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A 
 
 PROBATIONARY ESSAY 
 
 ON THE 
 
 MORBID ANATOMY 
 
 OF THE 
 
 URINARY BLADDER, 
 
 SUBMITTED 
 
 BY THE AUTHORITY OF THE PRESIDENT 
 AND HIS COUNCIL, 
 
 TO 
 
 THE EXAMINATION 
 OF 
 
 Clje Eo^al College of burgeons 
 of Ctmifmvglj, 
 
 WHEN CANDIDATE, 
 
 FOR 
 
 ADMISSION INTO THEIR BODY, 
 
 IN CONFORMITY 
 
 TO THEIR REGULATIONS 
 
 RESPECTING 
 
 C£e of £)etunaep jMlotog, 
 
 BY 
 
 DAVID CLARK, M.D. Surgeon. • 
 
 December, 1818 . 
 
 EDINBURGH : 
 
 PRINTED BY JAMES BALLANTYNE AND CO. 
 
 1818 . 
 
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TO 
 
 JOHN ABERCROMBIE, Esq. M.D. 
 
 FELLOW OF THE ROYAL COLLEGE OF SURGEONS, 
 EDINBURGH. 
 
 Dear Sir, 
 
 As the present may perhaps he the only op- 
 portunity which shall ever he in my power of so 
 publicly testifying my gratitude for the innu- 
 merable obligations under which your kindness 
 has laid me, I therefore perform an act no less 
 of duty than of love, in dedicating the follow- 
 ing pages to one who exercises such a paternal 
 influence on all who have the felicity to he con- 
 nected with him, and who is so filially beloved 
 by them ; and, I trust, by none more so, than by 
 
 His most affectionate Pupil, 
 
 David Clark. 
 
 December, 1818. 
 
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AN 
 
 ESSAY 
 
 ON THE 
 
 MORBID ANATOMY 
 
 OF THE 
 
 URINARY BLADDER. 
 
 In considering the Morbid Anatomy of any 
 part of the human body, a correct knowledge 
 of the part, or parts, in the healthy state, is 
 presupposed ; but, for the sake of connection, 
 I shall here ive an outline of the anatomy in 
 the healthy state of that part which I intend 
 to consider, viz. the Urinary Bladder — pre- 
 vious to entering upon it in the state of dis- 
 ease, which more peculiarly forms the subject 
 of this paper. 
 
 The urinary bladder, then, is a hollow vis- 
 A 
 
2 
 
 cus, situated in the anterior and inferior part 
 of the pelvis, in the healthy state capable of 
 containing about two lbs. of urine ; but when 
 morbidly distended, as in the retention of 
 urine from paralysis, it has been known to 
 contain 22 lbs,* When seen out of the pel- 
 vis, and unconnected with the neighbouring 
 parts, as in dried preparations of it, it is ge- 
 nerally of an oval shape, but in situ, on ac- 
 count of its connections and pressure of the 
 surrounding parts, has more of a triangular 
 appearance. It is divided into body, atlantal 
 and sacral fundus and neck ; is connected su- 
 periorly by the urachus and umbilical arteries 
 to the anterior and inferior parietes of the 
 abdomen ; anteriorly, to the symphysis pu- 
 bis ; and posteriorly, to the rectum in the 
 male, and uterus in the female, by fat, loose 
 cellular substance, and ligaments. These li- 
 gaments are chiefly formed by the perito- 
 neum ; but the peritoneum has a more ex- 
 tended and important connection with the 
 bladder. It covers one-third of it ; is re- 
 flected to it anteriorly from the abdominal 
 
 * Lieutaud, Obs. 1258. 
 4 
 
3 
 
 muscles ; covers its superior anterior part ; 
 all its atlantal fundus descending on its 
 posterior part till it reaches the vesicuhe se- 
 minaies, and is again reflected on the ante- 
 rior part of the rectum in the male, and ute- 
 rus in the female. It is evident from this, 
 that the peritoneum is only a partial covering 
 to the bladder, the sacral fundus, and the two 
 places of reflection being destitute of a co- 
 vering from it. But besides this partial coat, 
 it has two complete ones, a muscular and a 
 mucous. The muscular coat surrounds the 
 whole of the bladder, is pretty strong, and 
 the fasciculi run in various directions ; at die 
 atlantal part they chiefly take a longitudinal 
 direction, on the sides a circular, and at the 
 sacral fundus they cross in all directions. This 
 coat is very irritable, and has been called 
 Detrusor Urinas. Towards the neck, which 
 is situated at the anterior and inferior part cf 
 the bladder, the circular fibres are strength- 
 ened, and embrace the beginning of the ure- 
 thra, forming a sphincter ; the muscular fas- 
 ciculi have numerous interstices, through 
 which the next coat may be seen, viz. the 
 mucous or internal coat ; it is smooth and 
 
4 
 
 firm, lines all the internal surface ; when the 
 bladder is distended, no irregularities are to 
 be observed in it, but when contracted, it 
 falls into rugae. Portal* considers this coat 
 as only dense cellular substance ; a mucus is 
 secreted from its surface, which defends it 
 from the irritation of the urine, and when 
 formed in great quantities, constitutes the 
 disease called Catarrhus Vesicas; this mucus 
 has been supposed to take, its origin from nu- 
 merous small glands which have been said to 
 be found covering this coat.t There is a part 
 of this inner surface of the bladder which the 
 French call Trigone, and which, although 
 it s delineated by several anatomists, is de- 
 scribed by few ; it is rather whiter and 
 harder than the rest of the bladder — is bound- 
 ed before by the opening of the urethra, and, 
 posteriorly and laterally, by the opening of 
 the ureters ; the inner coat is very intimately 
 connected with it. Portal; thus describes it : 
 " Quant a la partie inferieure de ce sac, elle 
 
 * Cours d’Anatom. Medical, Tom. v. p. 398. 
 
 f Diction, des Sciences Med. Art. Cystitis. Winslow. 
 &c. 
 
 t Cours, &c. Tom. v. 
 
est adherente a un corps triangulaire de con- 
 sistance cartilaginemse, lequel est toujours 
 un peu saillant dans la cavite vesicate, mais 
 sur-tout dans la vieillesse : Lieutaud a donne 
 a cette partie de la vessie le 110m de trigone. 
 
 “ Des trois bords qu’on y observe, deux 
 sont lateraux, et le troisieme est posterieur et 
 le plus court ; ces trois bords sont termines 
 par autant d’angles dont deux sont posteri- 
 eurs ; le troisieme est anterieur. On remarque 
 a chacun des deux angles posterieurs, l’ouv- 
 erture oblongue des ureteres, et quant a l’angle 
 anterieur du trigone il est surmonte d’une 
 eminence un pen plus saillante, a laquelle 
 Liuetaud a donne le nom de luette. Cet ana- 
 tomiste a cru que le trigone avoit un peu 
 moins d’etendue chez les femme que chez les 
 hommes ; mais nous ne nous sommes pas 
 convaincus de cette difference. 
 
