II. Ectopia of the Unftssured Bladder, and Prolapse of the Bladder through llu3 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.
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 reske completas per fissurant tegumen forum abdominus s. ectopia cesiffe Malls.
Lichtenheim's patient suffered no inconvenience save from the scanty seeretion from the surface of the tumor, and no operation was under taken.
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 vesicse. One flap, or if the defect be large, one
from each side, is to be loosened (page 74), then slid over the bladder, and s-utured 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 over 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; incersio review urinarias cum prolopsu, exocystis, cystoptosis. Leveill6 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 nymphse 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, arid 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.