A Case of Cystitis, with the Formation of a 
Thick Epidermal Sheet in the Bladder- 
Pachydermia Vesicce. 
BY 
A. T. CABOT, A.M., M.D., 
OF BOSTON. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
February, 1891. Extracted from 
The American Journal of the Medical Sciences for February, 1891. 
A CASE OF CYSTITIS, WITH THE FORMATION OF A THICK 
EPIDERMAL SHEET IN THE BLADDER- 
PACHYDERMIAz-VESICtE. 
By A. T. Cabot, A.M., M.D., 
OF.JWSTON. 
The following case was reported before the American Association of 
Andrology and Syphilology, at their fourth annual meeting, in the hope 
that some member of the Association could put the writer on the track 
of the report of similar cases. None of those present had seen or known 
of such cases, except Dr. J. A. Fordyce, of New York. He brought to „ 
the meeting photo-micrographs obtained from sections of the bladder 
and ureter of a patient that he had seen on the autopsy table in Vienna, 
but of which he could give no clinical history. The condition shown in 
these photographs was exactly similar to that found in the case which 
forms the text for this paper, and one of them has been accordingly 
reproduced here (see Fig. 1). 
Fig. 1. 
Photogravure reproduction from a photo-micrograph of a dermoid sheet in the ureter. 
The sheet of epithelium lies on the connective tissue below with papillae running up 
into it. Some exfoliation is shown on the surface. (From Dr. Fordyce.) 
Dr. Fordyce also called the writer's attention to an article by Posner 
in Virchow's Archiv, upon " Dermoid Changes in Mucous Membranes,'' 
and it is to this article and other German investigations referred to by 2 
CABOT, A CASE OF CYSTITIS. 
Posner, that this paper is indebted for the pathological consideration of 
the subject. 
The following is the clinical history of the case: 
The patient, James E. B., was a strong-looking man aged forty years. 
In 1870 he was cut for stone by the lateral perineal method. The wound 
healed in about three weeks, leaving no fistulous track. Always after 
this time urination was more frequent than normal. Five years ago, he 
had an attack of acute cystitis, accompanied by much pain ; and from 
that attack the bladder never wholly recovered, giving him at times 
much trouble, but never, until the present illness, compelling him to 
stop work. 
in the middle of June, 1889, when feeling quite well, he had a sudden 
stoppage of water. For this he saw a doctor, who passed an instrument 
into the bladder, with some relief of his symptoms; and, shortly after, 
he passed a small phosphatic stone. He had severe pain for a week, 
and this continued, though somewhat less in degree, up to the time that 
he was seen by the writer, on August 2, 1889. The pain was felt just 
before, during, and after passing water, and lasted for about a minute 
after the act of urination was finished. Occasionally a few drops of 
blood came in the last part of the stream. The urine was loaded with 
mucus and pus, and contained many pavement epithelial cells, both 
singly and in clumps; it was usually colored somewhat by the presence 
of blood ; it passed in a fairly good stream. 
An examination with a sound at this time did not find a stone, but 
showed a slight narrowing in the deep urethra, at the site of the old 
operation. There being but little improvement under treatment, he 
was sent to the Massachusetts General Hospital for a more thorough 
investigation under ether. 
In this examination the sound failed to touch a stone or any calcareous 
matter, but, after the exploration, a washing with the Bigelow evacuator 
brought away several small papillomatous-looking masses. These bits 
were examined by Dr. W. F. Whitney, who reported that they were 
composed of papillary masses of epithelial cells mixed with lime salts ; 
and, though they did not have the branched forms common in papillary 
growths in the bladder, it seemed probable that they came from a papil- 
lomatous tumor. 
It was, therefore, decided to do a suprapubic cystotomy to remove the 
growth; and this operation was done on September 5, 1889. The 
Garson-Peterson method was followed. The bladder held seven ounces 
of boracic solution, and the rectal bag was distended with about fourteen 
ounces. 
On opening the bladder, the posterior wall was seen to be of a whitish- 
yellow color, and to the finger it felt stiff, and was rough on the surface. 
The rest of the bladder-wall was normal in appearance. It was 
presently found that a thick membrane could be detached from the 
diseased surface, and, with care, could be peeled off with the fingers in 
sheets of one or two square inches area. It was loosely attached, 
and after removal left a smooth surface, which bled but slightly. The 
wall of the bladder which it left felt soft and supple. 