 “ II y a une union tres-intime entre la mem- 
 brane interne de la vessie et le trigone. Cette 
 union se fait par divers trousseaux de fibres en 
 forme de ligamens ; mais on n’y voit aucane 
 fibre musculaire d’ou il doit resulter que, 
 dans cet endroit, la vessie n’est pas susceptible 
 de contraction, et par consequent que les ori- 
 
<3 
 
 iices des ureteres ne peuvent etre retrecis par 
 la contraction meme la plus fort de la couche 
 musculaire ; ce qui fait que l’urine peut couler 
 sans interruption dans la vessie.” These three 
 coats are connected with each other by means 
 of loose cellular substance ; that between the 
 mucous and muscular coat, being more con- 
 densed than the other, has by some been de- 
 scribed as a fourth coat. 
 
 Having described the coats of the bladder, we 
 shall now examine it more particularly exter- 
 nally Attached to its sacral fundus we fin d two 
 soft bluish white knotted bodies, enveloped in 
 cellular substance, and partially covered by the 
 fibres of the levator ani muscle, about four 
 fingers breadth in length, and one in breadth ; 
 these are the vesicula? seminales : they are for- 
 med of a tube coiled up, which, on being dried 
 and cut into, presents a cellular appearance ; 
 but this is owing to the distortions of the ca- 
 nal, and the duplication of the inner mem- 
 brane ; they converge and meet at an acute 
 angle behind the prostate gland. This is a 
 eland surrounding the neck of the bladder, 
 and about half an inch of the beginning of 
 
 o o 
 
 the urethra ; it is of a pyramidal shape, with 
 
its base towards the bladder, and the apex to- 
 wards the urethra ; it is of a fibro-cartilagi- 
 nous structure, and has three lobes, two late- 
 ral, and one in the middle, which slightly 
 projects. Mesial to the vesiculae seminales 
 are seen the vasa deferentia, or excretory 
 ducts of the testicle ; these run parallel to 
 the vesicular, and join them where they are 
 imbedded in the prostate gland. The blad- 
 der of the female wants this gland. Behind 
 the vesiculae seminales, and a little to the out- 
 side, are seen two other tubes ; these are the 
 ureters, or excretory ducts of the kidneys, 
 which, descending from them on the surface 
 of the psoas muscle, enter the bladder ob- 
 liquely between the muscular and mucous 
 coats at the superior and posterior angles of 
 the triangular space near the neck, formerly 
 described under the name of the trigone ves- 
 sicle ; and upon examining this point from 
 the inside, their mouths may be seen : by the 
 obliquity of their insertion, the urine which 
 they transmit is prevented from returning. 
 The peritoneum, although it descends on the 
 posterior part of the bladder as far as to touch 
 the vesiculae seminales, and is reflected from 
 
8 
 
 these to the rectum, yet descends lower in the 
 interval between them, so that its inferior 
 connection is by a semicircular line, the con- 
 vexity of which looks towards the neck. 
 A fascia lining the walls of the pelvis from 
 the sacro-sciatic notch and linia ilio-pectinea, 
 descends mid- way in the depth of the pelvis, 
 and is reflected from the surface of the mus- 
 cles to the prostate gland, neck of the blad- 
 der, and membranous part of the urethra, 
 binding these parts firmly to the arch of the 
 pubis.* Behind the attachment of this fa- 
 scia to the pubis, the under ligament of the 
 bladder extends from its neck and from the 
 prostate gland to be fixed to the inner side 
 of the symphysis, pubis. The posterior liga- 
 ments are redupli cations of the peritoneum, 
 extending from the inferior and posterior 
 part of the bladder to the sides and anterior 
 part of the rectum. The bladder is farther 
 connected to the bones of the pubis by the 
 fibres of the levator ani muscle which sur- 
 round its neck, the extremity of the rectum, 
 
 55 For a more particular description of this fascia, see 
 Colic's Surgical Anatomy, Part I., and Dr Gairdner’s 
 Probationary Essay, p. 17. 
 
9 
 
 all the prostate gland, and part of the vesi- 
 cular seminales. Mr Charles Bell describes 
 the cellular substance at the anterior part of 
 the bladder, where it is a little condensed, un- 
 der the name of the fascia vesicalis. The 
 bladder is chiefly supplied with blood from 
 the hypogastric, umbilical, common pudic, 
 obturator, and hemorrhoidal arteries; its veins 
 are more numerous and larger than the arte- 
 ries, and form numerous plexuses, particularly 
 at the sacral fundus, and between the loose 
 cellular substance and the fat, at the anterior 
 and posterior reflections of the peritoneum. 
 The nerves are from the hypogastric plexus. 
 
 i — INFLAMMATION OF THE BLADDER. 
 
 Inflammation being commonly connected 
 in some manner or other with most of those 
 changes which a part undergoing diseased 
 action takes on, it in a peculiar manner ob- 
 trudes itself on our notice as a primary ob- 
 ject of attention. It may be either of the 
 
10 
 
 phlegmonous or erysipelatous* kind, and 
 may terminate in adhesion, suppuration, 
 gangrene, or ulceration. It may either be 
 acute or chronic. When acute, it generally 
 arises from wounds, blows, retention of urine, 
 too large doses of cantharides, metastasis, occ. 
 When chronic, from calculi, or other foreign 
 bodies. It may attack any or all of the coats 
 of the bladder ; when it attacks the perito- 
 neal, it renders it thicker, more pulpy, less 
 transparent, and crowded with small vessels 
 containing red blood ; it very seldom attacks 
 this coat primarily,! but commonly spreads to 
 it from the internal coat. The occurrence of 
 this latter circumstance is considerably retard- 
 ed by the loose cellular substance intervening 
 between the coats. 
 
 The mucous coat is the one most fre- 
 quently diseased or inflamed, the muscular 
 only becoming so by the spreading of the in- 
 flammation from either of the other two coats. 
 The effects of inflammation on this coat are, 
 
 * Lieutaud, Observ. 1567. 
 
 -f- See a case of inflammation attacking the peritoneal 
 coat of the bladder from a blow, in Dr Sievwright’s The- 
 sis, “ De Cjstiticle,"’ Edin. 1815. 
 
11 
 
 thickening, induration, ulceration, and suppu- 
 ration. The inflammation may either be partial 
 or complete ; in the former case, it is com- 
 monly situated at the neck ; in either, nu- 
 merous red vessels, and even spots of extra- 
 vasated blood, may be observed.* 
 
 In the chronic inflammation of the internal 
 coat, producing' the disease called catarrhus 
 vesicas, the cavity of the organ is found to 
 have undergone a contraction, more or less 
 marked, and contains ordinarily a quantity of 
 turbid urine, the coats acquire an unusual 
 thickness, a consistence like bacon, or a hard- 
 ness which approaches to horn. From fre- 
 quent attacks of inflammation, the inner sur- 
 face becomes rough, and studded with pro- 
 jections, formed by coagulable lymph. * 
 One of the most common terminations, or 
 consequences of inflammation of the blad 
 der, is 
 
 Adhesion.-r- This may take place to any of 
 
 * From stricture of the rectum, Mr Hovrship has seen 
 its internal surface of the brightest scarlet colour . — On 
 . Diseases of the Urinary Organs, Case 1 1th. 
 
 f Mr Charles Bell’s Quarterly Report, p. 122. 
 
