is 
collection of much fluid, there is cystic projection toward the vagina, that 
is to say, a hygroma recto-vaginale. 
Although the anatomical examination of cysts of the vagina prove that 
they are of varied origin, this is still more apparent from the clinical 
findings. Cystic tumors growing down towards the vagina from neigh- 
boring organs or tissue cannot sometimes be differentiated from those 
which arise from the vagina. Maunel has recorded an instance of such 
a tumor with atheromatous and dermoid-like contents; Paul has reported 
a peculiar case where a cystic tumor pushing down the posterior vaginal 
wall proved an obstacle to labor; and after the mucous membrane Rad 
yielded longitudinally, a black body, the size of a man's fist, projected, 
the contents of which was a black fluid in which were pale gray, shiny 
bodies the size of a bean. That he was not dealing, as in Sucro's case, 
with a tear in the posterior vaginal fornix, with prolapse of an ovarian cyst, 
is proved by the thinness of the walls of the tear in the vaginal covering 
of the tumor, and by the fact that the puerperium was undisturbed. 
Although no anatomical examination was made, still this cyst of Paul's 
was probably an echinococcus-cyst. Latterly, Schatz, in a valuable paper 
on echinococci of the genitals and the pelvis in the female, has collected 
a number of such cysts, in part lying between the vagina and bladder 
(Hill, Eldridge), and in part between the rectum and vagina, in which 
number Paul's is included (Park, Blot, Paul, Schatz, Sibille). Possi- 
bly the crypts near the orifice of the urethra, which are occasionally long 346 
THE DISEASES OF THE VAGINA. 
ducts, may be converted into retention cysts. Von Preusen has reported 
an instance where a gland of the urethra developed into a cyst the size of 
a walnut and was prominent in the vagina. Belfield noted the presence 
of considerable bending and flexion in the course of Morgagni's lacunae of 
the posterior urethral wall, and considered this a favorable cause for the 
development of retention cysts in the female. 
Possibly certain deep-seated cysts in the urethro-vaginal septum, which 
being sub-mucous, may attain considerable size, may originate from par- 
tial dilatation of the urethra (urethrocele). This possibility implies that 
the entrance into the diverticulum has narrowed and closed, and this has 
not been seen to occur. Still, I will relate an incompletely observed case 
which suggests this possibility to my mind, although it does not prove it. 
A specially strong woman, who had been married for four months, had 
had for two months a tumor hanging from the genitals which rendered 
walking difficult and caused dysuria. I saw her in November, 1875, and 
I found a slight prolapse of the anterior vaginal wall. The catheter en- 
tered the prolapse without difficulty, and the wall intervening between it 
and the finger in the vagina seemed very thin. I saw the patient again 
in April, 1876. The prolapse of the anterior vaginal wall still existed, but 
the catheter no longer entere 1 it, passing over it into the bladder. There 
now existed a cystic sac, filled with pus, the size of a hen's egg, which 
was discharging into the vagina from an opening the size of a pin's head. 
I incised this opening to the extent of three-quarters of an inch, made a 
counter opening and passed a drainage tube. Under injections of carbolic 
the sac shrank, and in three weeks it was cured. Such a sac as this 
might readily be mistaken for cystocele. Scanzoni has recorded two cases 
very similar to mine. 
There is but little to be said in regard to etiology. Huguier's supposi- 
tion that pregnancy and labor had an influence has been disproved by 
Winckel, seeing that of fifty cases which he collected, only eight had 
borne children. Their dependence on catarrh can scarcely be granted, 
although the presence of catarrh near these cysts is noted, and, owing to 
the slight symptoms caused by these cysts, the time of their development 
generally cannot be stated. The cases are few in number when an exami- 
nation was made before their presence and then afterwards. Knowledge 
of the etiology is yielded in those caies where the cysts formed after 
traumatism, and generally then they follow on hemorrhage. 
Only larger' vaginal cysts cause symptoms by rolling down the vaginal 
walls into the lumen of the vagina, and outside of the genitals. They 
may then cause vaginal catarrh, bearing down, pain in walking and in 
sitting, dysuria, dyspareunia, and prove serious obstacles to labor. Hard- 
wicke recorded an instance of impediment to delivery, and cited similar 
cases from Ashwell, Langley, Lever, Peters, Munde. 
Munde's case is the only one of these which affected the anterior vaginal NEW GROWTHS. 
347 
wall. Catarrh of the vagina is frequently found near the cysts. We 
have already referred to the possibility of a catarrh favoring the develop- 
ment of these cysts. 
We need not say much in regard to diagnosis, since their fluctuation 
and their seat in the vaginal wall are sufficiently characteristic. Mis- 
taking them for a cyst of the Bartholinian gland is hardly likely, owing 
to the site of the latter. .Retention tumors in semi-atresia of the vagina 
are characterized by their longitudinal shape and their relation to the 
uterus; peri-vaginal hematomata and abscesses are suggested by the his- 
tory, the great pain they cause, the infiltration of the borders, the irregu- 
lar form, and when superficial by the color. 
In treatment simple puncture will not suffice. In a few cases after 
puncture and cauterization with lunar caustic or iodine, cure resulted, 
but this method is uncertain. The preferable method is incision and 
cauterization, or through drainage. The best way of all is extirpation, 
and this has the advantage that we can suture the surface and obtain 
union by prima intentio, as in Horder's case. Sometimes total extirpa- 
tion fails, and then we must be content with partial (Lee, Munde). 
Schroeder has lately advocated cutting off the projecting part of the cyst 
with the scisssors, and sewing its edges to the mucous membrane of the 
vagina. The inner wall of the cyst, which according to Huge is covered 
with cylindrical epithelium, soon cannot be distinguished from the rest 
of the vaginal mucous membrane. 
B. Fibromata and Fibro-myomata. 
The results of close histological examination of the tumors belonging in 
this category have been stated in such a limited number of the cases, 
that a differentiation between the muscular and the pure connective-tissue 
forms for the purpose of classification of the reported cases is scarcely 
possible. With the exception of Paget, who has described an instance of a 
tumor consisting of pure connective tissue, recent authors have found, with 
great regularity, smooth muscular fibre in sessile vaginal fibromata, and 
have hence compared them with uterine fibromyomata (Virchow, Klebs). 
These tumors are rarely met with, and probably develop in the submucous 
tissue, or in the deeper layers of the mucosa. According to Virchow's 
observation they grow from without inwards, and so seldom towards the 
lumen of the vagina, that this most expert anatomist never met with a 
myomatous polyp of the vagina. 
As these tumors increase in size they spread towards the vagina, become 
polypoid, and hang outside of the vulva (Scanzoni, Porro, Neugebauer, 
Lambl, Dufour, Demarquay's case), and therefore in this respect, also, 
they are analogous to uterine myomata. Kleinwachter is the most recent 
writer who has collected the cases reported in literature. In 1882 he 348 
THE DISEASES OF THE VAGINA. 
collected fifty instances, to which number he afterwards added three fur- 
ther cases, two from preparations in the Prague anatomical collection, and 
the third a personal case. To these fifty-three cases I am able to add 
five others: A case of Hermann's, two reported by Gaye from A. Martin's 
practice, one from Caswell, and one personal unpublished case. The 
history of this patient is: Thirty-seven years of age, and one delivery four- 
teen years previously. She nursed her child for nine months. The 
patient complained of haemoptysis, and there were signs of tuberculosis at 
the apices. She menstruated regularly and suffered from profuse leucor- 
rhoea. The tumor in the vagina was the size of a small date, hard, and 
adherent, partially covered by movable mucous membrane, and occupying 
the anterior fornix. I extirpated the growth on June 29th, 1883, by 
cutting into its capsule and lifting it out of its bed. A profuse arterial 
hemorrhage was checked by ligation. The sac was sutured, and iodoform 
tampons inserted into the vagina. Microscopically the tumor proved to 
be a pure myoma. 
These five additional cases were all examined microscopically. Cas- 
well's case was a fibroma, Hermann's and Martin's were fibromyomata, 
and mine a myoma. In 39 of the cases collected by Klein wachter, the 
seat of the tumor was noted, and adding these to the five additional cases, 
of the 44 the tumor was on the anterior vaginal wall in 28, in 11 on the 
posterior, and in 5 on the lateral wall. In general the upper vaginal seg- 
ment was implicated by the growth. 
In many instances these tumors attain great size, in a number of cases 
over 2£ pounds, and in two of the older cases (Baudier and Gjemler) over 
10 pounds. In the frequent polypoid form, the pedicle was usually thick, 
and but rarely thin (Scanzoni). Large polypoid fibromata, which re- 
main in the vagina only because of narrowness of the canal, are gener- 
ally expelled under energetic muscular pressure of the abdominal walls 
(Tratzl, W. Greene); in the majority of cases the expulsion is gradual. 
The growth of these vaginal tumors is a slow one, and in Neugebauer's 
case the patient had borne the tumor for twenty-two years. 
In regard to the influence of menstruation and pregnancy on fibrous 
tumors of the vagina, nothing definite can be stated. Softening and se- 
rous infiltration, the result of interference with the circulation, and occa- 
sional ulceration of the surface, have been frequently noted, aside from 
menstruation or pregnancy. (Paget, Honing, Chadwick.) 
As regards age, the majority of the patients were in the years of greatest 
sexual activity. The oldest patient (Greene's) was fifty-one years old and 
had known of the tumor for fourteen years. Three instances of fibroma- 
tous polyps in small children have been recorded. (Tratzl, Wilson, A. 
Martin.) 
In a fifteen months' old child, who had been unable to eitiier micturate 
or defecate for a day and a half, Tratzl found a soft, elastic, grayish-blue NEW GROWTHS. 
349 
tumor impacted in the introitus vaginae and compressing the urethra and 
the rectum. The bladder was greatly distended, the external genitals 
hot, reddened, and oedematous. By careful traction he pulled the tumor 
downwards and a small amount of urine was passed spontaneously. At- 
tempts to deliver the growth were not successful. On the following morn- 
ing the tumor had been spontaneously expelled. It was the size of a 
man's fist, shaped like a pear, and the pedicle was as thick as the little 
finger. Its surface was bluish-red, smooth and shiny in part, and in part 
furrowed. It was very vascular. Tratzl ligated the pedicle and on the 
sixth day the tumor dropped off. It was fibrous in structure. The child 
convalesced well. 
I have been unable to find Wilson's description of a large vaginal polyp 
in a child two and a half years old. 
A. Martin has latterly recorded the third instance. The child was two 
days old, and at full term. The midwife had noticed at once a bright 
red growth the size of a lentil projecting from the vagina. Martin found 
it surrounded by the rima pudendi, its surface reddened, and pulled it 
out with a dressing forceps. It was about f of an inch long, with slender 
pedicle inserted above the hymen, to the left of the mid-line at the level 
of a fold of the posterior columna rugarum. The pedicle was ligated as 
near its base as possible, and the polyp cut off. There was no hemor- 
rhage, and on the third day the ligature dropped. The child's general 
condition was not affected. The polyp was very hard to the touch, was 
covered with squamous epithelium and with papillae arranged like those 
of the vagina. Glands were not discovered, but in the centre were nu- 
merous large blood-vessels, imbedded in firm, connective tissue. Mus- 
cular fibres were not detected. 
The symptoms depend on the size, the early or late expulsion of the 
tumor, and on the complications. Usually, when small, fibromata of the 
vagina are not recognized. Gradually they lead to catarrhal secretion, 
cause dragging sensations, and as they increase in size, they produce 
dysuria, and finally retention of urine. Tumors which project from the 
genitals, are not alone troublesome by the traction they exert, but they 
are subject to the same irritant causes as prolapsus. They become swollen 
from venous stasis, and painful from ulceration and erosion of the surface. 
Van Doeveren found a polyp weighing one and a half pounds inserted 
on the anterior vaginal wall, and obstructing labor in a primipara. He 
was able by manual traction to push the tumor out of the way of the 
foetal head. According to their seat and size, these tumors are likely to 
interfere with cohabitation, and in case of conception to interfere with 
the progress of labor. In a case operated upon by Pelletan, the physician 
was able to pull down the partially expelled tumor, and the foetus was 
born spontaneously. In Gentrul's case the foetus was delivered by the 
forceps, the tumor tearing away from its upper vaginal attachment at the 350 
THE DISEASES OF THE VAGINA. 
same time. The most unfavorable result was in the case the specimen of 
which is in the Berlin pathological collection, and has been described by 
Virchow. An oval myoma, the size of two fists, was situated in the pos- 
terior vaginal fornix, and proved an obstacle to labor. In the attempt at 
delivery of the foetus, the vagina was ruptured and the pubic bone frac- 
tured. The woman died in four weeks from necrosis and suppuration 
of these parts. In other reported cases the fibroma did not prove an ob- 
stacle to delivery. In McClintock's thirty-nine year old patient, where, 
with Johnston's assistance, a fibroma two and a half inches long and of 
the same breadth, seated on the anterior wall, was removed by a ligature, 
delivery took place without difficulty. Neugebauer's patient was deliv- 
ered a number of times, notwithstanding the presence of a tumor. In 
Porro's case the tumor was driven by the pains in front of the foetal head, 
delivery was spontaneous, and after enucleation of the tumor the woman 
passed through a normal puerperium. A few cases have been noted dur- 
ing pregnancy, and in three the fibroma was extirpated, and in Gremler's 
case it weighed over ten pounds. In McCl in tock's case, the pregnancy 
was not interrupted, as also in Gremler's, and the women were, happily, 
confined at term. Another case of McClintock's was not so fortunate. 
Before operation the tumor had begun to break down, and had begun to 
project back into the vagina. Twenty days after its removal by the ecra- 
seur, the woman was delivered of twins, and died of exhaustion in twenty- 
four hours. At the autopsy septic endometritis was found. 
The diagnosis is readily made, seeing that the uniformly round, isolated, 
or pediculated form, with surface covered with smooth mucous membrane, 
and elastic to the touch, is characteristic. The surface may be lobulated, 
oi' narrowed by constriction at the orifice of the vagina, or there may be 
changes in consistency, the result of ulceration. Important diagnostic 
points are the slow growth and purely mechanical disturbance. These 
growths maybe simulated by faintly fluctuating cysts with thick contents, 
and with other tumors of slow growth, and the latter particularly cannot 
always be differentiated before extirpation. Demarquay satisfied himself 
that he was not dealing with a cyst by resort to the exploratory puncture, 
and this device also assisted Pelletan. In the living it will often be im- 
possible, before operation, to differentiate from many forms of sarcoma. 
