DISPLACEMENTS OF THE BLADDER.
Displacements of the bladder may be conveniently considered under four headings : (1) Displacement upward; (2) Descensus or partial displacement downward; (3) Extreme displacement down ward of a portion of the bladder; (4) Ectopia, or eversion.
None of the displacements above referred to, except the last, is a disease of the bladder per se. The upward and downward displace ments are due to the traction or pressure of tumors, or are associated with a prolapse of vagina and uterus. Displacements dependent upon the growths of tumors, or alteration in position of other organs which may be progressive, are liable to vary in degree with the changing positions of these organs, and are corrected when the associated causal trouble is removed.
Upward Displacement of the Bladder.—This dislocation is most frequently observed in cases of large myomatous uteri, in which the tumors develop under the pelvic peritoneum and spread out into the broad ligaments, and as they develop upward carry the bladder along with them.
The treatment in these cases must be directed to the removal of the tumors, by means of which the bladder is let down to the pelvic floor to, or even below, its normal position.
Descensas, or Partial Displacement Downward of the Bladder.— This difficulty is observed in cases in which the vaginal outlet is broken down and there is a tendency toward prolapsus uteri, as is seen in a descent of the cervix toward the vaginal outlet, together with a dropping down of the anterior vaginal wall, filling the open ing. On account of the association of the bladder with this dis placement of the anterior vaginal wall, the protruding mass is com monly called a cystocele. Much time has been unnecessarily wasted iu discussions of cystocele, and the analogous affection of the poste rior vaginal wall—rectocele. It is important to recognize the fact that these are not affections per se, but symptomatic merely of a con dition of the vaginal outlet.
Treatment.—I have long since given up operation upon either cys tocele or rectocele alone. Where the relaxation of the vaginal outlet is not marked and an operation is not indicated, a well-fitting Hodge or Gehrung pessary, especially the latter, will serve to lift up the anterior vaginal wall and relieve the bearing-down discomfort. The most complete relief will be obtained by a suitable operation upon the relaxed vaginal outlet, restoring it to its normal size and position under the symphysis pubis, thus building up the posterior vaginal wall again, and giving the vaginal canal its normal direction back ward and inward toward the lower part of the sacrum. This gives support to the anterior vaginal wall and effectively relieves the cys tocele.
Extreme Displacement Downward of a Portion of the Bladder.— This form of displacement is found associated with prolapsus uteri. Its occurrence is due to the intimate union between the bladder and the supra-vaginal portion of the cervix, which is so closely attached to it that, as the uterus escapes from the pelvis, all this portion of the bladder must of necessity pass out with it, forming a large lum on the anterior face of the prolapse. By passing a sound
through the urethra, which has changed its direction in the manner described above (p. 697), the lowest part of the diverticulum will be found to lie just above the cervix uteri at the most dependent part of the sac. By passing the sound in an opposite direction, a portion of the bladder will also be discovered occupying the pelvic cavity above the When distended the bladder forms a bilobate organ, of which the outer lobe can be distinctly felt to fluctuate upon touch.
Women suffering from prolapse always find difficulty in empty ing the bladder, and unless the prolapsus is returned each time, evac uation is never complete. The presence of the diverticulum predis poses to cystitis, if infectious material once finds its way into the bladder. Large numbers of calculi may also form in the sac.
The treatment of the condition is the same as that for prolapsus uteri. The operation devised for the relief of prolapsus must there fore be considered not simply as an operation for the retention of the uterus within the pelvis, but equally for the permanent correction of the displacement of vagina and bladder. Where the radical plan of retention by denudation and suture is out of the question, it may be effected by a series of buried silkworm-gut sutures encircling the vagina from the cervix down to the outlet, narrowing and stiffening the vaginal canal in such a manner as to render prolapse impossible. This is the plan recommended by Freund of Strassburg (Centrcdblatt fiir Gyniileoloyie, No. 47, 1893).
Ectopia of the Bladder Without Fissure.—Three cases of prolapse of the bladder through the urethra are cited in an article by Lichten hei (Laiigenbeck's Archly fiir klinische Chiruryie, Bd. XV.). The displacement occurred at the lower part of the abdomen, where the symphysis pubis was separated. The tumor protruded in the form of a bright-red mass, which was easily returned through the defect in the lower abdominal wall. There was no defect in the bladder wall, and therefore the retention of urine was not interfered with. The color of the tumor was due to its investment with a membrane presenting the characteristics of the mucous lining of the bladder.
Another kind of prolapse of the bladder is that in which it is forced through a lax urethra and out through the external urethral orifice, where it appears as a large, bright-red mass. On its under surface the ureteral openings are seen. One case of this kind together with prolapse of vagina and rectum has been observed in conse quence of a fall (v. Winckel in Billroth and Luecke's " Handbuch der Frauenkrankheiten," Bd. III., p. 421, 1886).