12 
 
 the neighbouring viscera, as the uterus, rec- 
 tum, jejunum, colon, or the inferior part of the 
 epiploon. From adhesion to the colon when 
 inflated, the disease has been mistaken for 
 distended bladder, * exciting extreme irrita- 
 tion in the bladder. 
 
 Suppuration . — When this takes place, it is 
 Commonly the termination of inflammation 
 of the inner coat, or the effect of the irrita- 
 tion of stones or ulcers ; it may occur to such 
 an extent, as to fill the whole bladder with 
 pus ; however, pus in a more circumscribed 
 state, as in that of abscess, occasionally occurs ; 
 this may take place at any part of the par- 
 ietes, or between the coats to any extent, but 
 it is most generally seated in the loose cellu- 
 lar substance about its neck. These abscesses 
 may either communicate with the cavity of 
 the bladder, or with each other, or remain 
 insulated ; f large foetid abscesses have been 
 found surrounding the whole bladder be- 
 tween its coats, and separating them into 
 
 * Mr Charles Bell’s Quarterly Reports. Part v. p. 37. 
 
 f Portal,, Cours d’Anat. Med. Tom. v. p. 407. 
 
IS 
 
 innumerable laminae between which it stag- 
 nated. * In a case in the Infirmary of Aber- 
 deen, of abscess near the neck of the bladder, 
 the consequence of a gonorrhoea, suppressed 
 by a strong injection, for twenty -four hours 
 before death the genitals were monstrously 
 swelled and inflamed, and at last sloughed, 
 the patient passed no urine but in drops, and 
 very sparingly. A catheter was once intro- 
 duced with great difficulty, but nothing 
 came through it, and when withdrawn was 
 very much tarnished. On opening the body, 
 the abscess was found to be about the size of 
 a small egg, the matter intolerably foetid, and 
 the whole mucous coat of the bladder, black 
 and broken down ; only a few days elapsed 
 betwixt the suppression of the gonorrhoea, 
 and the death of the patient. 
 
 Ulcer . — This, like the former, may either be 
 the termination of inflammation, or the effect 
 of the irritation of some foreign body in the 
 cavity. It not unfrequently attacks the 
 
 * Lieutaud, Observ. 1263 and 1264>. 
 
 Note. — See Howship on Diseases, Sec. p. 76, for an 
 abscess between the peritoneal and muscular coats. 
 
14 
 
 edges of the wound in lithotomy ; it may ei- 
 ther be partial or total, superficial or deep ; in 
 the latter case, it may form a communica- 
 tion between the bladder and the cavity of 
 the abdomen, or between it and the vagina 
 in the female, and rectum in the male. In 
 these cases, the salutary effect of the previous 
 adhesive inflammation, is seen in preventing 
 the contents of the bladder from beino’ ex- 
 
 \ O 
 
 travasated into the abdomen. The whole in- 
 ternal coat has been found destroyed by ul- 
 ceration, and the membranous desquamation 
 thrown off by the meatus uririarius, * leaving 
 the muscular bare as if by dissection, f The 
 case represented in plate 9th, of Marcet on 
 calculous disorders, is an example of this. 
 An ulcer is sometimes seen in the atlantal 
 fundus after a fatal case of lithotomy; this has 
 been ascribed to using too long a staff, and 
 with too great force, i Ulceration, with ad- 
 hesion of the bladder to the intestines, is the 
 only way in which we can account for foreign 
 bodies being found in its cavity after death, 
 
 * Lieutaud, Observ. 12T 3,— -Medical Essays and .Ob- 
 servations, Vol. I. p. 253. 
 
 + Baillie’s Morbid Anatomy, p. 301. 
 
 ± Dr Thomson’s Lectures. 
 
15 
 
 or in lithotomy, after having been swallowed 
 months or years before. * 
 
 Gangrene . — This most commonly takes 
 place before the rupture of the bladder, in re- 
 tention of urine; it may however be more 
 extensive, and attack any or all of its coats, 
 but the mucous coat is the one most general- 
 ly and extensively affected ; in this latter 
 case it is most generally accompanied with 
 stones, or some other foreign body ; it may, 
 however, take place without any such occur- 
 rence. Portal f found all the internal sur- 
 face covered with livid spots, from using 
 too strong an injection for stopping a go- 
 norrhoea ; and on opening the body of the 
 illustrious Barthez, the bladder was found 
 contracted, and filled with purulent matter, 
 its parietes were black, sphacelated, and mueh 
 thicker than usual, not the least trace of the 
 mucous coat was to be seen. \ Morgagni 
 
 -* Diction, des Scien. Med. Art. des Corps Etrangers 
 dans la vessie, Tom. vii. 
 
 Morgagni do Causis, &c. Epist. 42. obs. 43, &c. 
 
 -j- Cours d’ Anatom Med. Tom. v. 
 
 t Diction, des Scien. Medical. Art. Cystitis. 
 
16 
 
 relates two cases of gangrene of the bladder, 
 which he ascribes to the pressure of foreign 
 bodies in its cavity. The first case is that of 
 a girl, who introduced a hair pin into the 
 bladder, through the urethra ; it afterwards 
 formed the nucleus of a calculus, and occa- 
 sioned two abscesses in the hypogastrium, 
 which on dissection were found to communi- 
 cate between the peritoneum and abdominal 
 muscles, with the atlantal fundus of the blad- 
 der. At this place it was found adhering to 
 the parietes of the abdomen, so that no 
 urine could escape from it into that cavity ; 
 the internal coat of the bladder adhered to 
 the calculus, and was found ulcerated and 
 gangrenous in several places. In the other 
 case, the needle had pierced the urethra, and 
 projected into the vagina ; the bladder was 
 found sphacelated. * Gangrene has likewise 
 been found attacking the outside of the blad- 
 der, and the peritoneal coat ; in this case it 
 was filled with sanious matter, f 
 
 * Epist. 42. art. 20. 
 
 -J- LieutaucL Obs. 1592, and 1402. and Lib.II.Obs. Stil; 
 Bartholin us Acta Med. Vol. 5. Obs. 121, attacking the 
 peritoneal coat. 
 
17 
 
 Symptoms . — In cystitis there is pain err- 
 creased on pressure, both above the pubis, and 
 in the perineeum, accompanied with a full- 
 ness there, frequent painful attempts to make 
 water, or total retention with strong desire to 
 void it ; pyrexia, sickness, vomiting, some- 
 times delirium, and from the connection and 
 sympathy of the parts, tenesmus. 
 