The treatment consists in extirpation either by the ligature, excision, 
or enucleation. The ligature, even as in case of uterine myoma, best 
guards against hemorrhage, although it has not always so answered. In 
the case which McClintock treated with Johnston there occurred profuse 
hemorrhage on the fifth day following on necrosis and ulceration. On 
the eleventh day the ligature was removed, and thereafter the tumor was 
gradually taken off piecemeal, and only after three weeks did the growth 
entirely disappear. Although this case eventuated happily, it clearly 
proves the danger of the method. It belongs to the year 1845. Ecrase- NEW GROWTHS. 
351 
ment and the galvano-cautery, although they have the advantage of rap- 
idly removing the tumor, carry with them no immunity against hemor- 
rhage, and this is well illustrated by the two operations of Neugebauer on 
one and the same patient. The heated wire does not slip, like the cold, 
under the circumference of the round tumor, but cuts the more certainly 
at the locality where it is placed the more carefully the cautery is 
worked. A portion of the tumor may remain, which will slowly grow 
and necessitate a second operation. It seems to me that the ligature 
should be of special value in case of great vascularization of these tumors, 
although I have not tested it in case of fibromata of the vagina. Espe- 
cially do I think this is true, since, by guarding against hemorrhage, we 
also guard against slow necrosis of a large tumor. Where the fibroma 
has not a very broad base it may well be ligated in two portions; or else 
in case of pediculated fibromata, a wire ligature might be thrown around 
the pedicle and left there, the greater portion of the tumor being excised. 
Simple excision of pediculated tumors by means of the scissors has often 
been performed, and there has not always been much hemorrhage. Twice 
it had to be checked by iron tampons, and also in the slender pediculated 
myomatous polyp of Scanzoni. Simple excision is not so favorable as in 
case of uterine myomata, since these growths in the vagina do not lie in 
an organ which will contract after their removal, and thus aid in limiting 
the risk of hemorrhage. In case of vaginal myomata with fibrous pedi- 
cles, the ligature is to be recommended. In case of round, broad-based 
fibromyomata, which are fairly movable, enucleation, after cutting the 
mucous membrane next to the tumor, even as Dupuytren did, is, with- 
out question, the best method, especially since sutures may be more readily 
inserted. In case of small, long tumors, longitudinal incision into the 
capsule is preferable. If possible sutures should also be inserted here, 
since thereby there is greater chance of union by first intention. Where 
the cavity left after enucleation is large, much may be accomplished by 
means of compression with iodoform gauze and the wearing of a T-bandage. 
C. Striocellular Myoma.-Rhabdomyoma Myxomatodes. 
There exists only a single observation of this form of tumor. It was 
removed from a strongly built girl of fifteen, who had not as yet men- 
struated, who came to Seyfert's clinic at Prague in 1869 for the relief of 
difficult micturition. On examination a polypoid tumor with rather large 
pedicle was found on the anterior vaginal wall, which was removed and 
the patient was discharged in ten days, the wound having healed. In six 
weeks she returned, since the tumor had grown again. She then con- 
sulted Fr. Kaschewarowa. The maiden was in the full bloom of youth. 
The external genitals were not entirely developed, there was no hair on 
the pubes, but otherwise they were normal, and the uterus was sound and 352 
THE DISEASES OF THE VAGINA. 
in good position. On the anterior vaginal wall there was a tumor the 
size of a hen's egg, with fairly broad pedicle, lobular surface, and of red- 
dish color. The substance of the tumor was so soft that portions could 
be removed with the finger, and this was painful. With the naked eye 
a superficial layer could be seen on the removed portions (mucous mem- 
brane), and below it the loose tissue tumor. The latter had the color and 
consistency of soft wax, and it contained a large amount of blood. 
Neither by pressure upon, nor scraping a recent section with the knife, 
could turbid juice be obtained, but only a clear fluid, on great pressure, 
in which were particles of the tumor. During the patient's stay in the 
clinic the tumor increased in size. From time to time Seyfert removed 
small portions, and the end of May a piece the size of a hen's egg, which 
Fr. Kaschewarowa examined. The tumor turned out to be a rhabdo- 
myoma (Zenker), combined with myxomatous tissue. After the removal 
of a large portion, the patient was attacked with pelvic peritonitis. The 
growth necrosed in places, and then increased quickly in size until by the 
end of June it had attained the size of a child's head. The patient's 
strength failed, she suffered constant pain in the lower part of the abdo- 
men, and she died on the twentieth of July. At the autopsy the lungs 
were found tubercular. As to whether a lentil-sized adherent nodule 
which was found in a calix of the kidney was a metastatic growth, or not, 
the history does not state. The specimen is in the Prague anatomical 
collection (No. 2069) and has been examined and described by Klebs. 
In the right half of the anterior vaginal wall behind the orifice of the 
urethra there was found a nodular, broad-based tumor, the size of a fist, 
which extended about three-quarters of an inch towards the vaginal vault. 
It was broadest in front and diminished in size backwards. The poste- 
rior and left walls of the vagina were free. The mucous membrane spread 
over the tumor, and the surface was generally smooth. At the lower ex- 
tremity, which projected a trifle from the vagina, there was a funnel- 
shaped cavity. On cross section, the surface was smooth and fibrous. 
The growth extended into the perivaginal cellular tissue to the right and 
posteriorly. The uterus was small, body and cervix unchanged, the 
cavity one and a half inches deep. The adnexa were generally adherent, 
and Douglas's fossa contracted. The right tube and ovary could be freed 
from the adhesions, and were unchanged. The left tube was dilated, 
the left ovary unrecognizable. The bladder was healthy, the urethra was 
slightly pushed to the left by the growth. Kaschewarowa found in the 
examined sections all the developmental forms of striated muscular fibre. 
The muscular elements were arranged here and there parallel one to an- 
other, and bound together in a species of bundle; in other places they 
were intermingled with myxomatous tissue. The surface of the growth 
was covered with flat epithelium. The mucous membrane contained 
neither papilla) nor characteristic cellular tissue or muscular elements, NEW GROWTHS. 
353 
but these elements were scattered throughout the layer of the tumor 
under the epithelial stratum. Kaschewarowa concluded, hence, that the 
tumor had probably had its origin from the mucous membrane. Klebs, 
seeing that he was able to follow the young muscular fibres of the para- 
vaginal tumor into those which belonged to the levator ani, concluded 
with a greater show of reason that there existed rather a hyperplasia of 
normal muscular tissue. Thence there arose growth of the interstitial 
and muscular elements, some *becoming myxomatous, others of striated 
muscular fibres deprived of the sarcolemma, while the more recent intra- 
vaginal portions contained only spindle cells. The striated young spindle- 
form muscular cells, detected by Kaschewarowa and also by Treitz and Ep- 
pinger, in sections from the fresh preparation, were not found by Klebs in 
Fig. 32.-Myxomatous Rhabdomyoma of the Vagina. (Hartnack, 3, viii.) 
the alcoholic specimen. Neither can I find them in the sections kindly 
furnished me by Eppinger. I find, however, young striated cylinders 
next to the muscular bundles, as is shown in the illustration. 
In the diagnosis of vaginal tumors this peculiar arrangement must be 
remembered, and on account of their rapid growth they suggest the pos- 
sibility of the existence of the malignant soft sarcoma. Indeed, in a case 
of Hauser's, of primary sarcoma of the vagina in a two year old child, the 
same long striated spindle-cells were found, passing into young striated 
muscular fibres. In such instances complete extirpation down to the 
base of the growth is indicated, and as to whether the knife, scissors, 
ligature, or galvano-cautery is preferable will depend on the peculiarities 
of the individual case. 354 
THE DISEASES OF THE VAGINA. 
I). Papillary Tumors. 
In addition to the not uncommon condylomata which are found in the 
vagina, generally as the result of a virulent catarrh, and which, particu- 
larly in the gravid, often develop greatly, there are a few cases recorded 
of diffuse papillomatous degeneration of the vaginal mucous membrane. 
The papillary excrescences described by Klob are not properly tumors, 
but simple hyperplasia of the papillse in the neighorhood of ulcers, analo- 
gous to the enlargement of the villi around ulcers of the intestine. Al- 
though in these formations we are dealing with simple lengthening of 
papillae on inflamed surfaces, Miillerklein, Marsh, and Crook have de- 
scribed characteristic forms of new growths, the histological formation of 
which has not been definitely stated. They are, however, differentiated 
by their clinical phenomena. Miillerklein's case concerned a woman of 
thirty-eight, greatly weakened from protracted leucorrhoea and metror- 
rhagia. Miillerklein found on the upper portion of the posterior vaginal 
wall, a cauliflower-like tumor, the size of a hen's egg, with a pedicle an 
inch thick. He extirpated it with the scissors, and it had not recurred 
at the end of a year. Anatomically it was found to be a characteristic 
cauliflower growth. Marsh saw a two year old child, in whom for a long 
time many formed and colored new growths had projected from the vulva 
and the urethra, and had constantly recurred after extirpation. The 
child died speedily from exhaustion. The growths consisted in "a poly- 
poid swelling of the mucous membrane of the bladder and the vagina, 
with fibrous base, in part smooth, in part covered with epithelium, and 
generally very vascular." Sanger has since stated that Marsh's case had 
again been carefully examined, and that Beck's report pronounced the 
specimen to be hyperplasia of the cellular tissue in the vesico-vaginal 
septum associated with hyperplasia of the mucous membrane. In no 
part of the specimen was tissue found which did not correspond to simple 
hyperplastic swelling of the normal tissue. 
In Billroth's case, which is only briefly reported, the child, aged eighteen 
months, had suffered for two months from bloody purulent discharge from 
the vagina, and the vagina was filled with goft, pediculated, polypoid 
vegetations, which could not be determined as sarcomatous. 
Although, therefore, we are not justified in classing these cases under 
sarcoma, still the clinical course suggests their analogy with genuine sar- 
coma. The development is similarly rapid, the course malignant, the 
site the same on the vesico-vaginal septum where the infiltration is most 
marked, and here also there exist polypoid growths of the mucous mem- 
brane towards the vagina and to a less degree towards the bladder. It 
seems as though in the histological formation of these growths this locality 
is favored, and that occasionally a fibroma results, and then a sarcoma. 
In Hauser's case there was simultaneous development of sarcomatous, NEW GROWTHS. 
355 
myxomatous, and rhabdomyomatous elements. In regard to Muller- 
klein's case, we have no exact anatomical explanation, and the possibility 
exists that it may have been carcinoma or sarcoma, although there had 
been no recurrence at the end of one year. I have not been able to see 
the history of Crook's case. 
E. Partial Hyperplasia. (Polypi.) 
Under this name we include the rare cases which are recorded indiffer- 
ently as polypi or pediculated fibromata. Kiwisch refers to them as the 
most frequent variety of polyp forms, and describes them as ordinary 
mucous tumors, analogous to the glandular polyps of other mucous sur- 
faces. He seems to have met with them frequently, since he states that 
in the majority of his observations they were the size of a hen's egg. Ac- 
cording to Kiwisch they may spring from any portion of the vagina, 
although the posterior wall is the most common site. Generally they 
have a thin pedicle or they are club-shaped, and the texture is the same 
as that of othei' mucous polypi. • They cause symptoms only when they 
attain considerable size and work their way into the vestibule. In a case 
of labor Kiwisch witnessed such traction on a polyp the size of a hen's 
egg, that it became inflamed and degenerated in part. I am familiar with 
only a single case, which was shown me by Eppinger in the Prague col- 
lection. It is a broad-based, conical polyp, three-quarters of an inch long, 
and about as thick as the little finger at its base. The surface is smooth 
and covered by the epithelial layer. In texture it consists of simple 
hyperplasia of the submucous tissue and ectatic lymph vessels. I can 
find no recorded instance of the pediculated club-shaped growths which 
Kiwisch describes. As analogous to them I can simply mention the 
string-like or tongue-like projections which are occasionally found on the 
borders of the hymen in new-born foetuses, which may attain quite a size. 
I recently removed such a mucous, string-like projection, about two and a 
half inches long, and the thickness of stout twine. It turned out to be 
a simple enlarged papilla, in the connective tissue of which were ectatic 
vessels. 
A positive diagnosis of partial hyperplasia of the mucous membrane 
may be reached by the presence of a slowly developed, broad-based, poly- 
poid, soft tumor, of normal mucous membrane color, which differenti- 
ates it from the various growths of the vaginal mucosa. 
The treatment consists in excision. 
F. Lipoma. 
Pelletan has described lipoma in the recto-vaginal septum, spreading 
towards the lumen of the vagina, but he gives us no histological data. 
Still I will record the following unique cases: In a woman forty years old, 356 
THE DISEASES OF THE VAGINA. 
there had grown for three years a tumor in the recto-vaginal septum, 
which projected from the patent vulvar cleft, was cylindrical in shape 
and was eight inches in length. By rectal examination it appeared glo- 
bular. It was perfectly movable, and its mucous covering, which was 
ulcerated at its upper portion, could be slid over it. The growth was not 
at all painful even on pressure, but the patient suffered from leucorrhma 
and menorrhagia, which had greatly weakened her. Pelletan incised 
the capsule longitudinally, and enucleated the growth partially with the 
finger, and partially with the handle of a scalpel. He packed the cavity, 
which bled profusely, with charpie, and removed it on the fifth day. 
The patient recovered well, and. the menses became regular. Pelletan 
pronounced the tumor a lipoma. In a similar manner he removed a 
lipoma from a young girl of seventeen or eighteen years of age. The 
tumor had existed for two years and caused a profuse foul discharge. 
It lay between the vagina and the rectum, was globular, the size of a 
fist, and the surface was ulcerated. This tumor was also movable as 
well as the mucosa covering it; it was not at all painful, even on pressure. 
G. Sarcoma. 
The recognition of this variety of new growth in the vagina belongs to 
very recent times. It appears in the form of a circumscribed round tumor 
in the sub-mucous tissue, and also as a diffuse superficial degeneration of 
the vaginal walls. Without question instances of the first sort may, with- 
out close histological examination, be ranked with fibromyomata, and 
those of the second sort with carcinomata. Further, primary sarcoma of 
the vagina, as is proved by Sanger's case, may develop, in a similar manner 
to the rare forms of papillary sarcoma of the cervix (Spiegelberg, Winck- 
ler,) into polypoid papillary excrescences. It is interesting to note at 
what an early age this growth has appeared in the few recorded cases, 
and also that in a single case (Demme's) it is stated that at birth a tumor 
the size of a pea was found between the labia. In case Babes's instance 
of primary endothelial sarcoma, (a movable, walnut-sized, readily enucle- 
ated tumor, which returned after three years as a spindle-celled sarcoma), 
which existed in the introitus vaginas, be classed here, then I find six 
instances of sarcoma of the vagina in small children, as certified by 
microscopic examination. In Hauser's case the age was two years; in 
Soltmann's two and a half years; in Sanger's and Babes's three years re- 
spectively; in Ahlfeld's three and a half years; in Demme's five and a 
half years. Of the instances observed in adults, the youngest patient was 
seventeen (Kaschewarowa), the oldest fifty-eight (Spiegelberg.) 
