CYSTITIS WITH EPIDERMOID CONCRETIONS.

This is a very rare affection of the bladder, and I only mention it as a pathological curiosity. Rokitansky supposes it to be due to, or a sequence of, chronic cystitis. It consists in an unusually rapid formation of epithelium by the vesical mucous membrane, resulting in the shedding of quite large white, shining plates or bodies of this caked scale. The following case, related by Lowenson (1862), is thus given by Winckel. The patient spoken of by him, suffered from mitral stenosis, and came into hospital in a moribund condition. After death her bladder was found to be enormously dilated. From it were taken a great number of small, rounded yellow masses, lying between a number of plates of dullish color, the general appearance being that of yellow pea-soup, with some of the hulls left in. The whole of the internal surface of the bladder was covered with flakes, many of them having these little balls interposed and superimposed. Their diameter varied from one twenty-fifth to one half inch. These attached flakes were tolerably firm and bright, something like motherof-pearl. From the mucous membrane itself, after removal of these flakes, pieces of membrane could be stripped off. Except in these places the mucous membrane seemed normal. The urethra and ureters were normal, but the kidneys were in a condition of granular atrophy.

On microscopic examination it was found that the young, oftentimes fatty degenerated epithelial cells (in the commencement), as they approached the surface, took on gradually all the changes of the very large epidermic cell, becoming non-nucleated and granular. The little balls consisted of grains of fat, calciform concretions, little nuclei, and epidermic cells. There was considerable stearine but no cholesterine. Reich claims lately, however, to have found the latter in the vesical mucous membrane of a man fifty-six years old, who suffered from catarrh of the bladder.

Treatment. Of course I have no experience, never having seen a case, but on general principles I would suggest that the treatment would be to relieve any inflammation or irritation that may be present, the exhibition of alkalies and arsenic (in small doses) by the mouth, daily washing out of the bladder, removing all scales or plates that form, and the application of a strong alkaline solution to the diseased surface.

I am unable to give the symptoms of this disease. The same may be said of the diagnosis. I presume, however, that an examination of the urine would enable one to determine the nature of the trouble.

CHAPTER XLII.

NON-INFLAMMATORY DISEASES OF THE BLADDER.

DISLOCATION OF THE BLADDER.

II. Non-inflammatory diseases of the bladder. These are: 1. Dislocations.

2. Foreign bodies.

3. Rupture.

1. Dislocations.-These may be of six kinds: (a) upward; (b) backward; (e) forward: (d) lateral; (e) downward; in addition to these, we may have (f) inversion of the bladder.

Some of these are, even in their worst form, not true dislocations, but represent some hindrance to the proper distention of the organ or its position when distended. Of all dislocations, the most important are the upward, backward, and downward. All of them, however, interfere more or less with the vesical function. Marked dislocation of a healthy bladder often gives rise to less disturbance than slight dislocation of an already irritable organ.

Dislocations of the bladder have various causes, the most common and troublesome being abnormalities of structure and position of the uterus and vagina.

As a matter of fact, these dislocations are usually secondary to some affection of the other pelvic organs. This necessitates a description of their causes as well as the conditions under which they occur, thus deviating from the general order followed in this work.

(a) Dislocation Upward.-The upward dislocation of the bladder may be caused by the dragging up of the organ by the gradual rising from the pelvis of the gravid uterus. This, however, is a rare affection, and only occurs, I think, in cases where there has been previous inflammatory action in the pelvis, gluing the parts together. In most pregnancies the bladder retains what is, under the circumstances, its normal position. Bands of adhesion passing from the

bladder to the various abdominal and pelvic viscera may, when shortening takes place, produce this dislocation. It may also be produced by ovarian tumors, and, in some cases of uterine retroflexion and retroversion. The dislocation accompanying the last two affections is, however, usually more backward than upward.

The other most probable causes are tumors about the neck or base of the organ, tumors of the cervix uteri, pelvic deformities, and pelvic exostoses.

The symptoms are usually those of irritable bladder. In some cases of pelvic tumor the pressure on the neck of the bladder, forcing it against the pubes, produces retention. This is purely mechanical. In other cases, where there is no obstruction to the outflow, but pressure on the bladder, there may be incontinence; and, again, from traction on the muscular walls, patients are unable to contract and expel the vesical contents, and retention results.

I saw a case, in consultation with Dr. A. W. Ford, of Brooklyn, in which the patient had retention of urine, so that she could not urinate while standing, but was compelled to lie down before the bladder could be emptied. The retention lasted one week, and was brought on by the efforts to urinate, which wedged the uterus in the pelvis, and compressed the neck of the bladder. She was relieved by urinating while on the hands and knees.