 No symptoms, a priori, could lead us to 
 the certainty of adhesion having taken place, 
 unless at the same time ulceration had super- 
 vened, and a discharge of feculent matter or 
 air had taken place by the urethra, or of 
 urine by the rectum, or vagina ; and these 
 without being accompanied with abdominal 
 extravasation. 
 
 In the early stages, ulceration is accompa- 
 nied with pain and difficulty in making- 
 water, the urine more turbid than usual, and 
 mixed with shreds of coagulated blood. 
 When pus is formed in the bladder, it will 
 be excreted with the urine, but not so tho- 
 roughly mixed with it as if it came from 
 the kidneys ; shivering, &c. will likewise oc- 
 cur. 
 
 n 
 
1 8 
 
 II.— SCIRRHUS AND CANCER. 
 
 May either be partial or total, primary, ' 
 or secondary, but much more generally it is 
 the latter, and extends to the bladder from 
 the neighbouring parts, as the uterus, or 
 rectum. Under such circumstances, the viscus 
 becomes very thick and hard, and exhibits 
 the ordinary cancerous structure ; it has been 
 known to grow so hard, as scarcely to be cut 
 with a knife.f Cancer of the bladder is usu- 
 ally attended with a great degree of pain, but 
 instances have been known of a cancerous ul- 
 cer destroying all the neck of the uterus and 
 superior part of the vagina, and communica- 
 ting with the bladder by an aperture an inch 
 in diameter, without the occurrence of any 
 distressing symptom, except a copious foetid 
 discharge.;}; In a case related by Tulpius, I 
 
 * Diet, des Scien. Med. Cancer, 
 f Lieutaud, Obs. 129D 
 % Diet. &c. art. Cancer Uter, T. iii 
 || Lib. iv. chap. 38. 
 
19 
 
 the urine was discharged with excruciating 
 pain, for upwards of ten years, through a fis- 
 tulous communication between the bladder 
 and rectum ; the opening in the former was 
 surrounded with “ a foul and unequal car- 
 cinoma.” Fungi have been supposed to be 
 the common form of cancer of the bladder.* 
 In Obs. 1267 of Lieutaud, the anterior part of 
 the bladder was ulcerated and besmeared with 
 a thick foetid pus, and looked as if it were car- 
 cinomatous ; and in the 1303, the scirrhus was 
 confined to the neck, and occasioned obstinate 
 ischuria. In a great proportion of cases of 
 cancer of the bladder, stones or other foreign 
 bodies have been found in its cavity on dis- 
 section, or have escaped from it through the 
 communication, which, in all probability, will 
 sooner or later form into the vagina, or rec- 
 tum. 
 
 * Delpech Malad. Chirurg.Tom. I. Howship on Dis- 
 eases of Urinary Organs, p. 58, and case 10. 
 
III.— DISPLACEMENTS. 
 
 The slight displacements which the urinary 
 bladder is subject to, on account of the state 
 of vacuity, or fullness of itself, or the neigh- 
 bouring viscera, or from pregnancy, or pro- 
 lapsus uteri, must occur to the mind of every 
 one. A case of fatal retention of urine oc- 
 curred to Dr Hunter,* where the bladder was 
 thrust forwards, and upwards, by a large col- 
 lection of hydatids, situated between it and 
 the rectum. In a case of perineal hernia, 
 which occurred to Mr Broomfield,-}- the intes- 
 tines had pushed up the sacral fundus against 
 the os pubis, so that in the operation of litho- 
 tomy, he was obliged to introduce the forceps 
 perpendicularly, and pressure on the lower 
 part of the abdomen was necessary to bring 
 the bladder sufficiently low for laying hold of 
 
 * Transactions of a Society, &c. Vol. I. 
 
 t Chirurgical Observations. 
 
21 
 
 the stone. In infants, on account of the 
 smallness of the pelvis, from the os sacrum 
 being straight, and the little developement of 
 the other bones, the bladder is almost entire- 
 ly situated in the hypogastric region, and is 
 prolonged to within a very little of the um- 
 bilicus, where it terminates by a kind of 
 point. This might be mistaken for a morbid 
 affection, if it was not known that it is pecu- 
 liar to children. 
 
 IV.— DISTENTION AND RUPTURE. 
 
 i 
 
 From whatever cause distention of the 
 bladder has arisen, its position is greatly al- 
 tered. It may either rise so as to fill the whole 
 pelvis, or reach to the umbilicus,* and extend 
 laterally so as to fill the iliac fossa, t or it may 
 even rise to the scrobiculus cordis ; ; in gene- 
 ral, however, the distention laterally is greater 
 
 * Lieutaud, Obs. 1254. 
 
 -j- Portal Cours, &c. Tom. V. p. 408. 
 t Bell’s Principles of Surgery. Obstruction of Urine. 
 
2 2 
 
 than that atlantad ; the relative connection of 
 the bladder formerly explained, favours this 
 opinion. Distention of the bladder is accom- 
 panied with turgescence of its vessels, fullness 
 of blood in the part, and extravasation into 
 the cellular membrane. “ To those who ima- 
 gine that the extention of parts in the living 
 body, is like that of the dead, an attenuation 
 or mere dilatation ! who expect to find the 
 bladder on dissection, thin and transparent ! 
 its real condition must appear very surpris- 
 ing. The bladder has not indeed time to grow 
 by an actual deposition of parts, but it is 
 thickened by the fullness and turgescence of 
 its vessels, and by extravasation into its cel- 
 lular substance. I find always the veins ex- 
 tremely turgid, the muscular fasciculas big, 
 fleshy like, and apparently injected with 
 blood as in a preparation when the bladder is 
 injected with size, till it is extra vasated among 
 the coats. And while much blood is extrava- 
 sated into the cellular substance of the coats of 
 the bladder, some exudes into the cavity tin- 
 ging the urine.”* Portal f considers this thick- 
 
 * Bell’s Prin. of Surg. Art. Obstruction of Urine. 
 
 f Cours, &c. Tom. v. p. 419. 
 
23 
 
 ening of the bladder, as a thing to be wondered 
 at. Although this thickening of the bladder 
 is the common effect of great distention, yet 
 the coats are occasionally found preternatu- 
 rally thin. Observation 1255 of Leiutaud, 
 is an example of this ; the distention extend- 
 ed to the umbilicus, and was caused by in- 
 flammation of the neck, occasioning retention 
 of urine. 
 
 A short time after the bladder is distended 
 to its utmost, if the means of relief prove 
 abortive, inflammation begins at some part 
 of the bladder ; this terminates in gangrene, 
 and the viscus giving way at this point sooner 
 or later, constitutes what has been called 
 
 Rupture of the Bladder . — When this ari- 
 ses from the above mentioned cause, the aper- 
 ture by which the urine escapes is small and 
 circular, with a rough, ragged, and black mar- 
 gin. It commonly takes place at the atlan- 
 tal fundus ; but it may likewise happen at 
 the pubal part, when the urine will be extra- 
 vasated between the abdominal muscles and 
 peritoneum ; or from ulcers, gangrene, cancer, 
 &c., it may take place at the sacral fundus. 
 