The anterior vaginal wall was entirely or largely the seat of the growth 
in six instances (four times in children), and in the histories to which I 
have had access the posterior vaginal was affected twice, the right lateral NEW GROWTHS. 
357 
wall once, and. the entire circumference of the vagina once. Ordinarily, 
and five times in children, the first sign was the appearance between the 
labia, without subjective symptom, of a small polypoid tumor. In the 
adult the symptoms appear to have been slight until the tumor began to 
grow rapidly and to partially break down. When the growth was accom- 
panied by increased secretion, atypical hemorrhages, dysuria, bearing 
down sensations, then it had attained considerable development. When 
suppuration and extension to the neighboring organs had occurred, then 
the symptoms were dependent on the local changes, and in children, es- 
pecially, the pressure symptoms on the pelvic organs were very marked. 
Although in many instances the growth of this tumor extended over a 
number of years, especially the fibro-sarcomatous form, yet in the 
majority of cases the malignancy of vaginal sarcoma was most apparent. 
In every case, except Spiegelberg's, the growth recurred with great 
rapidity after extirpation (in Demme's case, where the record states that 
there was as yet no recurrence, this was written a short time after ex- 
tirpation). Although the quick recurrence in many instances may have 
been due to imperfect extirpation, yet there is not a single case on record 
where recurrence did not set in, and this is characteristic of this variety 
of tumor. 
Owing to the variety of these tumors we will record a number of in- 
stances. 
Kaschewarowa reports two cases. The one concerns a strong multipara, 
in whom two years previously there had appeared a small tumor on the 
posterior vaginal wall near the fornix, which slowly increased in size, re- 
sisting all local measures, and which was as large as a gulden and was 
ulcerated on the surface. Professor Kieter extirpated it, and it proved 
to be a spindle-celled sarcoma lying in the mucous membrane and extend- 
ing scarcely at all in the submucosa. Recurrence speedily set in. 
Kieter's second case, of a similar nature, was seen in the Moscow Marten 
hospital, and concerned a maiden of seventeen. On the posterior vaginal 
wall was a soft, easily torn, tumor, the size of a goose-egg, and in four 
months after extirpation it had recurred and was the size of a fist. The 
very anaemic patient died shortly after the second operation. 
In Spiegelberg's first case a circumscribed fibro-sarcoma of the lower 
portion of the anterior vaginal wall, the size of a walnut, was extirpated, 
and pronounced by Waldeyer to be a spindle-celled sarcoma. The patient 
convalesced well, although she was in poor condition at the time of 
operation, and four years afterwards there was no recurrence. The 
patient had borne four children, the last time four years previously. 
Spiegelberg's second case concerned a woman of fifty-eight, who had 
been married twenty-two years, was sterile, and had reached the meno- 
pause at forty. At fifty-seven she began to suffer from hemorrhage, 
which gradually became more profuse. The patient was anaemic but well- 358 
THE DISEASES OF THE VAGINA. 
nourished, and just within the introitus vaginae the mucous membrane 
was irregularly infiltrated, and bled readily. The condition suggested a 
superficial ulceration, epitheliomatous infiltration, nodular in places. 
The uterus was atrophied but healthy, the pelvic organs were not infil- 
trated, the inguinal glands not enlarged, the abdominal and thoracic organs 
were sound. Excision was accompanied by profuse hemorrhage. Conva- 
lescence was retarded by diffuse abscess of the inner surface of the left 
thigh, by lymphadenitis inguinalis of the same side, and by diphtheria 
of the wound. A deep abscess in the groin was repeatedly opened, but 
the drain on the patient's strength was too excessive, and she died in a 
few weeks. Waldeyer examined the growth and reported that it had 
the character of a small-celled medullary sarcoma. 
Bajardi's patient was twenty-five years old, of healthy parentage, and 
had menstruated regularly from her sixteenth year up to marriage. At 
the fifth to sixth month of her first pregnancy, she began to have the 
sensation of a foreign body in the vagina, and suffered from pain when 
she attended to her work, that of weaving, for a number of hours. 
Towards the end of the eighth month her suffering was so great that she 
entered the hospital. Raccaqui and Colombo found a tumor, the size of 
a. hen's egg, projecting from the vagina, and growing by a pedicle the size 
of the thumb from the posterior vaginal wall. On the pedicle was a 
lobule the size of a bean. There existed in addition a smaller isolated 
tumor to the left of the middle of the posterior vaginal wall. The large 
tumor, since from its size it would prove an obstacle to delivery, was re- 
moved by the galvano-cautery, leaving its base behind. Microscopically 
it proved to be a round-celled sarcoma. After two months, the patient 
having in the meantime been delivered, the pains recurred, and one 
month later she was seen by Bajardi. He found two tumors in the pos- 
terior vaginal wall, broad-based, the larger the size of a hen's egg, of vary- 
ing consistency. Examination caused neither pain nor hemorrhage, the 
inguinal and pelvic glands were normal. The tumors -were not ulcerated. 
They were extirpated by the galvano-cautery. No hemorrhage. Before 
being discharged the growth slowly recurred, the glands throughout the 
body becoming affected, and metastases were present in the skin and the 
mammae. The patient died in eight months of peritonitis. There was 
no autopsy. Microscopic examination of the larger tumor proved it to 
be a round-celled sarcoma, of the smaller a spindle-celled. 
Of the instances seen in children, Sanger and Hauser have recorded 
histories of uncommon interest. 
Sanger's Case.-A three year old child was brought to the Leipsic 
clinic the 16th of August, 1879. The mother stated that the child had 
been well up to four months previously. It had then begun to lose 
flesh, and to complain of painful micturition and defecation, the bowels 
acting only at intervals of two days. It had a profuse foul vaginal dis- NEW GROWTHS. 
359 
charge, and occasionally a tumor the size of half a finger appeared at the 
introitus vaginae. On one occasion a body the size of a small apple had 
been expelled with hemorrhage of three days' duration. Attempt had 
been made to rape the child about five months previously, from which 
date the mother dated its complaint. From the vulva hung two bodies 
like mucus polypi, pediculated from the posterior hymeneal border. On 
bearing down there appeared at the introitus a still larger tumor, with 
ulcerated surface, distending the vagina and sessile on the anterior wall. 
There existed in addition a number of polypoid excrescences, like hydatids, 
occupying various portions of the mucous membrane and readily separa- 
ble. These masses were curetted away with but slight hemorrhage. A 
few weeks afterwards examination under anesthesia revealed a number 
of the same polypoid excrescences. The broad ligaments were thick- 
ened, and dense masses occupied the recto-vaginal septum. The curette 
was used again. Microscopically the masses proved to be typical round- 
celled sarcoma. The child died in four months after Sanger first saw 
her. 
Hauser's Case.-The child was of healthy parentage. At the age of 
six months, on crying or bearing down, a tumor the size of a bean would 
appear at the vulva; at the ninth month it had attained the size of a 
walnut, and it remained external, where it soon ulcerated and caused 
great pain. In April, 1880, it was removed by the family attendant; 
in five months it had recurred; in October, 1880, it was again extirpated 
and recurred in four months, and grew rapidly. In January, 1881, the 
child was taken to the Erlangen clinic, and the tumor was the size of a 
medium-sized pear. The child's general condition was good. Zweifel 
removed as much as he could without injuring the bladder, and chloride 
of zinc was applied to its base. On the sixth day there was recurrence. 
The curette was used and the little one discharged on the 22d of January, 
1881. In April she returned to the clinic, and the tumor was the size of 
a walnut and ulcerated. It was easily removed without hemorrhage. 
The vagina was enormously distended with soft papillary excrescences, 
which were readily removed. The patient was discharged in six days, 
but in May Hauser again noted recurrence. The case was then lost sight 
of. Microscopic examination proved it to be a round and spindle-celled 
sarcoma. 
The diagnosis can only be made by the microscope. The prognosis, 
hence, cannot be stated before extirpation. The myoma-like forms are 
more favorable, since the\ can be entirely removed, than the flat, diffuse 
forms, as is proved by Spiegelberg's case, where there was no recurrence 
at the end of four years. 
As regards the treatment, the same measures are indicated for the round 
tumors as is applicable to fibromata, and for the flat, diffuse, the same as 
in carcinomata. \ 360 
THE DISEASES OF THE VAGINA. 
H. Cancroid and Carcinoma. 
These growths are also rarely primary in the vagina, but quite fre- 
quently secondary, in particular by extension of carcinoma from the 
uterus to the fornix vaginae, and next from that of the rectum, vulva, 
urethra, less frequently from the bladder, and further as metastases from 
distant carcinomatous foci. Kuster has given us the latest collection of 
cases of primary carcinoma of the vagina, and after the exclusion of a 
number of cases which seemed doubtful to him, he has obtained twenty- 
two instances, to which number Olshausen has added two. Primary car- 
cinoma of the vagina is met with in two forms: the first and most fre- 
quent is the papillary cancroid, and the second is the carcinomatous 
infiltration. The first is generally seen as a circumscribed broad-based 
excrescence, generally on the posterior vaginal wall, and the second as a 
substitution for the normal tissue of medullary or schirrous masses. Of 
nine instances of this variety (without differentiating the carcinoma form), 
in foui' the entire length of the vagina was affected. The posterior wall 
was affected nine times, the left posterior once, the right once, both 
lateral walls once, the anterior wall twice. 
In regard to etiology the reported cases give us meagre information. 
The same rule holds as regards age as in carcinoma of the uterus. The 
majority of the cases occurred between thirty-one and forty years of age, 
nine cases; four cases occurred between forty and sixty years. Excep- 
tionally the disease occurs at an earlier age. Kuster records two cases 
from fifteen to twenty, and two from twenty to thirty. In the Strassburg 
pathological museum there are four specimens of primary carcinoma of 
the vagina, and one is a broad-based glandular carcinoma, which was 
removed from the posterior fornix vagina? of a nine year old child. In a 
single case reported by Hegar, traumatism was the etiological factor, and 
he removed two cancroidal nodules in a woman fifty years old, caused by 
the pressure of a closed Hodge pessary against the ascending ramus of 
the pubes. 
All forms of carcinoma vaginae lead to rapid destructive ulceration, 
with peripheral and deep extension into the neighboring tissues. As the 
growth breaks down there results an elevated cancerous ulcer which may 
eat its way into the adjoining organs, and owing to the frequent seat on 
the posterior vaginal wall, a recto-vaginal fistula is often established. Ex- 
tension by the lymphatics into the glands of the pelvic cellular tissue 
occurs, as also into the inguinal glands in case of the deep-seated form. 
The usual symptoms are hemorrhage, suppuration and pain; occasionally 
there are mechanical symptoms, during cohabitation and delivery, the 
result of stenosis and obstruction of the lumen of the vagina; farther 
there are symptoms from the side of the adherent neighboring organs. 
The most important and never-failing symptoms are the anomalies in NEW GROWTHS. 
361 
secretion, the watery, bloody, and purulent discharges. These depend 
partially on the form and the vascularization of the carcinoma, partially 
on the stage of the growth. Coitus and other mechanical insult, such as 
distension of the recto-vaginal septum by constipation, are causes of hem- 
orrhage, as is proved by the recorded histories. Bod win's case of ' ' erectile 
cancroid" is an instance of unusual vascularization. It concerns a woman 
of thirty-one, whose father and grandfather had died of cancer, and who 
was suddenly seized with profuse hemorrhage from the genitals. Bod- 
win found a vascular tumor the size of a walnut, on the anterior vaginal 
wall near the urethra, from the centre of which an artery the size of a 
needle spouted. The hemorrhage was checked by the local use of a so- 
lution of sesquichloride of iron, tampons, and rest in bed. In a few days 
it recurred. On the seventh day the tumor was ligated, it fell off in a 
few days, and left an apparently healthy granulating surface. Soon a 
foul dark discharge set in, and after fourteen days a large cauliflower-like 
growth was present. The hemorrhage did not recur, but the discharge 
became more profuse and foul, depreciated the woman's strength, and she 
died six weeks after the first hemorrhage. At autopsy a number of large, 
soft, carcinomatous masses were found on the posterior vaginal wall, dis- 
tending the vagina; the rest of the mucous membrane was injected and 
thickened. The organs so far as they were examined, were normal. As 
a general thing, the discharges, the suppuration, and the inflammatory 
and septic complications only lead to death after wide extension of the 
disease. 
Complication with pregnancy has been noted once. Bailly saw a gravida 
with a voluminous, lobulated carcinoma of the recto-vaginal septum, 
which had developed in the fifth month of pregnancy, and proved an ob- 
stacle to delivery. In the last three months of this pregnancy, the patient 
began to have a watery, at times reddish discharge, which during the 
fourteen days preceding delivery became profuse, and since it had no 
odor it was considered to be liquor amnii. The patient had only suffered 
pain during coitus, after which act she had ordinarily lost a small quantity 
of blood. During the second stage of labor the posterior vaginal wall to- 
gether with the tumor was driven down to the vulva by the advancing 
head, and they retreated during the intervals. The tumor was neither 
torn nor did it bleed, although the child was removed artificially. The 
puerperium was normal. A month later the patient was very thin and 
anaemic, any exertion causing hemorrhage, and in the intervals there was 
a constant serous discharge. The speculum was carefully introduced, 
and the surface of the tumor was seen to be warty and white; it occupied 
the entire posterior vaginal wall. The tumor was much softer than at 
the time of delivery. On touch by the finger or instruments, there re- 
sulted hemorrhage, and pain, with faintness. Five months after deliv- 
ery the woman died of exhaustion. Kuster has recorded an instance of 362 
THE DISEASES OF THE VAGINA. 
induction of labor by means of an elastic catheter in case of extensive 
carcinomatous infiltration of the vagina in a woman of twenty-four, who 
had previously miscarried three times. During the third pregnancy she 
began to suffer from profuse leucorrhoea, and since the third puerperium, 
she had almost constant hemorrhages, and in the interval watery dis- 
charges. During the fourth pregnancy, she bled almost continuously. 