This membrane having been removed as thoroughly as possible, the 
bladder was drained by a double rubber tube carried to the bottom of 
the cavity, and an antiseptic dressing was applied. CABOT, A CASE OF CYSTITIS. 
3 
The operation was followed by very little fever or discomfort, and the 
wound did uninterruptedly well. On the fourth day one tube was re- 
moved and a catheter was tied in through the urethra. On the ninth 
day the remaining tube was taken out, and the wound rapidly closed ; 
so that, on the eighteenth day, the catheter was finally left out, and the 
patient passed water by natural efforts. 
Urination was now quite frequent, and the urine showed a large trace 
of albumin and contained considerable ropy pus with an admixture of 
blood. This condition of the urine improved quite rapidly under the 
daily injection of a solution of nitrate of silver, one grain to three 
ounces, and, at the same time, the capacity of the bladder steadily 
increased. 
The patient finally left the hospital on October 31st, at which time he 
could hold his water for from one and a half to two hours, the bladder 
having a capacity of about four ounces. There was still quite a large 
amount of sediment in the water, which consisted chiefly of mucus, but 
which for some days had begun to contain a number of epithelial flakes 
similar to those noticed before the operation. 
After leaving the hospital, he continued the bladder irrigation, using 
a boracic solution twice a day ; and every second day, in addition to 
this, he injected the bladder with a solution of nitrate of silver, twro 
grains to the ounce, taking care afterward that this wholly escaped. 
Under this treatment, supplemented by the occasional passage of 
sounds to keep the deep urethra properly dilated, he slowly improved, 
gaining both in power of holding water and in general condition. 
During the winter he took turpentine for a time, which cleared the 
urine somewhat; and, later, under the moderate use of sandal oil, the 
improvement was still more marked. 
In May, 1890. he was finally able to resume hard work. He then 
weighed as much as he ever did. The urine still contained considerable 
sediment, but it was of a light flocculent character and there was no 
appearance of blood. There were whitish clumps of epithelium in it, 
but these were lighter in texture and not so large as the solid white 
masses that it formerly contained. 
A thorough rectal examination was made at this time, but nothing 
abnormal could be detected about the posterior bladder-wall. 
In August, 1890, he continued wTell, and the urine no longer con- 
tained any of the epithelial flakes or clumps. It was still somewhat 
cloudy from a slight admixture of mucus. 
The membrane removed at the operation covered an area of about 
forty-five square centimetres, and when fresh was from two to three 
millimetres in thickness, varying within these limits in different parts. 
Fig. 2 shows very well the microscopical appearance of a cross-section 
of this membrane. It is composed of epithelial cells, which are arranged 
much as they are on the surface of the skin. 
In the deeper parts they are penetrated by papillae of connective 
tissue, and the cells are square or rounded, while, as the free surface 
is approached, the cells become flattened like ordinary epidermal cells, 
and on the surface they are being exfoliated in ragged flakes. In places, 
near the surface, there are well-marked onion bodies, or epidermal 4 
CABOT, A CASE OF CYSTITIS. 
pearls; but at no part are these to be found in the lower layers of the 
epithelium. 
There is, in the lower part of the horny epithelium, a well-defined 
stratum of cells containing kerato-hyalin-which is a proof, if any were 
needed, that these are true dermoid cells. 
At no place is there any apparent tendency of the epithelial elements 
to burrow down into the connective tissue beneath, after the manner of 
a cancer. 
Fig. 2. 
Cross section of membrane. 
The mucous membrane of the bladder is normally covered by several 
layers of epithelial cells, which in the deep parts are more or less 
rounded, and on the surface are flattened. Krause and Oberdieck1 
describe four layers of epithelium; and the latter has determined the 
thickness of the epithelial portion of the mucous membrane to vary 
between 0.036 and 0.068 millimetre in the empty bladder, and to be 
about one-half to one-third as thick in the full bladder. 
The epithelial layer forms a flat sheet on the connective tissue 
beneath, and has no papillary arrangement such as exists in the deep 
layers of the skin. 
The membrane in the case reported, which was made up entirely of 
1 Ueber Epithel u. Drusen der Harnblase, etc. Gottingen, 1884. CABOT, A CASE OF CYSTITIS. 
5 
epithelium, was therefore from fifty to one hundred times as thick as the 
epithelial layer normally existing on the bladder-wall, and its nourish- 
ment was provided for by papillae thrown up by the connective tissue 
below. 