21 
 
 In these cases, a communication between the 
 intestine and bladder is established, and air* 
 or foeces will be discharged by the meatus 
 urinarius.t This communication of the blad- 
 der and rectum has been known to occur as 
 an original malconformation.t The bladder 
 may likewise be ruptured by concussion, 
 blows, or wounds. A case of rupture from 
 concussion is related by Sponius.|| A man 
 fell from a height, was seized with severe 
 pain in the right hypochondrium and ensi- 
 form cartilage ; no urine flowed, except on 
 introducing the catheter ; the abdomen swell- 
 ed, with pain, fever, thirst, and a feeling of 
 straightness in the breast ; hiccup and hypo- 
 thimea came on. This was thought to be 
 occasioned by extraVasated blood in the ab- 
 domen. Hence paracentesis abdominis was 
 performed, and six ounces of blood escaped. 
 In two days after he died. On dissection, a 
 great quantity of fluid blood escaped, and the 
 
 * Hennen's Military Surgery, p. 467. 
 
 -j- Edin. Med. Comment, vol. ii. — Memoirs of the Lond 
 Med. Society, vol. iii. 542 — 600 — 643. 
 
 ± Baillie’s Morbid Anatomy. 
 
 || Lieutaud, Obs. 1284. 
 
25 
 
 bladder was found ruptured in its fundus, 
 with symptoms of inflammation and gan- 
 grene. Observ. 1752 of Lieutaud, is an in- 
 stance of rupture from a blow. A man re- 
 ceived a stroke on the hypogastrium, which 
 produced suppression of urine and swelling 
 of the abdomen ; and on dissection, the blad- 
 der was found ruptured, with effusion of 
 urine into the abdomen. A simultaneous 
 rupture of the bladder and umbilicus has 
 been known to take place, and the urinary 
 fistula by the umbilicus continue open till 
 the natural passage has been re-established. 
 This has been thought to be owing to the 
 permeable state of the urachus, or to the 
 previous adhesion between the bladder and 
 parietes of the abdomen*. Let us consider 
 the urachus , &c. more particularly. In the 
 foetus, and somewhat less distinctly in the 
 adult, there is a ligament like the remains of 
 a duct, which rises up between the perito- 
 neum and linea alba towards the umbilicus. 
 Although it is a tube in the foetus of the 
 quadruped, communicating with the mem- 
 
 * Delpecli. Malad. Chirurg. Tom. ii. p. 246. 
 
26 
 
 brail e called alantois, ) T et it is rarely found 
 pervious in the human subject. Professor 
 Walter* supposes that the urachus is always 
 open from the umbilicus to the bladder ; but 
 shut at the former by mechanical constric- 
 tion, and that as soon as the muscular fibres, 
 surrounding the entrance of the urachus into 
 the bladder, are dilated or weakened, the 
 urine enters and extends it to a preternatural 
 size, forming in that way a sort of hernia. 
 When the umbilical ring is not strong enough 
 to resist the urine, it is likewise dilated, and 
 either a hernia umbilicalis brought on, or the 
 urine runs out from the dilated urachus. It 
 seems rather more probable that urinary fis- 
 tula at the umbilicus is formed by the dilated 
 and inflamed bladder forming an adhesion 
 there, and afterwards becoming ruptured ; or 
 what is possible, according to Richerand, that 
 the internal coat of thebladderpassing through 
 the interstices of the muscular may be pro- 
 longed, and open there. A case is related 
 by Richerand f of a girl of 20 years of age, 
 
 * Med. Journal, vol. v. 
 
 f Richerand, Nos. Chir. T. iv. p. 330. 
 
27 
 
 who had passed her urine by the umbilicus 
 from her birth, and on examining the mea- 
 tus urinarius, it was found closed up by a 
 membrane, which being removed, the urine 
 after some time took its natural course. 
 
 It occasionally happens in old people, after 
 frequent temporary pains in the neck of the 
 bladder, that the urine daily diminishes in 
 quantity till it entirely stops, and then be- 
 gins to flow by the umbilicus.* In the case 
 of a man of 45 years of age, who fell from a 
 height on his abdomen, and where the urine 
 flowed by the umbilicus soon after the acci- 
 dent, Portal found on dissection the urachus 
 of a conical shape ; the base, which was si- 
 tuated at the bladder, was an inch and a half 
 broad ; and the apex at the umbilicus one- 
 third of an inch ; its length was six inches, 
 and its parietes of unequal thickness ; the an- 
 terior part being four times thicker than the 
 posterior. The anterior parietes were com- 
 posed of two membranes, and a ligament be- 
 tween them. The internal membrane, or 
 continuation of that of the bladder, adhered 
 
 * Portal sur plus Malacl. Tom. i. p. 25 and 49. 
 
28 
 
 strongly about the muscular ring, which em- 
 braced it on the side of the bladder ; it ter- 
 minated about three fingers breadth from 
 the umbilicus. The structure was such as is 
 observed at that age, viz. hard, forming a 
 kind of triangular ligament. The external 
 membrane was prolonged on the bladder, and 
 was only a false lamina of the peritoneum. 
 
 V.— BLADDER CONTRACTED, THICKENED, 
 AND HARDENED. 
 
 These are commonly found combined ; but 
 simple contraction, without disease, is found 
 as a congenital affection,* or in those who die 
 a violent or sudden death. The thickening, 
 and consequent contraction of the cavity of 
 the bladder, are the result of its frequently 
 contracting on small quantities of urine, oc- 
 casioned by ulcers, strictures, old age, stones, 
 or other sources of irritation, and producing 
 
 '* Lieutaud, 1259. 
 
2.9 
 
 chronic inflammation. This state of disease 
 sometimes proceeds to such a length, that the 
 bladder is found as small, and almost as solid 
 as an orange.* Camerariusf gives an exam- 
 ple of a bladder, the parietes of which were 
 two inches thick, and its cavity the size of a 
 nut. Renaulden J has seen it of a hard con- 
 sistence, callous, and tumified, and almost 
 equal in volume to a child’s head, and at the 
 same time its parietes so thick, and its cavity 
 so small, that it could only contain an egg. 
 In an aged woman, Portal || saw it so con- 
 tracted, that its cavity could only contain a 
 small nut ; its neck was very hard, like burnt 
 parchment ; the opening by which it com- 
 municated with the urethra was totally obli- 
 terated, and the parietes were like cartilage. 
 In a case related by Dessault, (tom. ii.), where 
 the parietes were like cartilage, the symptoms 
 so much resembled those produced by stones, 
 that an operation was performed. In the 
 case of dissection of the urachus formerly 
 
 * Bell’s Principles, vol. ii. p. 23. 
 
 -j- Ephem. Nat. Curios. Cent. iii. Obs. 40. 
 
 X Diet, des Scien. Med. Art. Cystitis. 
 
 || Sur plus Malad. Tom. i. 
 