The vaginal walls were covered with a large number of elevations and 
depressions, the lower inch of the canal alone being normal, smooth 
and soft. The external os was smooth and intact, and the cervix as well, 
although the canal was patulous. To the right and posteriorly the cervix 
was roughened. The masses were curetted, and the vagina irrigated with 
carbolic acid. Labor was induced eight days thereafter, delivery occur- 
ring in two days. During labor the patient was feverish and complained 
of pain to the right of the uterus. Seven days after delivery she died of 
septic pyemia. A. crescentic ulcer, 3f inches in diameter, was found in 
the vagina, with hard walls. The base of the ulcer was uneven, torn, 
covered with a yellowish-green deposit. It extended down to the mus- 
cularis. It began a finger's breadth above the introitus and extended on 
to the cervix, more to the left than to the right. On the anterior wall 
the mucous membrane was not implicated longitudinally for about $ of 
an inch. In the diagnosis of carcinoma of the vagina, the well-known 
broad-based, nodular, immovable tumors are characteristic. They readily 
bleed on touch, and the serous or purulent discharges are always present. 
Papillary cancroids may appear as marked cauliflower-like excrescences, 
with great tendency to hemorrhage, and readily breaking down, and even 
microscopically they may thus be differentiated from large simple papil- 
lary hypertrophies. It is important to determine as to whether the growth 
is primary or secondary. It is necessary to carefully examine the neighbor- 
ing organs, in particular those of predilection. Only where the cervix is 
not implicated, or else only externally near the vaginal growth, only 
where the rectum and the vulva, the bladder and urethra, are free, and 
no traces are found in other organs whence metastasis might take place, 
can we assert that the growth is primary in the vagina. Differentiation 
from sarcoma is to be made by the microscope. The cancroid and papil- 
lary forms generally extend from neighboring organs, the flat and strati- 
fied are usually primary, while the infiltrated nodules are most frequently 
metastatic from distant organs, such as the stomach. 
The nugatory results from the treatment of carcinoma when primary 
in the vagina depend on the difficulty of removing the growth in its en- 
tirety. Curetting with the sharp spoon, removal by the galvano-cautery 
and ligature, cauterization by various agents, and the hot iron, extirpation 
with the knife, these have all been tried without result. Nevertheless 
attempts should ever be made at extirpation. Where the tumor is still 
circumscribed in extent and in depth, so that its removal with the knife NEW GROWTHS. 
363 
or scissors is possible, the procedure is to be recommended not only on 
account of the certainty of being able to work in non-infiltrated 
tissue, but also on account of the possibility of checking the hemorrhage 
by ligature or suture, since the movability of the vaginal walls allows of 
the approximation of quite large wounds by means of suture. According 
to Hegar and Kaltenbach we should not abstain from operation fox' fear 
of injuring the bladder or the rectum, for any incision into them, after 
the removal of diseased portions, may be closed by suture. Schroeder has 
recently performed the most radical operation in such cases. He operated 
in three cases of carcinoma of the posterior wall, where the disease reached 
the fornix. He first incised superficially the vaginal mucous membrane 
from the entire tumor. At the upper border he prolonged the incision 
through the entire thickness of the mucous membrane, and loosened the 
carcinoma from above downwards. In one of these cases the peritoneum 
in Douglas's fossa was torn, and brought together by suture. In the first 
two operations he simply united the edges of the mucous membrane cross- 
wise, and this left a depression in the posterior fornix, where the secre- 
tions collected, and this led to suppuration. In the last case he included 
the rectal wall by sutures which did not extend through it, and then fixed 
a drain tube in the posterior fornix. The first patient died of sepsis 
from suppuration of the wound; the second recovered and two and a 
half months thereafter there was no recurrence; the third patient recov- 
ered from the operation, but it is too early to make any statement in 
regard to ultimate result. 
It is very exceptionally, however, that cases suitable for operation are 
met with, and ordinarily our operative aim can only be palliative in order 
to control for awhile the hemorrhage and the suppuration, and this is 
done by the measures we have spoken of. The more deeply we are able 
to cauterize, the longer in duration the result. Exceptionally, however, 
this may cause profuse hemorrhage, as is proved by the following case 
recorded by Griinewaldt: In a woman of thirty-two the cervix was am- 
putated for carcinoma, and six months thereafter there was recurrence 
on the posterior vaginal wall which included the cicatrix left by the previ- 
ous operation. In the attempt at removal of this recurrent growth, by 
the galvano-cautery, a profuse parenchymatous hemorrhage occurred, 
which resisted treatment, the patient dying in about six minutes. At the 
autopsy it was found that the anterior branch of the hypogastric artery 
had been cut through in the incision. Spiegelberg records an instance of 
sarcoma, where an analogous operation was performed, and where ab- 
scess occurred which quickly led to the death of the patient. CHAPTER IX. 
FOREIGN BODIES IN THE VAGINA. 
T^OREIGN bodies of most varying nature have been found in the 
-L vagina. Aside from pessaries, which, in addition to their curative 
properties, are able to inflict great damage, and aside also from tampons, 
many articles, such as pomade boxes (Dupuytren, Schroeder), pepper 
boxes (Mavel), spools (Pearse, Hoffmann, Carter, Breisky), needle cases 
(Forster), hairpins (Getchell), purses (Forster), lead pencils (Jobert), etc., 
have often been extracted from the vagina. Worms and insects, and we 
are not speaking now of parasites, have also been found. Voigtel found 
ascarides, which had crept from the anus into the vagina, as the cause 
of a persistent discharge; Cockson has reported a similar instance; Wal- 
denstrom found the lumbricus communis in the vagina. 
The foreign body usually gets into the vagina by the introitus, and only 
very exceptionally by perforation from the bladder or rectum. At times 
manipulation with fragile instruments results in retention of a foreign 
body; Kurz extracted the upper extremity of a glass speculum, which 
was imbedded in granulations; Day a broken remnant of a glass syringe 
which had been used for injections. Ascarides, as we have stated, proceed 
from the anus; and as for the common worm we should remember, as 
Meissner has stated, that certain women will introduce them. 
In children foreign bodies may be inserted during play, as Meissner 
detected in a two year old girl, and at times articles, such as purses, may 
be concealed in the vagina. In the majority of instances, the foreign 
bodies are unquestionably inserted during masturbation, and, slipping 
from the fingers, they are carried deeper into the canal by its contractions. 
Where small objects are inserted into the canal, they may be sucked in 
deeply in the presence of negative intra-abdominal pressure. Of the in- 
stances of foreign bodies in the vagina, which I have noted, I will record 
two here, one in particular being of special value from the standpoint of 
diagnosis, sequelae and treatment. 
A twenty-eight year old nullipara had seven years previous to my see- 
ing her inserted a wooden spool into the vagina. Thereafter she had 
occasional purulent discharge from the canal and menstruation, which 
had previously been regular, became painful. Three years after the in- 
troduction of the body, a swelling appeared in the left groin, which was FOREIGN BODIES. 
365 
opened by a physician, and a large amount of pus was evacuated. For 
three months the purulent discharge continued, the patient being confined 
to bed with high temperature. After the wound in the abdomen healed, 
the menstrual disturbances increased, the discharge becoming brownish- 
red in color; in the inter-menstrual periods she had a foul, thin, dark, 
discharge. She finally entered the hospital. The patient had always 
denied the insertion of the foreign body, although the history suggested 
it. Careful examination, however, pointed to the falsity of her assertions. 
As is shown in the figure, there existed cicatricial contraction of the 
vagina, so that the vagino-abdominal examination was negative. By 
recto-abdominal examination the uterus was found slightly enlarged, and 
Fig. 33. 
behind it there existed a fluctuating sac the size of an orange, and in this 
sac a hard, movable body could be felt, which could be readily recognized 
as a spool. I finally managed to obtain from the patient the fact that 
she had inserted such an object into the vagina, as also particulars in 
regard to its nature. With considerable trouble the small fistula leading 
into the cavity above the stenosis in the vagina was found, and under 
chloroform it was thoroughly dilated, a canula was inserted, and a large 
amount of stinking pus was evacuated. While an assistant steadied the 
foreign body by means of his fingers in the rectum, I was enabled to seize 
it with the fingers and to extract it. The spool measured about one and 
a half inches long and was about three-quarters of an inch thick. The 
sac -was washed out with 5 per cent, carbolic acid, and packed with iodo- 
form gauze. On the following day this gauze was removed, and the 
patient menstruated without special pain. I afterwards treated the ste- 366 
THE DISEASES OF THE VAGINA. 
nosis by dilation and incision, and when the patient was discharged in six 
weeks medium-sized specula could be inserted. 
In the second case, a young woman had been delivered two weeks pre- 
vious to my seeing her; the perineum had been lacerated to the sphincter, 
and although the primary operation had been performed, union had not 
occurred. The patient's husband, who was a physician, detected faecal 
matter in the vaginal discharges, and he and his colleague came to the 
conclusion that a recto-vaginal fistula existed. I was asked to see the 
case, detected no fistula, although there was unquestionably faeces in 
the vagina. On close questioning, the patient told us that a few days pre- 
viously she had had a copious movement of the bowels, and that a portion 
of the faeces had passed into the vagina. The vaginal injections which 
had been administered had not sufficed to cleanse the passage of these 
masses, and they had acted as foreign bodies, causing the profuse, foul 
discharges. 
The results of the presence of foreign bodies vary, of course, according 
as injury has been inflicted during their insertion; further, on the mate- 
rial, size, form, and length of retention of the object. In general all for- 
eign bodies soon lead to catarrhal secretion, and they become coated with 
the same. As a result, in course of time triple phosphate and lime salts 
are deposited, and the foreign body becomes eventually the kernel of a 
concretion, even as happens in the bladder. Getchell has recently re- 
corded an instance where a hairpin formed the kernel. Without ques- 
tion the cases frequently recorded by the older writers are similar in- 
stances, although certain of them were calcified fibromata, which had 
escaped from the uterus, and also vesical calculi, which had ulcerated 
into the vagina. The incrustation of the foreign body roughens its sur- 
face, and it becomes still more of an irritant with resulting increase in 
the catarrhal symptoms. In case of access of air or putrid matter the 
secretion from the inflamed mucous membrane may become purulent or 
the source of sepsis. Ulcers and fistula? are apt to be caused, the ulcera- 
tion eventuating in peri-vaginal abscesses, purulent pelvic peritonitis, 
septic infection, which, as in one of Hoffmann's cases and in Leonard's, 
maybe fatal. Another of the sequelae is hemorrhage, the result, not alone 
of the traumatism, but also of the secondary ulceration. In case of 
chronic ulceration, the granulations spread over the foreign body, which 
is thus fixed in cicatricial tissue from which it is difficult to extract it, 
and further, the cicatricial process may lead to atresia vaginae of high 
grade, as in the cases seen by Siixinger, Carter, and myself. 
In many cases the history will suggest the presence of a foreign body, 
although sometimes the patients have forgotten or do not know that they 
are in the vagina. Most careful examination may be necessary for their 
detection by all the methods at our disposal, and strict antiseptic rules 
should be followed. FOREIGN BODIES. 
367 
We can lay down no general rules for the removal of foreign bodies, 
for we should choose in each case that method which permits our attain- 
ing our object with the least possible injury. Small and loose bodies in a 
cul-de-sac (worms and insects) may often be dislodged by copious injec- 
tions of warm water through a speculum. Round and hard bodies, in 
case of narrow vagina, may be pressed out by a finger in the rectum, as 
Meissner did in the case of his two year old patient, who had a small 
stone in the vagina. Many foreign bodies may be removed under guid- 
ance of the finger, but for others the speculum must be used. In case 
of pins it should be remembered that the points are rarely directed up- 
wards, but that they must be loosened anteriorly before they can be 
extracted. In case, during extraction, injury to the vaginal walls is 
feared, these must be protected by retractors. For the removal of larger 
objects the obstetrical forceps may be useful. The greatest difficulty in 
extraction is offered by those bodies which must first be diminished in 
size, as is the case usually with hard rubber pessaries. Where the object 
is buried in cicatricial tissue, this must be incised, rather than torn. 
After the removal of the foreign body, attention must be turned to 
healing the damage inflicted by it. Although in general the symptoms, 
when they have not been very intense, will disappear spontaneously, often 
after-treatment is requisite, such as the use of antiseptic irrigation, to 
restore the parts to the normal. Cicatricial contraction, in particular, 
calls for treatment. CHAPTER X. 
INTESTINO-VAGINAL FISTULA. 
TN general the fistula is between the rectum and the vagina, communi- 
cation with other portions of the intestinal tract being exceptional, 
and then usually with intestine prolapsed in Douglas's pouch (usually 
coils of the lower ilium.) 
A. Recto-Vaginal Fistula. 
In reference to the regional anatomy of the recto-vaginal septum these 
fistula? affect ordinarily the lower (perineal) and middle (rectal) divisions 
of the posterior vaginal wall. Exceptionally they are also found in the 
upper division, the peritoneal, the fistula extending from the vagina 
through Douglas's pouch into the rectum. They result either from trau- 
matic causes, or else aside from these, through necrotic and ulcerating 
circumscribed sloughing of the recto-vaginal septum. 
Most frequently fistulas result during labor, in particular where the 
obstacle to delivery is great. Contrarywise to that which holds for ves- 
ico-vaginal fistula?, the cause is rarely prolonged pressure, since the recto- 
vaginal septum, except in funnel-shaped pelves, or where there is anchy- 
losis of the coccyx, is seldom for any length of time exposed to pressure, 
, the reverse being true of the vesico-vaginal septum. In the majority of 
cases the fistula? have their origin in lacerations of the distended posterior 
vaginal walls. The deep recto-vaginal fistula? result either after rupture 
of the posterior commissure or else after complete rupture of the peri- 
neum. 
Above the perineal division of the recto-vaginal septum, fistulae result 
from obstacles to delivery due to abnormal tension above stenosed parts, 
to tumors, or to pelvic contraction. Narrowness and rigidity of the 
vagina lead, ordinarily, to laceration which often extends into the rectum. 
Generally traumatism during difficult labor is the cause of fistulas. For- 
ceps, manual extraction, cephalotripsy, etc., play a large part in the 
etiology of recto-vaginal fistula?. Operations on the genital organs for 
atresia, the extirpation of tumors from the posterior vaginal wrall, etc., are 
also factors. Unskillful administration of enemas may result in perfora- 
tion of the recto-vaginal septum, and I have myself noted such an instance INTESTINO-VAGINAL FISTULA. 