These papillae are entirely unusual in this locality, yet they nowhere 
showed any tendency to go beyond limits of growth that are physiological 
in other parts of the body. There was at no point any formation of 
extremely long, branched papillae, such as are seen in papillary growths 
of the bladder. In short, the condition resembled the hyperplasiae that 
are met, not uncommonly, on other epithelial surfaces as the result of 
long acting irritations. On the skin we have corns and callouses, due 
to a pathological process almost exactly identical. There is, however, 
this difference, that whereas in the skin we have a simple hypertrophy 
of the horny layer which is normally present on that surface, we here 
have the formation of a highly-developed horny layer on a surface on 
which true epidermal cells do not normally exist. 
Virchow1 has described a similar condition of the mucous membrane 
of the larynx, which he has named "pachydermia laryngis." He has 
shown that, when the mucous membrane of the larynx is exposed to 
persistent irritation, the epithelium may become much thickened into 
many layers and cornified, while papillse are thrown up out of the con- 
nective tissue below. This change he noticed only on those parts of the 
larynx where the epithelium is of the pavement variety. And he 
regards those parts of the laryngeal mucous membrane which normally 
have pavement epithelium, as allied to the outer skin, and, therefore, 
subject to changes and pathological processes such as are met with on 
the skin, while the portions of the larynx which are covered with ciliated 
epithelium-i. e., the more properly mucous surfaces-he thinks, are not 
subject to these changes. 
Posner2 points out, however, that the kind of cell on a given surface 
is not a reliable guide in determining the relation of that surface to 
others which seem to resemble or to be allied to it. Thus the nasal 
cavities, which are infoldings of the ektodermal layer, and are, there- 
fore, allied to the outer skin, are covered with ciliated epithelium and 
are plentifully supplied with mucous glands-in short, are covered by a 
true mucous membrane. 
Posner, therefore, divides the question of the cornification of mucous 
membrane into two parts: (1) Can mucous surfaces covered with cylin- 
drical cells undergo dermoid changes? And (2) Can surfaces of a meso- 
or ento-dermal origin take on a dermoid character ? 
The first of these questions he answers easily in the affirmative, and 
brings forward in proof many observations showing the change of 
cylindrical epithelium into dermoid cells. 
1 Berl. klin. Wochenschrift, August, 1887. 
2 Virchow's Archiv, vol. cxviii., 1889. 6 
CABOT, A CASE OF CYSTITIS. 
The second question is, however, the one that particularly interests 
us in connection with our cases; for the bladder, being derived in the 
embryo from the sinus urogenitalis, is distinctly of entodermal origin, 
and has no close relationship, therefore, with the external skin. 
In the consideration of this question Posner points out the frequent 
occurrence of the dermoid change on the mucous membrane of the 
upper portion of the vagina in cases of prolapse. Similar changes are 
also observed in the uterus, in the larynx, and in the male urethra.' It 
is to be remembered, however, that the anterior portion of the urethra- 
i. e., all of the canal anterior to the constrictor urethrae muscle-is of 
ektodermal origin, being formed by an infolding of the outer epithelial 
layer, so that only when dermoid changes are found in the deep urethra 
can they be regarded as occurring on mucous membranes of entodermal 
origin. 
When we come to the bladder we find instances of dermoid changes 
extremely few and doubtful. V. Antal has reported a case of epithe- 
lioma of the bladder in which all the histological characteristics of the 
outer skin were observed. Even the kerato-hyalin layer was there. 
Posner justly says, however, that great care is necessary in such cases, to 
be sure that the tumor is primary on the mucous membrane. He also 
quotes a case of Marchand's1 to show to what extent the epithelium of 
the skin may grow over onto the mucous membrane of the bladder. In 
this case, a boy with a perineal fistula following lithotomy, had the 
bladder, the ureters, and the pelves and calices of the kidneys covered 
with a lining of horny epithelium which had grown in from the skin. 
These are the only instances that Posner has been able to find of epi- 
dermal changes of the mucous membrane of the bladder. He considers 
neither of them as clear examples of a change (umwandlung) of the 
vesical mucosa iuto epidermis, but rather as instances of transplanta- 
tion or of direct growth of epidermis onto the bladder by continuity 
of tissue. 