(b) Dislocation Backward.-This dislocation stands next in order of importance and unfavorable results to downward dislocation. It may be caused by tumors of the abdomen or by pelvic adhesions, but the most frequent cause is backward dislocation of the uterus, such as retroflexion and retroversion. Retroversion affects the bladder in the same manner as prolapsus, except when the uterus is very much enlarged, and is thrown backward and impacted in the pelvis, so that the cervix presses firmly on the urethra. In such cases urination is impossible. Examples of this are seen in retroversion, occurring in the early months of pregnancy or after delivery. Schatz gives a case due to retroflexion of the uterus during pregnancy, producing the same trouble in the bladder as retroversion.

Winckel saw a case in the body of a non-puerperal woman, in which the uterus was lying almost horizontally in the pelvis, with its fundus adherent to the rectum. That part of the bladder that was drawn most backward had a diverticulum, containing a calculus. The neck of the bladder was fastened down posteriorly by tight bands of adhesion that passed from it over the uterus to the

rectum.

In retro-displacements of the bladder, with no pressure on the

vesical neck, the symptoms are usually those of irritation, causing frequent urination and tenesmus.

I give here the following cases, as they are of interest, and

widow three years, of a marked nervous temperament. Has never been pregnant. Menstruation always normal, and general health fair in early life. Her general system has been much reduced by nursing her husband, who died of phthisis. Nervous system also much impaired. When first seen, all the functions except those of the bladder were performed well. She suffered night and day from frequent urination, but there was no pain either during or after the act, unless she tried to hold her water for a few hours, when there was great pain after the completion of evacuation. Nervous excitement, pleasant or unpleasant, made the trouble much worse. Her urine was normal. On examination, complete retroversion of the uterus was found, with shortening of the anterior vaginal wall; the bladder was much contracted, but otherwise normal. The uterus was restored to its place, and held there by a pessary. Hydrobromic acid in thirty-minim doses was given four times a day. She made a rapid recovery. The next is a case of vesical tenesmus and partial retention from a sudden retroversion of the uterus.

Mrs. G., aged forty-three, the mother of four children. Widow for several years. She was a strong, healthy lady, and had been on her feet all day attending to her household duties, and in the evening, while hanging some pictures, slipped from a chair, and fell heavily to the floor, striking on her feet. She was at once seized with a desire to urinate, and soon after pelvic tenesmus came on. The desire to urinate was constant, and, after strong expulsive

efforts, she was able to pass a little urine from time to time, but without relief. The bowels became distended and tympanitic. On the following day she was ordered anodynes, but they gave very little relief.

On the next day she was examined, and the uterus was found to be completely retroverted, and the bladder full, but not overdistended. Replacing the uterus gave her great relief at once, and she has remained well and free from all bladder trouble since the accident occurred, some two years ago. This was a case of acute retroversion of the uterus, producing an intensely painful affection in a normal bladder.

(c) Dislocation Forward.-Forward dislocation of the bladder, unless it be through the open abdominal walls, is very rare. Some change in its shape from pressure of organs or tumors from behind may occur, but this is really not a true displacement, except in some rare and marked cases. The most frequent cause is pressure from the anteverted and enlarged uterus in either the virgin or puerperal state. Anteversion of the uterus usually causes frequent urination, perhaps as much so as prolapsus; but whether this frequency is due to the fundus uteri resting on the bladder, or to the supersensitiveness of the whole pelvic organs, which usually accompanies this dislocation, I have not always been able to determine. I have been inclined to the belief that the latter was the case. In this displacement (anteversion) the uterus is generally enlarged and elevated, so that the body and fundus rest upon the bladder, and impede its distention.

True dislocation of the bladder forward is the rarest of all dislocations, only three cases being on record. It has been variously called ectopia of the unfissured bladder, ectopia vesicæ totalis, and prolapsus vesicæ completus per fissuram tegumentorum abdominis. The first name is too vague, the last best of all, but rather lengthy for every-day use.

The three cases on record are by G. Vrolik, Stoll, and Lichtenheim. In all these the bladder was protruded through a small slit in the abdominal wall, and appeared as a bright-red, rounded tumor at the lower and anterior part of the abdomen. In Lichtenheim's case only was the tumor reducible. The pubic bones were separated about two inches. The urine could be retained perfectly, and the patient was able to micturate in a small stream. Microscopical examination of the outer covering of the bladder-walls proved it to be mucous membrane, like that lining the interior of the organ.

In G. Vrolik's case, according to Winckel, there is doubt as to