369 
in a puerpera. We have already noted the fact that foreign bodies may 
canse fistulae, in particular pessaries. The seat of the fistulae varies 
greatly, those in Douglas's fossa, accompanied by prolapse of intestines, 
being of peculiar interest. Degenerated extra-uterine gestation sacs and 
ovarian cysts, may ulcerate through Douglas's pouch, and leave a fistu- 
lous tract; and further still, pelvic abscesses, diphtheritic and syphilitic 
ulcers, carcinoma and other new growths. 
The etiological factors noted act almost entirely in the adult. Recto- 
vaginal fistulae have very seldom been met with in children. Bednar re- 
ported an instance in a four weeks old infant, from gangrene of the vagina. 
The separation of the slough was followed by a fistula. Cellulitis of the 
right arm complicated the case, and the child died on the 21st day. G. 
T. Witter has recently recorded an instance in a seven months old child. 
For some months it had been troubled with aphthae, was much emaciated 
and complained of great pain on defaecation. Passage of faecal matter 
by the vagina was noted and on examination a fistulous communication 
between the rectum and the vagina was found. With improvement in 
the child's general condition, the administration of enemas, the tam- 
ponade of the vagina with cotton dipped incarbolized glycerin, the fistula 
closed, and the child was discharged in ten days. 
Aside from the cause of the fistula, the length of time that it has ex- 
isted has an influence on the size. There is present a tendency to cica- 
tricial contraction. Generally the fistula, when not caused by extensive 
breaking down of new growths, appears as a roundish gap on the vaginal 
and the rectal walls. When caused by traumatism one opening is gener- 
ally larger than the other, the' larger being on that wall where the trau- 
matism or ulceration began. In case of ulceration this is not always so, 
since the suppuration may extend and a secondary outlet may communi- 
cate with the first. A valve over the vaginal opening of the fistula is 
often formed by overlapping of the resisting muscular layer of one of the 
vaginal rug®. In a twenty-nine year old woman under my observation, 
who had a funnel-shaped fistula extending downwards obliquely towards 
the rectum, the vaginal opening was covered by a tongue-like valve from the 
lower end of the columna rugarum. The fistula dated from her first 
delivery, which was a difficult one. Immediately after delivery there was 
hemorrhage from the vagina and the rectum, and on the sixth day there- 
after passage of watery faeces and flatus by the vagina. In case of high- 
seated recto-vaginal fistulae, the vaginal opening is often directed from 
the mid-line, and fixed there by a cicatricial band. In two instances I 
noted this deviation to the left. 
The chief accompaniment of a recto-vaginal fistula, spontaneous pas- 
sage of faeces and of flatus by the vagina, makes the complaint most un- 
bearable and is the cause of great depression, owing to the loathsome 
nature of the affection, and the resulting irritation of the neighboring 370 
THE DISEASES OF THE VAGINA. 
parts. This symptom is not, however, always of the same intensity, but 
it depends on the size and the direction of the fistulous tract, as well as 
on the consistency of the faeces. Nevertheless, even under most favorable 
conditions, there is always likelihood of occasional uncontrollable passage 
of gases or of fluid faeces. The remaining symptoms from these abnor- 
mal communications, such as inflammation and erosion of the borders of 
the fistula, the foul vaginal discharge caused by mixture of faecal matter 
with the vaginal secretions, the vaginitis, depend essentially on the atten- 
tion which is paid to strict cleanliness. As long as there is no ulceration, 
these further symptoms, under favorable conditions, are scarcely noticea- 
ble, and exert scarcely any effect on the patient's general state. 
The ultimate result depends on the cause, size, and complications of 
the fistula. Fistulas, the result of carcinoma, simply increase in size; 
traumatic and ulcerous fistulas shrink considerably in the process of cica- 
trization, and this is the method of cure, frequently, in case of small fis- 
tulas. Occasionally spontaneous healing results in recent large communi- 
cations between the rectum and the vagina, those following on delivery 
for instance, which, owing to the traction at the time of occurrence, 
appear still larger. Winckel records an interesting instance of spontane- 
ous cure within two weeks after delivery. During the exit of the head 
the perineal division of the septum was torn so that the hair on the foetal 
head could be seen in the rectum. Large fistula?, with cicatricial edges 
remain stationary, and cause greater symptoms than the smaller. Very 
small fistulas may be enlarged at the next delivery, and again diminish in 
size, even disappear entirely, as I noticed myself in a case where a small 
fistula remained after a perineorrhaphy. At the next delivery it was en- 
larged so that it was patent for the finger, and yet three months p)ost- 
partum, it could not be detected. 
The etiological connection between difficult laborsand puerperal ulcer- 
ations makes clear the frequent association of recto-vaginal and vesico- 
vaginal fistulas with cicatricial contraction of the vagina. The complica- 
tion with chronic ulcers and with tumors, leads to permanency of the 
fistula. We would make special mention here of the rare cases where, 
in the presence of deep-seated recto-vaginal fistulae, tumors had prolapsed 
through Douglas's pouch into the vagina. Winckel saw an instance 
where the tumor was composed of intestinal coils as far as the sigmoid 
flexure. The patient had been delivered by forceps, and entered the 
Dresden lying-in hospital later for the relief of escape of faeces by the 
vagina. In the upper portion of the posterior vaginal wall, there existed 
a tumor the size of an apple, and in its centre was an opening which led 
into the sigmoid flexure. By the side of this irreducible tumor, to the 
right and to the left, was a large opening into the rectum. Winckel 
made the diagnosis of recto-vaginal fistula through which the upper por- 
tion of the sigmoid flexure had inverted and had united to the vaginal INTESTINO-VAGINAL FISTULA. 
371 
borders of the fistula. He endeavored to re-invert the gut by the col- 
peurynter, and by loosening the portion of the intestine which was adher- 
ent, and when he had accomplished reposition he sewed the edges together, 
inserting fifteen sutures. The patient was entirely relieved. 
I have seen a very rare instance of prolapse of a dermoid cyst through 
a deep-seated recto-vaginal fistula. A woman of thirty-nine, who had 
borne nine children and miscarried once of twins, was delivered for the 
eleventh time on the 25th of April, 1875. The breech presented and 
the after-coming head was only extracted manually after great effort. 
The placenta was artificially removed on account of profuse hemorrhage. 
On the ninth day of the puerperium, the patient had an attack of pelvic 
peritonitis accompanied by high fever and great pain. At the same 
time a profuse diarrhoea set in and a purulent vaginal discharge. In 
four months particles of hair began to be passed in the vaginal discharge, 
and a large mass from the rectum. A few days afterwards the vaginal 
discharge became fetid and contained feces. These symptoms lasted 
intermittently for a number of months. In nine months after delivery 
the menses recurred at normal intervals. With the disappearance of the 
inflammatory symptoms the discharge, and the passage of hair and faecal 
matter, ceased. I saw the patient first in June, 1876. She was thin 
and anemic, but able to attend to her household duties. The vagina was 
distended by a tumor the size of a fist, and pear-shaped, and resembling 
a polyp. The surface of the tumor was covered in places with hair which 
could readily be removed by the finger. The pedicle was as thick as the 
finger and proceeded from an opening in the left lateral fornix, through 
which the finger could be passed into a cavity resembling that of Douglas. 
There was a second opening at the lower border of the pedicle, which ex- 
tended into the rectum. The uterus was elevated and anteposed, not 
specially movable, and a trifle enlarged. There was no palpable exudation 
in the pelvis, and the ovaries and the tubes could not be felt. I reached the 
diagnosis of inverted dermoid cyst prolapsed into the vagina; my explana- 
tion of the occurrence was that a dermoid cyst (of the left ovary?) adher- 
ent in Douglas's pouch, had proved the obstacle to delivery, at which 
time the fornix vaginae was torn transversely, and through this tear a 
portion of the cyst prolapsed and this was the beginning of the inversion. 
The communication with the rectum did not form till later, since feces 
did not pass per vaginam till the fourth month after delivery. I re- 
moved the cyst (yide Fig. 34), and the patient recovered well, but as yet 
she has refused operation on the fistula. 
The diagnosis of recto-vaginal fistula is easy ordinarily, since we can 
readily examine the recto-vaginal septum. The finger may usually 
detect even a small fistula when its borders are thickened. The patency 
of the fistula may be determined by one finger in the rectum, and another 
in the vagina. In case of very small fistulas the sound is of assistance. 372 
THE DISEASES OF THE VAGINA. 
If the matter is still in doubt, injection of fluid into the rectum will settle 
it. Further still, the posterior vaginal wall and the anterior rectal may 
be exposed by the speculum. As for differential diagnosis, the only thing 
which might simulate the symptoms of fistula is the passage of air and 
of fgeces into the vagina from without. (See under Foreign Bodies in the 
Vagina, for a case in point.) 
The treatment of a recto-vaginal fistula can only be effective when it is 
possible to control the ulcerative process, and to cause regular cicatricial 
contraction of its borders, and when the size of the defect permits of 
closure. At the outset, then, a good result is rarely possible in case of 
Fig. 34.-Longitudinal Section through the Extirpated Tumor, aa1, External surface of 
the inverted dermoid; at a'a few hairs are seen. 6, bones, c, teeth alveoli, c', a tooth, d, inver- 
s .on opening covered with smooth peritoneum. 
carcinomatous fistula or those complicated by a chronic ulcerative pro- 
cess. Fortunately, the reverse holds true for the large majority of recto- 
vaginal fistulae, and the results of treatment are not unfavorable, although 
it cannot be stated that their cure by operation is certain. The tendency 
which we have noted towards shrinkage, and the not infrequent instances 
of spontaneous cure, exemplify this statement, especially when the fistula 
is of rather recent date. In case of fistulas following on labor, they 
should be left alone for six weeks before an attempt is made at artificial 
repair. Separation of the recto-vaginal wall, of recent traumatic origin, 
should, when possible, be repaired by suture. Defects the result of 
ulcerating processes should be incited to cicatrization of the borders. INTESTINO-VAGINAL FISTUL.E. 
373 
For this purpose rest and cleanliness, irrigation twice or thrice daily, and 
small lukewarm enemas, suffice. Tampons, carbolized or glycerinized, 
should be inserted into the vagina; where the ulcers are not healthy- 
looking, antiseptic applications may be made per vaginam, with occasional 
cauterization. In case of chronic recto-vaginal fistula? the treatment con- 
sists either in cauterization or in denudation followed by suture. 
Cauterization is applicable alone to small fistulae, the size of a pea even, 
and results more frequently in cure than do similar vesico-vaginal fistula?. 
Since the object is to destroy entirely the cicatricial tissue along the edges, 
and to cause the subsidence of fungous granulations, the caustic must be 
applied to both openings of the fistula. Lunar caustic, less frequently 
fluid caustics (nitric acid, tincture of cantharides, liq. hydr. nitr., etc.), 
are used. After cauterization the immediate effect is often a slight en- 
largement of the fistula, and later marked shrinkage sets in. It is ad- 
visable not to cauterize oftener than once in eight days. In cicatricial 
fistulae the cautery acts more energetically. R. Liston used with success 
the glowing wire. Dieffenbach laid stress on the necessity of causing 
concentric shrinkage. It was his custom to touch the rectal side of the 
fistula with nitrate of silver, and then for days afterwards he applied the 
actual cautery to the vaginal opening and the fistulous tract as well. 
Both vagina and rectum were then filled with charpie, and mild or strong 
injections, according to the case, were administered occasionally. Lat- 
terly, frequent application of the actual cautery has been rightly con- 
demned by Hegar and Kaltenbach, since the cicatricial tissue interferes 
with subsequent denudation and union by suture. In general, the small 
oblique fistulae are best suited for cauterization. Small thin-walled fistula? 
with sharp cicatricial borders are rather made larger than smaller by cau- 
terization. 
The method of denudation and suture has the advantage that it is ap- 
plicable to large and deep-seated fistula?, but the technique, even as in 
case of other vaginal fistulae, is difficult, and not infrequently the opera- 
tion fails even in skilled hands. The reasons for failure depend not alone 
on the contact of faecal masses with the wound, and the varying traction 
according to the amount of gas in the rectum, and the muscular con- 
traction, but also, in particular, on the difficulty in reaching the fistula 
when it is deep-seated, on the thinness of its walls when it is seated in 
the middle segment of the recto-vaginal segment, and lastly, in case of 
fistula? on the boundary between the rectal and perineal segments, on 
the unequal thickness and tension at the upper and the lower borders. 
Further still, the borders of the thin and loose rectal mucous membrane 
readily prolapse into the wound if it be not perfectly secured by suture, 
and then again the sutures readily tear out. 
These possibilities have caused surgeons to busy themselves, for long, 
in attempts at overcoming them. On the one hand, in ordei* to get rid 374 
THE DISEASES OF THE VAGINA. 
of contact with the contents of the intestine, and to control the move- 
ments of the rectum, protracted constipation has been advocated, the 
bowels having been thoroughly cleansed before operation. Recent authors, 
Simon, and later Hegar and Kaltenbach, have objected to this constipa- 
tion-method. Without question the first movement from the bowels 
after ten to twelve days constipation, and the pressure on the line of 
union by the hard faecal masses, are strong reasons for objecting to the 
method. On the other hand, the maintainance of diarrhoeal discharges 
is not to be advocated, on account of the ease with which fluid faecal mat- 
ter may penetrate into the wound. Hegar and Kaltenbach recommend 
the following procedure: Before the operation the bowels should be 
thoroughly emptied; for the first three days after operation the diet should 
be milk and soups. On the evening of the fourth day, about one and a 
half grains of calomel should be given, and on the next morning a glass of 
bitterwasser. As soon as the bowels begin to move the rectum should 
be explored, and hard scybala are to be removed by the finger or else soft- 
ened by an enaema. On the following days a glass of bitterwasser in the 
morning generally suffices to move the bowels without difficulty. In 
order to prevent pressure and traction on the fistula by collection of gas 
and ffeces in the rectum, and in order to control the movements of the 
lower rectum, R. Liston and Copeland have advocated incision of 
the sphincter ani, a procedure which has found advocates in Baker 
Brown, Richet, and Demarquay, while Dieffenbach and Simon have 
rejected it. Simon stated that the same aim could be attained by dilata- 
tion of the sphincter, and that incision was therefore unnecessary, and in 
an instance which he has recorded where the sphincter was incised, he 
noticed that twelve hours after both gas and water were retained. Al- 
though in this instance it is apparent that the incision may not have 
been properly done, it follows from Simon's results that dilatation will 
suffice. 