30 
 
 mentioned, the bladder was very hard, its 
 size did not exceed that of an apple, and it 
 could scarcely contain half a glass of liquid. 
 The neck was very hard, puckered, tough, 
 like half-burnt parchment, and the opening 
 to the urethra entirely shut. The bladder 
 has from gonorrhoea been found so rigid, that 
 it could neither be contracted nor dilated. * 
 Some have supposed this thickening of the 
 bladder to proceed from the muscular coat, 
 thinking it the one most subject to disease.! 
 Mr Bell thinks, if it were entirely muscular, 
 the contractile power of the bladder would 
 be destructive ; but it is much in the other 
 coats, and owing to a deposition between 
 them. Depositions do sometimes take place 
 between the coats. Portal J found a bed 
 of lymphatic substance between the peri- 
 toneal and muscular coats, of four lines in 
 thickness, and of a texture so solid, that it 
 looked like cartilage. Some think that the 
 whole coats are thickened, but especially the 
 
 * Lieutaud, 109 k 
 \ Bell’s Principles, vol. ii. p. 23. 
 t Cours, &c. tom. v. 
 
31 
 
 muscular ;* and others, that the cellular sub- 
 stance may likewise participate ; by others, 
 the mucous coat has been supposed most af- 
 fected, f Renaulden saw the bladder six lines 
 thick ; it did not exceed the size of a small 
 apple ; no muscular tunic could be distin- 
 guished, only a fibrous tissue, of a greyish 
 colour, could be perceived. Portal,! on open- 
 ing the body of an old man, found the neck 
 of the bladder hard, and totally obliterated ; 
 its cavity very much diminished, its parietes 
 eight or nine lines thick, and, on a more at- 
 tentive examination, he saw the internal mem- 
 brane Avas the only one which had acquired 
 thickness. The peritoneal coat was natural, 
 the muscular fibres Avere scarcely visible, and 
 so intimately united to the external mem- 
 brane, that they could scarcely be separated. 
 The internal membrane resembled cartilage ; 
 it Avas not of equal thickness throughout, 
 was double at the neck, but especially at the 
 trigone. 
 
 * Monro’s Anatomy, vol-. iii. p. 33. 
 
 f Diction, des Scien. Medical— Cystitis. 
 
 t Sur Plus Malad. tom. i. 
 
32 
 
 Symptoms . — The bladder may be known 
 to be preternaturally distended by the tense 
 elastic swelling which it makes above the pu- 
 bis, or when felt through the rectum, with 
 frequent calls to make urine. We have seen 
 that adhesion of the bladder to a distended 
 colon, has occasioned the latter to be mista- 
 ken for the former. I know of no symptom 
 prior to the introduction of the catheter, 
 which would lead to the suspicion of this 
 having taken place. When the bladder is 
 ruptured, after having been distended for 
 some time, there is a sensation as if some- 
 thing had given way in the abdomen, with a 
 noise, and sudden mitigation of pain, which, 
 however, is soon renewed by the inflamma- 
 tion caused by the extravasation of urine. 
 The bladder may be suspected to be con- 
 tracted and thickened, if, after strictures, ca- 
 tarrhus vesica?, ulcers, &c. the patient have 
 frequent calls to make water ; and, if upon 
 introduction of the sound, no stone can be 
 felt, and the progress of the instrument be 
 suddenly obstructed by the atlantal fundus, 
 which, with the other parts of the cavity with 
 
33 
 
 which it comes in contact, are felt firm and 
 strongly resisting. The suspicions will be 
 strengthened, if the patient is advanced in 
 years. 
 
 VI. — CYSTOCELE. 
 
 This is oftener consecutive and partial, 
 than primary and complete ; it is usually 
 preceded by a distention of the bladder, from 
 retention of urine, from paralysis, which, de- 
 stroying its tone, renders it flaccid and more 
 easily displaced ; or by some other hernia 
 dragging it along with it as a bubonocele or 
 prolapsus uteri, &c.,* or by the incumbent 
 weight of the pregnant uterus pressing it to 
 each side. It may present itself in the groin 
 and scrotum, vagina and pudendum, peri- 
 neum, crural arch, f or umbilicus ; the four 
 last are very uncommon. Portal | says, that 
 
 * London Medical Observations, vol. iii. 
 f Verdier’s Memoir, Obs. ii. 
 if Lib. Cet. tom. v. p. 423. 
 
 C 
 
34 
 
 cystoceles at the crural arch, foramen ovale, 
 and ischiatic notch, are very frequent ; but 
 for this assertion he neither cites cases nor au- 
 thorities. It may either be simple* or com- 
 pound, single or double, t complete| of in- 
 complete. When it is simple, it is common- 
 ly at its commencement at the abdominal 
 ring, or in the vagina ; when double, it is 
 owing to the pressure of the uterus, and pre- 
 sents at both abdominal rings, or in the va- 
 gina and inguinal ring of one side. At the 
 two abdominal rings it has been known to at- 
 tain the size of a hen’s egg.|| The combined 
 and incomplete cases are the most common ; 
 when, considering the anatomy of the blad- 
 der, it was mentioned that the peritoneum 
 covers all the atlantal fundus, and a small 
 portion of its sides, that, when distended, this 
 takes place laterally in a greater proportion 
 
 * Diction, des Sciences Medic. — Cystobubon. 
 
 •J- Memoir de l’Academ. de Chirurg. tom. ii. p. 123. 
 
 J Ruysch, Obs. Anat Chir. 98. 
 
 || For a case of this in the male, see Verdier’s Memoir, 
 Obs. x., and for a double cystocele in the female at the 
 abdominal rings, Obs. xii. 
 
35 
 
 than in the atlantal direction, which is parti- 
 cularly observable in pregnancy, or in those 
 women who have had many children ; that, 
 when rising, it pushes the peritoneum before 
 it, having, of course, the parts opposite the 
 inguinal rings destitute of a peritoneal cover- 
 ing ; this then is a peculiar character of cys- 
 tocele, that it is destitute of a hernial sac, pro>- 
 perly so called. 
 
 In old cystoceles, a portion of the protru- 
 ded bladder will be covered with peritoneum, 
 although, in a case of old cystocele, which 
 came under Mr Pott’s care, from the anterior 
 surface of the bladder being the part pro- 
 truded, it, of course, wanted that covering. 
 It took seven years in descending to the bot- 
 tom of the scrotum.* Verdier relates a case, 
 where the urachus and impervious umbilical 
 arteries were drawn into the scrotum ; this 
 case, of course, would have a partial covering 
 of peritoneum. 
 
 In cystocele, combined with bubonocele, 
 whether the former shall have preceded or 
 followed the latter, the bladder will have come 
 
 * Pott’s Works, by Earle, vol. ii. and iii. 
 
36 
 
 down with that portion of the peritoneum 
 before it, which forms a sort of pouch, in its 
 reflection from the sides of the bladder ; the 
 cystocele will be situated behind this portion 
 of the protruded intestine, &c., and between 
 it and the spermatic vessels. 
 