Whether the case presented with this paper can be accepted as au 
undoubted instance of the bladder mucous membrane undergoing an 
epidermal change must be decided by the consensus of opinion of those 
best able to judge. 
The fact that the patient had a lithotomy many years before, intro- 
duces the doubt whether here we have not a case of the growth of the 
epidermis of the skin over on to the mucosa of the bladder. It is to be 
remembered, however, that the perineal wound was open for only three 
weeks, that it then healed solidly and smoothly, and that there is now 
no dipping in of the skin, such as is seen in cases of old fistulse. 
It seems to the writer that this rapidity of healing precluded the pos- 
1 Naturforscher Versamlung zu Wiesbaden. CABOT, A CASE OF CYSTITIS. 
7 
sibility of any continuity of growth of epithelium between the skin and 
bladder, such as occurred in Marchand's case. 
Furthermore, the clinical history of this case seems to throw some 
light on the etiology of the affection. After the operation the clumps 
of epithelium exfoliated from the dermoid surface reappeared in the 
urine, persisted, though in diminishing amount, for more than six months, 
and only finally disappeared after about ten months. This would seem 
to show that the dermoid condition continued over portions of the 
bladder-wall, and was finally so modified by treatment that all evi- 
dences of it vanished. 
The nitrate of silver injections were not of a strength to destroy 
epidermal tissues, and no other part of the treatment could be supposed 
to have any power to effect the destruction of this membrane. 
All of the treatment was directed against the cystitis, and the disap- 
pearance of the dermoid flakes coincidently with the mitigation of the 
inflammation in the bladder would suggest that the dermoid condition 
was induced by the irritation of the cystitis, and disappeared pari passu 
with the cessation of this irritation. 
Virchow has shown that pachydermia laryngis has resulted from not 
unsimilar irritations of the mucous membrane of the larynx, and the 
writer is inclined to the view that in his case the dermoid change in the 
bladder was a result of the chronic cystitis. 
In making a diagnosis of this condition in future cases the points to 
be taken into consideration are the chronic character and obstinacy of 
the cystitis, and the presence in the urine of flakes and clumps of horny 
epithelial cells. 
It seems quite possible that a pachydermia vesicie exists not infre- 
quently in a less degree than in the case reported and goes unrecognized. 
The appearance in the urine of considerable numbers of flakes of epi- 
thelium is not uncommon in the course of severe cystitis, and that the 
dermoid condition should not be recognized on the autopsy table may 
well be due to the maceration which the epithelium rapidly undergoes 
after death. This is so great that in order to obtain correct ideas of the 
condition of the epithelium in a normal bladder it has been necessary 
to inject the bladder immediately after death with absolute alcohol to 
fix the cells and prevent their separation. The present more frequent 
performance of suprapubic cystotomy will probably give us opportuni- 
ties to recognize this dermoid change during life. 
With the cystoscope the whitish color of the surface might perhaps 
be appreciated, and in places where the edge of the membrane was 
sharply defined, characteristic pictures might be obtained. It would 
probably, however, be very difficult to distinguish this condition from 
some of the yellow surfaces furnished by tuberculous ulcerations of the 
bladder. 8 
CABOT, A CASE OF CYSTITIS. 
As far as we can judge from this one case, the treatment of a similar 
condition should be directed to the allaying of the inflammation. Cer- 
tainly the injections of nitrate of silver seemed to answer an excellent 
purpose. And every measure that allayed the irritation and enabled 
the patient to carry his water longer and to urinate with less pain was 
followed by a corresponding diminution in the amount of pus in the 
water and in the number of epithelial flakes. 
Dr. J. P. Bryson, of St. Louis, suggested the possible utility of injec- 
tions of salicylic acid solution. He said that he had had excellent 
results from the use of these solutions in the treatment of cystitis, and 
he thought they would be peculiarly applicable in cases of this sort, for 
salicylic acid has the well-known power to remove warts, corns, and 
other growths of hyperplastic epithelium. 
If milder methods of treatment fail, and resort to operation seems 
indicated, the suprapubic section affords the only satisfactory method 
of dealing with the membrane; for its separation and removal by the 
limited route through the perineum are manifestly impossible. THE AHERKAN JOURNAL 
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