As far as I know, no one has treated of the operation for the repair of 
rectal fistulas better than G. Simon, and I follow his description. The opera- 
tion may be performed either from the vagina in a similar manner to that 
for the repair of vesical fistula, or else after incision of the perineum by 
the rectal suture, or finally from the rectum. 
1. Denudation and Suture from the Vagina.-To expose the fistula 
Simon recommended a fenestrated speculum, but this instrument narrows 
the space and makes the vaginal wall too tense, and for these reasons it 
has not been generally used. The depression of the anterior vaginal 
wall by an elevator, and similarly the lateral walls by retractors, and the 
pulling down of the posterior vaginal wall by forceps or tenaculum, or by 
the finger of an assistant in the rectum, these measures suffice for expos- 
ing the fistula except where it is fixed by cicatrices or there exists stenosis. 
When the shape of the fistula allows, the attempt should be made to INTESTINO-VAGINAL FISTULAE. 
375 
cause transverse union, since thus we may expect less traction on the 
united edges. The denudation is funnel-shaped, and many interrupted 
sutures are inserted, or else a number of superficial and deep. Either 
fine silk or wire should be used, and results have been obtained with 
catgut. 
2. Incision of the Perineum from the Fistula and Triangular Union. 
-This method, which has been resorted to in case of large fistula, such 
as those which exist from incomplete union of a laceration of the perineum 
extending into the rectum, Simon has also used and recommended in 
case of small fistulas when they are in the perineum and in its immediate 
neighborhood. In such instances obtaining union by simple denudation 
is often a very difficult matter, while after incision of the perineum it is 
far easier to denude, and traction from the perineum is done away with. 
This traction must be carefully guarded against, further, by not inserting 
the perineal sutures too deeply. Di effen bach's objection that incision of 
the perineum caused a large wound with consequent greater risk of non- 
union, and with increase in the size of the fistula, has been proved un- 
tenable by Simon's results, and the everyday good results from plastic 
operations speak in favor of this method in case of fistula which occupy 
this locality 
3. Operation from the Rectum -Failures in operations from the 
vagina, and in order to cure a transverse fistula in the upper third of 
the recto-vaginal septum, led Simon to attack the fistula from the rectum 
where the posterior rectal wall is readily accessible. This aim is readily 
attained under deep anaesthesia, the rectum being exposed by Simon's large 
spoon-shaped speculum and lateral retractors, and the anterior wall being 
pulled down by two double tenacula. (Fig. 35.) With the patient in 
the dorsal position the anterior rectal wall appears transversely and pos- 
teriorly across the anus. Careful denudation may be controlled by the 
vagina. The sutures are inserted from within outwards, from the vaginal 
surface towards the rectal, about | cm. from the border of the wound on 
the vaginal side, and issuing at the edge of the border on the rectal side. 
In this way prolapse of the rectal mucous membrane between the edges 
of the wounded surface is prevented. The sutures are knotted in the 
rectum, and Simon removed them from the vagina owing to the difficulty 
of so doing from the rectum. Herein I cannot agree with him, and I 
question if the advice is acceptable. Simon claims that this method is 
the only one which assures exact union in case of fistulas in the upper 
third of the recto-vaginal wall. 
According to Emmet the operation per rectum is only applicable to 
small fistulse where the defect is greatest in the vagina and the edges can- 
not be approximated from the vaginal side. In these instances an inci- 
sion may be made into the mucous membrane on each side of the fistula, 
and parallel to the axis of the canal, in ordei* to overcome tension, and 376 
THE DISEASES OF THE VAGINA. 
then the operation from the vagina is the simplest method and most likely 
to be followed by good results, the hemorrhage being less and the sutures 
not tearing out so readily. Emmet notes a further indication for the 
operation from the rectum. When, as the result of sloughing after pro- 
tracted labor, a vesico-and a recto-vaginal fistula exist in the midst of con- 
tracted cicatricial masses, it may happen that the vesical fistula can be well 
exposed and operated upon, while the rectal fistula is concealed behind the 
cicatricial mass. This mass should not be incised in order to expose the fis- 
tula, since it answers the purpose of assisting in causing retention of urine 
by keeping the urethral walls in contact. In such instances the fistula 
must be closed from the rectum, or else, when this is not possible, from 
Fig. 35.-Simon's Operation for the Repair of a Vesico-Vaginal Fistula from the Rectum. 
the vagina, without eyesight, however, but under the guidance of the 
finger. This is a difficult procedure, of course, but Emmet has succeeded 
in a number of instances. 
In my opinion Simon is deserving of our thanks chiefly for pointing 
out the methods after which it is possible to cure these recto-vaginal fis- 
tulas. The choice of method will vary with the case, and it will be differ- 
ent according to the locality and form of the fistula. Strict rules for each 
case cannot be formulated. Winckel's case, to which we have referred, 
proves that under circumstances even large fistulas, deep-seated, can only 
be attacked and even cured from the vagina. In case of small fistulas in 
the median division of the septum it is advisable to attempt cure by sim- 
ple denudation before incising the perineum, and the same holds for fis- INTESTI NO-VAGIN A L F 1ST ULaE. 
377 
tulae near the perineum. Ordinarily one or another of the methods advo- 
cated by Simon will be followed. Occasionally, in case of fistulse with 
thin edges in the median division, it may be advisable to attempt to cover 
them by a plastic operation with folds from the vagina, as Kidd did in 
case of vesico-vaginal fistula. Maurer records a case of cure by trans- 
plantation of a flap of rectal mucous membrane over the denuded fistula 
aftei' having split the sphincter. In other instances cicatrices must be 
divided in the rectum or in the vagina before resorting to operation. 
Further, the sutures may be passed from both sides, those towards the 
rectum being of very fine carbolized silk or catgut, and those towards 
the vagina being stronger, more numerous, and including more tissue. 
The sutures should always be removed from the side where they are knotted 
or twisted. The time for removal depends on the material, according to 
ordinary surgical rules. In addition to the methods of treatment which 
we have mentioned, there are others which are largely of historical inter- 
est, such as compression with metallic plates or compresses from the rec- 
tum and vagina (Cullerier, Nelaton, Duparque). 
B. Ileo-vaginal Fistula, and Anus Praeternaturalis Vaginalis. 
When coils of intestine are in fistulous communication with the vagina, 
then either the continuity of the intestine is entirely broken by the fistula 
and the upper end of the intestine discharges its contents into the vagina, 
anus praeternaturalis vaginalis, or else the continuity is not broken and 
the fistula is purely a partial defect in the intestinal wall communicating 
with the vagina, fistula ileo-vaginal is. Such is Simon's definition, and 
he was the first as far as I know to sharply differentiate the conditions. 
The anus praeternat. vaginalis is formed as the result of traumatic rup- 
ture, generally intra-partum, of Douglas's pouch, prolapse of the intesti- 
nal coils into the vagina, the formation of adhesions, and gangrenous 
separation of the intestine, associated generally with symptoms of incar- 
ceration. Since such instances are usually followed by death, the 
number on record is small. Generally but one part of the intestine is 
affected, although a number of coils may be implicated, as happened in 
the case reported by Bartels. 
L. H. Petit has with great care collected all the instances of fistulous 
communication between the small intestine and the vagina, as also those 
between the intestine and the uterus, and given the histories in extenso. 
Of forty-two instances in twenty-one the communication was between the 
small intestine and the vagina, Smellie's and Penell's cases not being in- 
cluded, since they appeared doubtful. Of these twenty-one cases only eight 
can be classed as anus praeternat. vag. Here belong the cases of Birkett, 
McKeever, Favera, Jones, Cassamayor, Heine, Bartels. The cases of 
Boux, Verneuil, Kiwisch, Gussenbauer, certainly dated from difficult 378 
THE DISEASES OF THE VAGINA. 
labor, and without prolapse of intestine having been noted the contents 
of the intestine were passed per vaginam on the sixth to the tenth day 
after delivery. With the exception of Favera's case, where the cause was 
brutal rape of a ten year old child, in all the instances there was trauma- 
tism during labor as the cause. In a number there is no statement in 
regard to a mechanical obstacle to labor. Jones witnessed prolapse of the 
intestinal coils in a healthy woman of twenty-four, in the third month of 
her second pregnancy, as the result of rough examination on the part 
of the " physician " whom she had consulted on account of pain in the 
abdomen which had set in after lifting a heavy weight. Cassamayor's 
often-quoted case concerns a VH-para after miscarriage at the fifth 
month. In Heine's case the vaginal fornix was torn during the removal of 
the after-birth. Generally, where long coils are prolapsed they are taken 
for the umbilical cord or the membranes twisted into a cord. In Jones's 
cases nineteen and a half feet of intestine were separated from the mesen- 
tery, one end of which was completely torn, and the other only connected 
to the intestine by a band. Jones was led astray in his diagnosis and 
amputated the intestine, the patient urviving for seventeen days. 
McKeever's patient, a II-para of twenty-six with narrow pelvis, was de- 
livered by perforation after a long labor, and without doubt the cervico- 
vaginal vault was torn. On the following morning a " substance " six 
inches long was found in the vulva and taken for membranes. Since 
after two days interval they had not been expelled, one of her attendants 
pulled on them strongly until the patient's screams made her desist. 
McKeever found about 4$ feet of gangrenous intestine prolapsed with 
substance defects here and there. He also detected a vesico-vaginal 
fistula. Cassamayor's patient, where the intestines had prolapsed to the 
thigh, necrosed and perforated, while waiting for hex* medical attendant 
had tied them as high as possible. In Heine's case two and a half feet 
of intestine, reaching about to the knee, had been drawn down by an at- 
tendant who thought the placenta was thus being detached. 
In all these cases prolapse of the intestines have caused more or less 
marked symptoms of incarceration, with consecutive necrosis and perito- 
nitis. As the result of the injury, only one of the patients died (Jones's), 
and she at the end of seventeen days. 
In case of anus praeternat. ileo vag. there are originally two separate 
openings from the intestine into the vagina, the one belonging to the 
upper, the other to the lower extremity of the small intestine. The 
vagina represents, as Heine has pointed out, the widened extremity of 
the intestinal canal which leads into the vaginal anus; the lower extrem- 
ity together with its continuation into the large intestine is shut off from 
the faecal masses. In consequence of the incomplete digestion of the in- 
testinal contents, the patients emaciate and complain of hunger. The 
retention of particles of faeces in the vagina leads to the local irritation of INTESTIXO-VAGINAL FISTULA. 
379 
the mucous membrane and of its surroundings, on which we have laid 
stress. 
The outlook for spontaneous cure of an anus praeternat. ileo vag. is 
slight, since from the recorded cases it is apparent that union and closure 
of the separated intestinal extremities has rarely occurred, the closure 
being brought about by retraction of the spur, by narrowing of the open- 
ings of the infundibulum. The more interesting, hence, is McKeever's 
report of spontaneous cure of an anus praaternat. vag. which followed on 
pregnancy. After absolutely no faeces had passed by the rectum for two 
years, the patient (in the fourth month of pregnancy?) complained of 
great pain and tenesmus, and a half hour afterwards she had a stool by 
the natural passage, consisting of a mass of black, hard, faecal nodules. 
Afterwards the intestinal contents were passed in part by the rectum, in 
part by the vagina; the amount, however, passed by the vagina diminished 
gradually for a few months, and finally ceased altogether. McKeever re- 
marks that the influence of pregnancy in affecting the change was marked, 
and the more so as the uterus projected into the abdominal cavity. The 
patient was delivered at home, without assistance, of a small but living 
female. The placenta was passed spontaneously, and she nursed her 
baby. During the puerperal state the intestines were evacuated by the 
natural passage, and when McKeever examined her the only trace of an 
artificial anus which he found, was a slight projection on the posterior 
vaginal wall which marked the site of the previously existing anus. The 
patient, however, still retained her vesico-vaginal fistula. 
Although in Favera's case it is stated that there remained only a small 
recto-vaginal fistula, yet the particulars in regard to the case are too few 
to justify the belief that here also there occurred cure of an anus praeter- 
nat. vag. 
In regard to diagnosis we must first establish the fact that the abnor- 
mal communication is with the small intestine, and next that it is due to 
complete opening of an end of the intestine and not to a partial defect in 
the wall. The first point is proved by the nature of the intestinal con- 
tents, which consist not of faeces, as in case of a recto-vaginal fistula, but 
of chyme. Faecal mattei' and foul odor may, however, be present, and 
then in addition to the intestinal contents, we must note the rapidity with 
which the characteristic ingesta appear at the fistula. (In case of fistula 
of the small intestine, characteristic remnants of the ingesta may be 
passed by the abnormal opening one to two hours after a meal.) To 
test this point, among other means, the lycopodium seeds answer well, for 
they are readily recognized in the intestinal contents. On the other hand 
the absence of a communication between the rectum and the vagina may 
be proved by inserting a speculum into the rectum and injecting milk or 
colored fluid, which in case there exists a recto-vaginal fistula, will pass 
out by the vagina. The sunken abdomen, the extreme emaciation, the 380 
THE DISEASES OF THE VAGINA. 
hunger, these speak for the seat of the fistula being the small intestine. 
That the communication is the result of an anus praeternat. and not of 
an ileo vag. fistula is proved by the existence of two openings into the 
vagina, separated by a projecting spur. If, as in Cassamayor's case, there 
is but one opening, the examination with the sound or, better, with the 
finger will prove that the lumen is patent in only one direction, and this 
speaks for anus praeternat., and also the history that the abnormal com- 
munication followed on the loss of a prolapsed coil of intestine. 
0. Weber and C. von Heine have devised and followed a method of treat- 
ment of anus praeternat. ileo vag. which fulfills every indication. It aims 
at restoring the lumen of the intestinal canal, and then at the closure of 
the fistulous opening into the vagina. Weber formulated the first steps 
of the method, and after his death Heine completed it and obtained a per- 
fect result. First the blades of a modified Dupuytren's intestinal scissors 
(Fig. 36) were inserted into the upper and the lower openings of the in- 
testine to the extent of one and a half inches. The spur between the 
blades was then cu^ through by screwing them together and leaving them 
till the aim was secured. With the separation of the spur the lumen was 
opened up, and the anus prseternat. was converted into an ileo-vag. fis- 
tula. 
Then the opening between the intestine and the vagina was denuded 
and sutured even as in case of a simple recto-vaginal fistula. This case is 
the only one in which this method was followed by success, and it is of 
such interest that I will record it. 