 A case is related by Keate,* where the 
 spermatic vessels were situated on the exter- 
 nal side of the hernia ;f but, I believe, that 
 both they and the epigastric artery, for the 
 most part, will be found mesial to the hernia ; 
 in other words, the hernia will pass through 
 the inguinal canal in the usual manner ; this 
 seems to be the opinion of the French : — 
 “ Que le plus grand partie des cystoceles sont 
 du nombre des hernies inguinales externes, 
 ou de celui des crurales internes, presqu’ils 
 ne sont autre chose que des hernies inguinales 
 ou crurales, formees selon les procedes les plus 
 commun et compliquees seulement d’un de- 
 placement consecutif de la vessie auquel la 
 grande distention de cet organe a donne oc- 
 
 * Cases of Hydrocele. 
 
 •j- Boudon has seen this appearance twice, and Le Dran 
 once — Verdier’s Memoir. 
 
3 ? 
 
 casion.”* But, if this is not the fact, it may 
 be easily understood how cystocele may oc- 
 cur in old hernia, when, by the long conti- 
 nued pressure, the two rings are brought into 
 opposition, and the opening nearer the usual 
 seat of the bladder ; or, it may take place 
 originally as a ventro inguinal hernia. A 
 case is mentioned in Lieutaud, of a fatal 
 strangulated cystocele, in an old man who 
 had been subject to it for twelve years ; the 
 only troublesome symptom he had, was oc- 
 casional difficulty of making water ; he was 
 suddenly seized with severe pain in the groin, 
 fever, vomiting, and hiccup, which soon pro- 
 ved fatal. On dissection, the bladder was 
 found partly in the abdomen, partly in the 
 inguinal canal, and partly in the scrotum, ad- 
 hering strongly. Verdier relates a case of 
 inguinal cystocele, the size of a large melon.f 
 Perhaps the most common kind of cystocele 
 is that which the accoucheur has the greatest 
 opportunities of observing, viz. — 
 
 * Diction, des Scien. Med. — Cystocele. 
 
 + Obs. vi. 
 
38 
 
 Vaginal Cystocele . — This commonly occurs 
 from violent exertion during gestation, or af- 
 ter delivery. It may descend atlantad to the 
 vagina, or on either side of it, and may be 
 simple or complicated, single or double, par- 
 tial or complete ; when it* occurs at the sides, 
 it will be situated between the mucous mem- 
 brane of the vagina, os ischium, and muscles, 
 and if in the posterior part, will have a par- 
 tial covering of peritoneum. From the inti- 
 mate and extensive connection between the 
 bladder and vagina at the atlantal part, and 
 between the vagina and rectum at the sacral, 
 vaginal cystocele generally takes a lateral di- 
 rection ; yet two cases are related by Mr 
 Cooper, w r here it occurred directly under the 
 meatus urinarius. Hethinks it arises from a re- 
 laxed state of the portion of peritoneum, which 
 is reflected from the bladder to the uterus, 
 and which allows the bladder to yield to the 
 superincumbent weight of the intestines. 
 Garingeot and Verdier likewise relate cases, 
 where it occurred at the atlantal and pubal 
 
 * Clarke on the Diseases of Females, See. 
 
39 
 
 portion of the vagina. A case of double va- 
 ginal cystocele was dissected by Mr Burns, 
 where the tumour formed on each side of the 
 urethra. The oblique direction of the axis 
 of the pelvis, renders this hernia less fre- 
 quent, than it otherwise would be. When 
 it still continues to protrude, it will descend 
 into the labium, forming 
 
 Pudendal Cystocele . — In this case it passes 
 the edge of the levator ani, or between its fi- 
 bres, and appears in one of the labia. Mr 
 Cooper relates a case where it attained the 
 size of a pigeon’s egg, accompanied with symp- 
 toms of strangulation. In a patient of Mr 
 Burns, it protruded between the origins of 
 the levator ani, and obturator interims.* 
 
 Perineal Cystocele . — In the male subject, 
 the cystocele will probably pass between the 
 fasciculi of the levator ani, or between that 
 muscle and the sphincter, and form a tumor 
 in the perineum. In a case of perineal her- 
 nia related by Mr Cooper, in which the blad- 
 
 * Edin. Med. and Surg. Journal, vol. iv. p. 512. 
 
40 
 
 der covered an inch and three quarters of it, 
 the lower extremity of the sac was placed be- 
 fore the anus, the prostate gland was situat- 
 ed immediately anterior to the fundus of the 
 sac, and the fundus of the vesiculae seminales 
 was placed upon the lateral part of the sac, 
 and its apex was situated more anteriorly. 
 The rarity of this kind of hernia, may be 
 judged of by a question of Rieherand’s, who 
 asks, if perineal cystocele is any thing else 
 than a dilatation of the bulb of the urethra.* 
 In the female, the anatomy of this kind of her- 
 nia, will be still more intricate, as, before the 
 bladder can arrive at the perineum, it must 
 turn round the neck of the uterus, and de- 
 scend by the side of the vagina.f 
 
 Congenital Cystocele . — Cystocele is some- 
 times, though very rarely, foundas a congenital 
 affection. A case of this kind is quoted from 
 Stoll, in Mr Wishart’s translation of Scarpa 
 on Hernia, and in the Memoirs of the Acade- 
 my of Surgery ,| mention is made of a case of 
 
 * Nos. Chirurg. Tom. iii. p. 500. 
 
 f Verdier’s Memoir. 
 
 J Tom. ii. p. 15. 
 
41 
 
 hernia vesicalis, which a man had from his 
 earliest infancy, and which becoming strangu- 
 lated, caused his death. Facts in support of 
 this kind of hernia, are to be found in Ar- 
 naud’s paper.* 
 
 Symptoms . — Wh enever cy stocele presents it- 
 self, it may be known when the bladder is dis- 
 tended by a fullness and elasticity of the 
 parts which go off when the patient has made 
 water ; if it does not entirely disappear, the 
 pressure of the hand, and laying the patient 
 on his back, will make the water return into 
 that portion of the bladder which is situated 
 within the abdomen, and will excite the desire 
 to evacuate it ; this, with the deviation of the 
 canal of the urethra (if the cystocele is a crural 
 one) towards that side on which the hernia is 
 situated, f the dysuria and occasional reten- 
 tion, and other concomitant circumstances, 
 will be sufficient to distinguish this affection, 
 especially if a stone can be found in the tu- 
 mor, which is sometimes the case. There is 
 
 '* Verdier’s Memoirs, p. 79. 
 
 f Diet, des Scien. Med. Cystomerocele. Verdier’s 
 Memoir, obs. 11th. 
 
