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 vesicte 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 vesicee, 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 eases have been observed by Ilaussmann, 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 from 1.2 to .2 inches. Its inner surface was encrusted with urine salts, and it contained free in its atvity 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 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 ccmposed of uric acid crystals, elastic fibres, masses of fibrin and detritus; hardly any epitheliutn 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 lmmatoidin 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 diplitheritis. The patient had suffered from retroflexio uteri gravidi with constriction, and died seven hours after giving birth to a fcetus 6 inches long and weighing 4i ounces.
Tuberculosis of the urinary bladder is extremely rare in women. Slobs 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 bad 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 vesicce 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. Tbe entire mucosa was studded with pinhead to pea sized pale gray tubercles. The larger nodules were flat, and had in part ecehymosed edges.
No. 2. (January 24, 1864, No. 21.) Patient 66 years old, had died of 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.