It concerns a slightly-built woman of twenty-three, of tubercular paren- 
tage, who at her first delivery suffered a large rupture in the vagina fol- 
lowing on artificial removal of the after-birth. The unfortunate "ac- 
coucheur " inserted his hand through the laceration into the abdominal 
cavity, and thinking that he had grasped the placenta, pulled down a 
coil of intestine, removed it, and did not recognize his error; sixteen 
hours thereafter the placenta was spontaneously expelled. Dr. Winterwe- 
ber saw the patient one hour afterwards, and found the abdomen swollen 
and tender, the temperature elevated and a pulse of 144. Between the 
thighs lay a long piece of the small intestine, about two and a half feet 
and reaching to the knees. The intestine was separated from the mesen- 
tery, dark-red in color, in places black, and filled -with gas and fluid. In 
the posterior cul-de-sac he found a transverse laceration. Rest in bed, 
ice, morphine, and antiseptic cloths over the intestine, kept the patient 
in good general condition, and on the fifth day the intestine separated. 
At the end of four vreeks the patient left her bed, but she did not im- 
prove in health, and she complained of constant hunger. The constant 
passage of grumous brown intestinal contents from the opening in the 
vagina, which caused severe excoriation of the skin and the external geni- 
tals, impelled Winterweber to send the patient to the surgical clinic at INTESTINO-VAGINAL FISTULA. 
381 
Heidelberg, which was then in charge of 0. Weber. He found extreme 
emaciation, no fever, constant appetite, and all the functions, except the 
rectal, in order. The faeces were passed from time to time from the red- 
dened and sensitive vagina. None were passed by the anus, and the 
patient never had the desire to go to stool. Only the excoriated skin and 
mucous membrane were painful. The patient disseminated a faeculent 
Fig. 36. 
odor. In the posterior vaginal cul-de-sac, to the right of the os, there 
were two separate intestinal openings, the one a trifle above the other. 
The anterior median one alone gave exit to the intestinal contents. The 
sound entered it to the left and upwards, and into the other to the right 
and upwards. The intestinal mucous membrane was prolapsed through 
both openings. 
Weber endeavored to convert the anus praeternat. into a fistula ster- 382 
THE DISEASES OF THE VAGINA. 
coral., and after thorough cleansing of the parts, he passed the blades of 
a modified Dupuytren's scissors into both openings to the extent of about 
one and a half inches, and clamped the spur between them. On the 
third day the first natural passage since the delivery occurred. At the 
end of six days the instrument was removed, and there remained but one 
opening of the intestine into the vagina. Over this the opposed rectal 
wall still fell, and caused partial closure of the lumen. The attempt was 
then made to prevent this prolapse by a sponge on a holder, and this kept 
the intestinal canal patent, but caused intense inflammation of the vagina 
and the vulva. After further treatment, the hot iron was applied to 
cause shrinkage and closure of the fistula, but this only partially suc- 
ceeded. The patient then returned home for awhile, where she remained 
in bed for six and a half months, when she was again brought to the 
clinic. Weber had in the meantime died, and Heine undertook the treat- 
ment. Since the spur still projected considerably, he again applied the 
clamp. After awhile, since the fistula had contracted down to the size of 
the top of a finger, Heine denuded the edges of the fistula and converted 
it into a transverse slit which he united by suture. Union resulted ex- 
cept at a point to the left covered by the anterior lip of the cervix, and 
at a small opening in the right angle of the wound, which shortly closed 
spontaneously. Since slight cauterization was negative in its results, 
Heine denuded again with implication of the remnant of the posterior 
lip. In a few days a small amount of faecal matter was passed from an 
opening at the inner angle, the size of a large pin's head. This healed 
eventually under repeated applications of tr. cantharid. and ung. prseci. 
rubr. The patient regained her strength quickly, but in three months 
tuberculosis developed and she died from this disease. At the autopsy 
Heine found complete cure of the anus praeternat. 
In comparison with this method of Heine's the other procedures are 
not of special value, as for instance Jobert's plan of separating the upper 
opening from the vagina and sewing it into an opening made between the 
rectum and the vagina. Simon's plan is not preferable, and it consists in 
making a large opening between the rectum and the vagina below the site 
of the ileo vaginal anus and then in closing the vagina transversely, so 
that this canal forms part of the intestinal canal. Finally we would 
mention a still more practical plan, that of Cassamayor, which consists in 
so connecting the anus vaginalis with a rectal fistula as to leave a broad 
lateral union between the upper extremity of the small intestine and the 
rectum. With this end in view Cassamayor inserted one blade of a rectal 
scissors into the opening of the small intestine, and the other into the 
rectum, and caused the intervening portion to separate. He was not 
able to obtain closure of the stercoral fistula, however. 
All these procedures, aside from risks and inefficiencies, are open to 
one and the same objection, namely, that a considerable part of the intes- INTESTIXO-VAGIXAL FISTULA. 
383 
tinal canal is shut off from the intestinal contents, and that these, hence, 
are not entirely digested. 
From Petit we learn that Roux attempted the following procedure: 
Laparotomy, resection of the loosened extremity of the injured intestine, 
and suture of the opening. Owing to the small opening through which 
he worked, however, he mistook the portion of intestine, and, as the 
autopsy proved, he sewed the intestine not to the lower but to the upper 
end of the descending colon. 
Weber and Heine's procedure is not always as simple as it seems from 
the report of their case. Cassamayor, for instance, found only one open- 
ing into the small intestine, and Wilms (Bartel's report) met with such 
complicated conditions that Heine's procedure was out of the question. 
For certain of these cases Cassamayor's method, therefore, must be con- 
sidered relatively the best, and his failure in securing union of the fistula 
is not to be accounted against it. The cutting off of the part of the in- 
testine below the opening into the intestine will always result in the 
patient's nourishment suffering, since the perforated coils uniformly be- 
long to the lower ilium; still the greater part of the small intestine func- 
tionates, and Cassamayor's plan fairly well subserves the desired end. 
Before, however, in case of one opening, we decide to follow Cassamayor's 
method, it is advisable to dilate the fistula, and whenever possible to find 
the opening of the projecting intestinal extremity, and when we can 
Heine's plan should certainly have the preference. Aside from these 
methods there remains the possibility of performing laparotomy, loosen- 
ing the adherent intestines, resecting them, and suturing them, even as 
Roux did in his unfortunate case. Petit remarks with justice that to-day, 
under antiseptic rules, such a procedure would not be so dangerous as in 
Roux's time (1828), particularly if we attend to the technique of to-day 
in regard to the intestinal suture. We cannot, however, grant Petit's 
statement that the risk from such an operation would be less than in case 
of removal of an adherent ovarian cyst. Although Weber and Heine's 
procedure in comparison with laparotomy is less dangerous whenever it 
is practicable, under other conditions laparotomy should be resorted to 
since by it alone, after Heine's method, are we able to secure normal re- 
sults. In case of anus praeternat. ileo uterinus laparatomy alone offers 
the hope of cure. So far, however, instances of the kind, where such an 
operation was resorted to, have not been recorded. 
In case of fistula? between the vagina and the small intestine, properly 
so-called, there exists a single opening into a coil of the adherent ilium 
lying in Douglas's cul-de-sac; there is present only a partial defect in the 
wall of the intestine, and through it a portion of the faecal matter is dis- 
charged, the rest following the normal route towards the anus. 
The formation of such a fistula necessitates the adhesion of a portion 
of the ilium to the peritoneum covering in the vaginal vault. As the re- 384 
THE DISEASES OF THE VAGINA. 
suit of ulceration, a communication is formed between the vaginal and in- 
testinal walls. The ulceration depends occasionally on laceration of the 
vagina, more frequently on puerperal inflammatory processes; it may, how- 
ever, be dependent on other causes, such as cauterization (Simon). It may 
also follow on the rupture of an extra-uterine gestation cyst, and on 
degeneration of malignant growths of the vaginal and neighboring intes- 
tinal wall. 
Kiwisch saw an ileo-intestinal fistula after rupture of the cervix, of the 
bladder and of the vaginal fornix, the cause of which he believed to be 
partial pressure. The result, no prolapse of intestine, spontaneous cure 
in fourteen days, speak for an ulceration into a small portion of the in- 
testine, in consequence of pressure. In Dahlmann's case, where a vesico- 
vaginal and an ileo-vaginal fistula formed after difficult version, a likely 
cause was primary rupture. In the remainder of the cases occurring 
during the puerperium there is no reference to laceration as a cause, al- 
though considerable trauma resulted during labor, as, for instance, in 
Veit's, Breitzmann's, Thurmann's, Roux's, Demarquay and Verneuil's, 
and Gussenbauer's cases. 
Colman and Muller have recorded instances of ulcerous communica- 
tions between the ileum and the vagina from extra-uterine gestation cysts. 
In Simon's case the use of caustic potass for the cure of a small vesico- 
vaginal fistula lying in the midst of dense adhesions, resulted in perfora- 
tion of a portion of the small intestine. 
Hufeland has recorded an instance of fistula between the vagina and 
small intestine due to carcinoma of the uterus and the vagina. 
The usual seat of the vaginal opening of these fistufe is the posterior 
cul-de-sac, since it is above this that the intestines ordinarily lie. Breitz- 
mann and Dahlmann have, however, seen fistufe anteriorly in the vesico- 
uterine pouch. 
Owing to the small size of these fistulas and the practical continuity of 
the fecal current, their course is more favorable than that of anus pras- 
ternat. ileo-vaginalis, and there are four recorded instances of spontaneous 
cure (Breitzmann, Kiwisch, Veit, and Dahlmann) [in the latter the result 
of cauterization by nitrate of silver]. 
In general, spontaneous cure will depend on the size of the fistula and 
the complications; the larger the fistula, the more copious the escape of 
feces, the more the conditions approximate those of anus praeternat. 
The most frequent complication is pelvic abscess, which ordinarily leads 
to depreciation of the patient's strength. So far the results from opera- 
tion have not been favorable, but it does not follow that such will be the 
case in the future with the better means at our disposal. 
The diagnostic points are: 1. The seat in the posterior cul-de-sac, at 
the upper part, which is covered by peritoneum, (exceptionally in the an- 
terior fornix). 2. The thin grumous chyme which flows through the fis- INTESTINO-VAGINAL FISTULAE. 
385 
tulous opening. 3. The single opening through which the sound may be 
passed both upwards and downwards. 4. The intact condition of the 
portion of the rectum near the fistula. 5. The cause being ulceration with 
or without the concurrence of inflammatory puerperal conditions, gener- 
ally without symptoms of incarceration, in no instance association with 
prolapse and expulsion of intestine. 6. Passages by the rectum regularly 
occurring. The characteristics noted under 3, 5, and 6 differentiate at 
once anus praeternaturalis. 
The treatment of fistula? between the vagina and small intestine is 
similar to that of recto-vaginal fistula?, cauterization, or denudation and 
suture. Where the fistula is small, the reported cases of cure from sim- 
ple cleanliness, injections, frequently changed tampons, speak possibly in 
favor of the slower but less radical method by cauterization. Where the 
fistula is larger, however, as in Heine's case, where it was formed artifi- 
cially from an anus praeternat., then the above measures are not likely 
to be followed by good result, and the denudation method is requisite. 
In these instances the operation is only possible per vaginam. They are 
less readily accessible owing to their elevated seat and the complicating 
cicatricial tissue. It may be necessary as in Heine's case to denude at the 
same time the lip of the cervix. The technique is similar to that in 
cases of other fistulae. 
A. Bidder, in a remarkable case (also seen at an earlier stage by Rbseler) 
of anus praeternat. colo-utero-vaginalis, which had changed into a utero- 
vaginal fistula, was able to cause closure by dissecting off the intestinal 
mucous membrane from the uterus and vagina, and thus obtaining broad 
surfaces for union of the vaginal flaps. The dissected intestinal mucous 
membrane projected into the intestinal lumen, and like a valve protected 
the walls from the intestinal contents. Bidder recommended this method, 
which has latterly been followed by Krbnlein, and which is termed by 
French surgeons " dedoublement " of the fistula-edges, in the treatment 
of fistulae implicating the small intestine and the vagina. INDEX- 
Bladder, developmental deformities of, 
66, 81 
etiology of, 69 
prognosis of, 74 
treatment of, 74 
deformities, anatomy of, 66 
diseases, history of, 1 
differences between male and fe- 
male, 8 
examination of, 13 
illumination of, 19 
displacements of, 81 
diagnosis of, 86 
nutritive disturbances of, 176 
anatomy, 176 
partitioned, 79 
• diagnosis, 80 
prolapse of, through urethra, 90 
Carcinoma urethrae, 53 
vesicse, 166 
vaginae, 360 
etiology, 360 
symptoms and course, 360 
treatment, 363 
in pregnancy, 361 
Carunculae, urethral, 49 
Calculi, urethral, 65 
vesical, etiology, 192 
symptoms, 193 
diagnosis, 195 
prognosis, 196 
treatment, 197 
by vestibular incision, 199 
by lateral lithotomy, 199 
vesical, treatment by suprapubic 
lithotomy, 200 
by epicystotomy, 200 
by sectio alta, 200 
by lithotrity, 198 
Abcess, urethral, 48 
Anaspadia, 32 
Angiomata, urethral, 52 
Anus praeternaturalis vaginalis, 377 
symptoms, 378 
treatment, 379 
Artificial urethra, Heppner's opera- 
tion for, 32 
Atresia vaginae, acquired, 265 
frequency of, 266 
treatment of, 265 
congenital, 225 
causes, 224 
diagnosis, 231 
prognosis, 231 
treatment, 240 
operation for, 248 
and acquired, differential diagnosis, 
235 
with duplex canal, 236 
symptoms, 236 
unilateral, 239 
differential diagnosis with haema- 
tocele peri-u terinum, 240 
hymenal is, 231 
causes, 225 
operation for, 248 
urethrae congenitalis, 28 
treatment, 32 
Atrophy of bladder, 187 
diagnosis of, 187 
treatment of, 187 
Bladder, absorption by mucous mem- 
brane of, 10 
catarrh of, 176 
acute, 176 
chronic, 176 
double, 79 
deficient development of, 79 388 
INDEX. 
Calculi, vesical, lithotomy by vesico 
vaginal incision, 199 
by urethral dilatation, 192 
Cancroid, vaginal, 360 
etiology, 360 
Chancroid, urethral, 38 
diagnosis, 45 
vaginal, 337 
Chancre, urethral, 38 
Communications between stomach and 
bladder, 153 
bladder and other abdominal or- 
gans, 152 
Condylomata, urethral, 49 
vaginal, 337 
Cysts, urethral retention, 49 
vaginal, 341 
anatomy of, 341 
etiology of, 341 
treatment of, 347 
vesical, 164 
Cystitis, frequency of, 24 
acute, symptoms of, 181 
etiology of, 182 
diagnosis of, 182 
prognosis of, 184 
treatment of, 184 
chronic, symptoms of, 181 
etiology of, 183 
diagnosis of, 182 
prognosis of, 184 
treatment of, 184 
croupous, 177 
etiology, 183 
symptoms, 181 
prognosis, 184 
diagnosis, 182 
treatment, 184 
diptheritic, 177 
symptoms, 181 
diagnosis of, 182 
etiology of, 183 
prognosis of, 184 
treatment of, 184 
epidermoidal, 180 
Lowenson's case, 180 
Cystocele vaginalis, 83, 81 
anatomical relations, 84 
etiology, 83 
symptoms, 84 
diagnosis, 85 
Cystocele vaginalis, anatomical rela- 
tions, prognosis, 86 
treatment, 87 
operation for, 88 
Cystoptosis (see inversio vesicae), 91 
Cystotomy with artificial inversion for 
bladder examination, 15 
Cystospasmus, 201 
symptoms of, 201 
diagnosis of, 202 
prognosis of, 202 
therapy of, 202 
Distoma haematobium of bladder, 190 
Dysuria, 24 
Echinococcus cysts of bladder, 189 
diagnosis of, 190 
of vag'ina, 345 
Ectopia of unfissured bladder, 90 
Elephantiasis of urethra, 54 
Elytrorraphy, 287 
Episiostenosis, operation, 137 
Episiorraphy, Fricke's, 287 
Epispadia, 32 
Epithelioma, of urethra, Melchiori's 
operation for, 60 
Emphysematous vaginitis, 317 
anatomy of, 318 
etiology of, 320 
symptoms of, 317 
treatment of, 320 
Enuresis, 203 
nocturna, 205 
continua, 24 
causes of, 203 
symptoms of, 204 
diagnosis of, 205 
prognosis of, 206 
treatment of, 206 
Eversio vesicae, 67, 72 
Billroth's operation for, 78 
Ashhurst's operation for, 76 
Ayres' operation for. 75 
Gerdy's operation for, 75 
Thiersch's operation for, 77 
Frommel's operation for, 78 
Vogt's operation for, 78 
Wood's operation for, 76 
Exocystis, 91 
symptoms of, 92 INDEX, 
389 
Extrophea vesicas, 67 
Fibromata, vaginal, 347 
urethral, 50 
Fibromyomata, vaginal, 347 
symptoms of, 349 
diagnosis of, 350 
treatment of, 350 
vesical, 165 
anatomy of, 165 
Filaria sanguinis hominis in bladder, 
190 
Fissure, vesical, 66 
Fissura vesicae inferior, 66 
superior, 66 
Forceps canula, for atres. vag. op. s., 
250 
Foreign bodies in bladder, 189 
symptoms and treatment, 191 
in vagina, 264 
varieties, 366 
treatment, 367 
Fistula, urinary, 94 , 
history of, 94 
varieties of, 96 
causes of, 97 
symptoms of, 107 
diagnosis of, 110 
prognosis of, 112 
treatment of, 114 
cauterization of, 116 
sequelae, 141 
non-puerperal, 101 
external, 104 
colica-vesicalis, 157 
intestino-vaginalis, 368 
of urachus, 96 
symptoms of, 72 
uretero-uterine, 96 
ureteral, 96 
external, 96 
utero-vesical, 96 
anatomy of, 104 
uretero-vaginal, 96 
urethro-vag'inal, 96 
urinary, puerperal, 98 
causes of, 98 
ileo-vaginal, 377, 384 
treatment, 384 
vesico-abdominalis, 24 
external vesical, 96 
Fistula, vesico-intestinal, 96 
shape and position, 104 
vesico-vaginal, 24, 96 
superficial, 96 
deep, 96 
seat of, 103 
shape of, 103 
vestibular incision for, 137 
vesico-utero-vaginal, 104 
superficial, 134 
deep, 134 
vesico-ventricular, 104 
vesico-intestinal, 156 
diagnosis of, 158 
prognosis of, 158 
treatment of, 159 
Valenta's case of, 157 
vesico-gastric, 158 
vesico-umbilical, 66 
vesico-ovarian, 158 
vesico-rectal, 156, 96 
shape and position of, 104 
recto-vaginal, 368 
causes, 368 
symptoms, 370 
diagnosis, 371 
treatment, 372 
cauterization of, 373 
operation for, 373 
Simon's operation, 374 
perinaeal incision for, 375 
rectal operation for, 375 
and delivery, 370 
Gangrene of vagina, 340 
Gartner's canals, 213 
Gonococcus, 313 
characters, 314 
mode of finding, 314 
Gonorrhaea urethral, frequency of, 46 
symptoms, 44 
treatment, 46 
vaginal injections in, 324 
tampons in, 327 
Gonococci, comparative action of ger- 
micides on, 325 
HALLERIAN spots, 310 
Haematuria, 34 
vesicae, 186 
Haematoma of vagina, 302 390 
INDEX. 
Haematoma of vagina, symptoms, 303 
causes of, 303 
diagnosis of, 303 
treatment of, 303 
Hyperaemia of urethra, 46 
treatment of, 46 
Hypospadia, 29 
Hyperaemia of bladder, 176 
' acute, 176 
chronic, 176 
etiology of, 183 
symptoms of, 181 
prognosis of, 184 
therapy of, 184 
Hypertrophy of bladder, 186 
Incontinentia, 203 
causes of, 203 
symptoms of, 204 
diagnosis of, 205 
prognosis of, 206 
treatment of, 206 
Incontinence pessaries of Schatz, 32 
Inversio-vaginae, 280 
symptoms, 282 
treatment, 283 
palliative, 288 
operative, 287 
by tying, 287 
by cautery, 286 
vesicae cum prolapsu per uracham, 
68 
per fissuram, 68 
per urethram, 68 
Inversion of bladder, 92 
diagnosis, 92 
symptoms, 92 
treatment, 93 
operation for, 93 
Ischuria, 203 
causes, 203 
symptoms, 204 
diagnosis, 205 
prognosis, 206 
treatment, 206 
paradoxa, 204 
Kolpitis simplex, 307 
dysenteric, 332 
milearis, 309 
anatomy of, 309 
Kolpitis granularis, 307 
anatomy of, 307 
acute, 307 
anatomy, 307 
chronic, 308 
anatomy, 308 
vesicular, 309 
senilis, 307 
anatomy of, 308 
Kolpohyperplasia cystica, 316, 317 
Kolporrhaphy, 287 
Kolpokleisis, 137 
Leptothrix in bladder, 190 
Lipoma of vagina, 353 
Lithiasis of urethra, frequency, 24 
Lupus of urethra, 53 
Malformations, congenital, of female 
urethra, 30 
diagnosis of, 31 
treatment of, 31 
of female bladder, 30 
symptoms of, 30 
diagnosis of, 31 
treatment of, 31 
Mucous patches, vaginal, 338 
Myoma, striocellular, vaginal, 351 
Myxadenoma, urethral, 50 
Neuralgia, urethral, 62 
symptoms, 62 
diagnosis, 62 
prognosis, 62 
treatment 62 
vesicae, 201 
symptoms, 201 
diagnosis, 202 
prognosis, 202 
treatment, 202 
Neuroses of bladder, 201 
Noma, vaginal, 340 
Ovary and bladder, abnormal com- 
munication between, 153 
Ovarian cysts, perforation of bladder 
by, 153 
Paresis of urethra, frequency of, 24 
vesicae, 203 
causes, 203 INDEX. 
391 
Paresis vesica;, symptoms, 204 
diagnosis, 205 
prognosis, 206 
treatment, 206 
Paralysis of bladder, 203 
causes, 203 
symptoms, 204 
diag-nosis, 205 
prognosis, 206 
treatment, 206 
Papillomata, vaginal, 354 
vesical, 165 
Pessaries, for inversio vaginae, 289 
egg, 290 
Pilmictio vesicae, 167 
Pregnancy, vesical, Josephi's case, 154 
Sentin's case, 154 
Ziesslers case, 155 
Prolapsus vaginae, 268 
in infancy, 269 
Epstein's case, 269 
complications, 273 
anterior, 272 
symptoms, 276 
diagnosis, 275 
treatment, 276 
pessaries in, 276 
in relation to cystocele, 274 
posterior, 277 
pessaries in, 280 
symptoms, 278 
treatment, 280 
secondary, 278 
treatment, 280 
partialis, 277 
Perivaginitis phleg-monosa, 335 
symptoms, 336 
treatment, 336 
Polypi, urethral, 52 
mucoid, of bladder, 164 
vaginal, 354 
diagnosis of, 355 
treatment of, 355 
Polypoid hypertrophies of mucous 
membrane of bladder, 164 
Rectocele Vaginalis, 278 
Rectum and bladder, communicating, 
153 
Renal substance in bladder, 190 
Retentio urinae, 24 
Rhabdomyoma myxomatodes, 351 
Rupture, vesical, 159 
etiology, 159 
symptoms, 161 
anatomy, 160 
treatment, 161 
of introitus in child-birth, 296 
of vagina, 292 
spontaneous, 293 
traumatic, 294 
causes .of, 292 
location of, 292 
extent of, 292 
prophylaxis, 298 
prognosis, 297 
treatment, 298 
operation for, 299 
of vagina in child-birth, 294 
predisposing- causes, 294 
symptoms of, 295 
course of, 296 
termination of, 296 
prognosis of, 296 
treatment of, 298 
Sarcoma Urethra, 50, 166 
pathological anatomy,'166 
vaginae, 356 
symptoms, 357 
prognosis, 359 
treatment, 359 
Sinus, uro-genitalis, persistence^of, 31 
Spasm, urethral, 62 
treatment of, 62 
vesical, 201 
symptoms of, 201 
diagnosis of, 202 
prognosis of, 202 
treatment of, 202 
Stenosis, urethral, 37 
treatment, 39 
vaginal, 254 
congenital vaginal, 255 
origin of, 224 
diagnosis, 260 
prognosis, 260 
acquired vaginal, causes, 263 
frequency, 266 
course of, 265 
treatment, 265 
hymenal, 255 392 
INDEX. 
Stricture, urethral, 37 
frequency of, 24 
causes, 37 
symptoms, 38 
treatment, 39 
Scanzoni's case of, 37 
Gayet's case of, 37 
chancroidal, 39 
treatment, 39 
spastic of vagina, 260 
Syphilis of vagina, 337 
vaginal, frequency of, 337 
diagnosis, 339 
treatment, 339 
Syphilitic ulceration of vagina, 337 
Tumors of urethra, 49 
symptoms, 54 
diagnosis, 56 
complications, 56 
etiology, 57 
course, 59 
prognosis, 59 
treatment, 59 
by ferrum candens, 59 
by excision and cauterization of 
base, 59 
by chemical caustics, 59 
by extorsion, 59 
by ablation, 59 
by ligature, 59 
of bladder, 164 
frequency, 164 
pathological anatomy, 164 
diagnosis, 168 
symptoms, 168 
etiology, 169 
prognosis, 171 
treatment, 171 
of the vagina, 341 
Trichiasis vesicas, 167 
Trichomonas vaginalis, 315 
Thermometry of urine, 23 
Tuberculosis, vesical, 179 
vaginal, 339 
treatment, 339 
Urethra, anatomy and physiology 
of, 6 
development of, 27 
catheterization of, 16 
Urethra, Simon's specular examinat ion 
of, 13 
nutritive disturbances of, 43 
etiology of, 43 
Urethralgia, 62 
treatment of, 62 
Ureters,cutting of, in fistula operations, 
129 
Urethrocele, 35 
Jobert's operation for, 35 
Urethra, duplexity of, 32 
L. Furst's case of duplex, 32 
Lewis's case of duplex, 33 
abnormal dilatation of, 34 
partial dilatation of, 35 
G. Simon's case, 36 
Gillette's case, 36 
Priestley's case, 36 
Foucher's case, 36 
total dilatation of, 34 
symptoms of, 35 
treatment of, 35 
by cautery, 35 
by Jobert's urethrocele opera- 
tion, 35 
abnormal shape and position of, 34 
prolapse of, entire, 42 
congenital malformations of, 27 
foreign bodies in, 64 
treatment of, 65, 191 
inflammation of lacunae, 37, 48 
ulceration of, 43 
acute catarrh of, 43 
chronic catarrh of, 43 
Urethrae, defectus totalis, 28 
def ectus intern us, 28 
Urethral displacement, 39 
mucous membrane, prolapse of, 39 
causes, 40 
diagnosis 40 
prognosis, 41 
treatment, 41 
hyperaemia, 43 
rupture, frequency of, 24 
catarrh, prognosis of, 46 
treatment of, 46 
Urethritis foeminae, 44 
virulenta, 44 
symptoms, 44 . 2 
diagnosis, 45 
prognosis, 46 393 
Urethritis virulenta, treatment, 46 
Ulcer round, of vagina, 340 
Vagina, development of, 211 
true position of, 214 
connections of, 220 
arterial supply of, 218 
minute structure of, 217 
congenital malformation of, 224 
congenital longitudinal septa of, 
261 
origin of, 224 
treatment of, 262 
catarrhal inflammations of, 322 
prognosis, 322 
treatment, 323 
inflammations. 305 
classification of, 305 
displacement of, 268 
causes, 268 
descent of, primary, 271 
secondary, 271 
Vaginae, descensus, anterior, 272 
posterior, 277 
Vaginitis, 305 
symptoms of, 219 
adhesiva, a cause of vaginal steno- 
sis, 264 
catarrhal, 306 
INDEX. 
Vaginitis, catarrhal, etiology, 310 
symptoms, 313 
pathological anatomy, 306 
acute catarrhal, symptoms, 313 
chronic .catarrhal, symptoms, 314 
dysenteric, 332 
symptoms, 334 
diphtheritic. 331 
symptoms, 334 
exfoliativa, 328 
follicular, 315 
erysipelalosa, 333 
granuloma, 315 
herpetiformis, 317 
miliaris, 315 
septica, 333 
vesiculosa, 317 
Vesical development, deficient, 80 
diagnosis of, 80 
treatment of, 80 
Vesical diseases, relative frequency of, 
66 
bil ocularis, 79 
diagnosis of, 80 
treatment of, 80 f 
duplex, 79 
diagnosis of, 80 
treatment of, 80