42 
 
 a watery tumor which sometimes occurs in 
 ascites, to such an extent, as to produce ob- 
 struction to the flow of urine, and s transit- 
 ry. This might, perhaps, lead to a mistake of 
 its being a case of vaginal cystocele, the con- 
 comitant circumstances, and there being no 
 desire to make water, or flow of it, when 
 the tumor is pressed, were not attended ’to. 
 It has been mistaken for procidentia uteri, 
 but in this, the cervix uteri at the bottom of 
 the tumor, and the absence of the stomach 
 complaints, which usually attend the latter, 
 will assist in the diagnosis, as will likewise 
 the pain referred to the umbilicus. * When 
 cystocele occurs at the pudendum, it is said 
 to have been mistaken for bubonocele, but 
 the direction of the hernia into the vagina, and 
 the free state of the ring, and upper and out- 
 er part of the labium, will easily undeceive 
 the practitioner. If it occurs during labour, 
 or before it, care must be taken to distinguish 
 it from the membranes. It may be mistaken 
 for swelling of the lacunte on the inside of the 
 
 * C. M. Clarke on the Diseases of Females which are 
 attended with discharges. 
 
43 
 
 labium, but this labial tumor does not dilate 
 on coughing, and is not affected by change of 
 position ; it cannot be traced entirely into the 
 cavity of the pelvis, and the os ischium can be 
 felt behind it. 
 
 VII.— CYSTS, &c. 
 
 These are pouches or bags which appear on 
 the inside or outside of the bladder, and may 
 communicate with its cavity by a small or a 
 larger orifice ; they may be formed by all the 
 coats of the bladder, or, what is more common, 
 by the protrusion of the inner coat, through 
 the interstices of the muscular, forming what 
 Walter calls hernia vesicas.* They have even 
 been known to occur externally, without any 
 communication with the bladder ; they are 
 often the receptacles of stones, which may 
 either be contained in separate ones, or col- 
 lected in them in numbers. Cases of this 
 
 * Medical Journal, vol. v. 
 
 9 
 
44 
 
 kind, says a late writer, have been more 
 talked of than seen.* A cyst was observed 
 by Home,f in the posterior portion of the 
 bladder, of the size of an orange, situated 
 above the prostate gland, and communicating 
 with the bladder by a small orifice of the size 
 of a goose quill ; its coats were of the thickness 
 of a common bladder, and covered on the in- 
 side with coagulable lymph. In Heister's 
 3 2d plate, there is the representation of a sac- 
 culated bladder, which, viewed externally, 
 looks as if a number of tumors about the size 
 of oranges were growing from it ; and in the 
 7th plate of Home on the Prostate, there is the 
 representation of a sort of cyst, which could 
 contain about a half a pint of urine. It was 
 formed by the inner membrane of the blad- 
 der, which protruded to this degree between 
 the opening of the ureters, by the efforts of the 
 muscular coat.J 
 
 * Bell’s Quartevly Reports, iv. 
 
 t On the Prostate. 
 
 f Note. — The same symptoms as those of stone, hare 
 been known to be produced by this transverse valvular fold 
 of the inner membrane across the neck opposite to the 
 orifice of the urethra. Howship, &c. p. 71. 
 
45 
 
 Boudou* mentions a case of an encysted 
 stone in the bladder, where lithotomy was 
 performed, and, on dissection, the stone was 
 found only detained in its place by the por- 
 tion of the peritoneum, which covered that 
 part of the bladder. An analogous case to 
 this is mentioned by Mr C. Bell, t the perito- 
 neum covering the bottom of the sac, was in- 
 flamed, and seemed to threaten ulceration ; 
 and the edges of the orifice of communication 
 between the sac and the bladder were ragged, 
 as if ulcerated. 
 
 What has been called Double Bladder, 
 seems to be nothing more than an uncom- 
 monly large cyst, caused by the protrusion of 
 the inner membrane, through the interstices 
 of the muscular fibres, although Dr Baillie 
 supposes that there is a marked growth of 
 the inner membrane, forming a ridge at some 
 particular part, and at length, by a continua- 
 tion of this process, making a septum more 
 
 * Memoire de l’Acad. de Chir. tom. i. p. 424;. — Portal, 
 Lib. Cit. tom v. 
 
 + Quarterly Reports, p. 445. 
 
46 
 
 or less complete in the bladder. They are 
 known to be real cysts, by the ureters and 
 vesiculee seminales belonging only to one of 
 the sacs. The cyst may be disposed, so 
 that the septum may be either in a longitu- 
 dinal,* * * § transverse,! or oblique J direction, with 
 an opening of communication of greater or 
 less magnitude. In these cases, the supposed 
 cyst has been found with its parietes much 
 thinner than those of the real bladder.^ In 
 the 1300 Observ. of Lieutaud, the bladder was 
 thick and contracted, and at the left side ap- 
 peared perforated, and ending in a sac, larger 
 than a common sized bladder. An example is 
 on record of two such large cysts being found, 
 that they put on the appearance of a triple 
 bladder; the middle sac, which was consider- 
 ed as the true bladder, was larger than that 
 on the left, and less than the other on the 
 right. || An extraordinary instance of a mor- 
 
 * Verdier’s Memoir, Obs. xviii. 
 
 + Baillie’s Morbid Anatomy. 
 
 J V erdier’s Memoir. 
 
 § Ditto. 
 
 || Do. Obs. xix. 
 
47 
 
 bid affection, resembling a double bladder, 
 occurred to Mr Foubert, on opening the body 
 of an old officer. “ In the hinder and upper 
 part of the bladder, a pit, or depression of a 
 conical figure, was discovered with the sides 
 tending inwardly, a portion of the intestinum 
 ilion, near half a foot long, was lodged in this 
 depression ; and, on opening the bladder, he 
 found that the point of the cone advanced as 
 far as its neck.”* The double bladder, or the 
 bladder divided into two chambers, has been 
 supposed to occur now and then as a tempo- 
 rary affection, caused by a strong contrac- 
 tion of the muscular fibres at some particular 
 part ; it then receives the name of the hour- 
 glass contraction, being analogous to an 
 affection which sometimes takes place in the 
 uterus, and which has received that name. 
 
 Symptoms . — We can never determine a 
 priori, whether a bladder is sacculated or 
 
 * Verdier, Obs. xx. — Bell’s Quarterly Report, p. iv. — 
 Med. Museum, No. 40. triple bladder.— Memoirs Med. 
 Society of London, vol. i. interesting case of double blad- 
 der. 
 
48 
 
 not ; but if the sac, or sacs, contain a stone, 
 then, with the assistance of a sound, a proba- 
 ble conjecture may be formed. But more of 
 this hereafter. When the case of an uncom- 
 monly large cyst occurs, so as to resemble a 
 second bladder, a conjecture of its formation 
 may be indulged, when there is a consider- 
 able circumscribed tumour above the pubis, 
 which is not diminished on making water, 
 except in a particular position, and then to 
 the immediate relief of the patient. 
 
 VIII.— ANTERIOR PART WANTING. 
 
 This is a congenital affection, which con- 
 sists in a deficiency of the anterior part of the 
 bladder, with a protrusion through it of the 
 posterior part, and likewise a deficiency of 
 the abdominal muscles. It generally makes 
 its appearance in the form of a pale red, or 
 dark livid tumor, varying in size from that 
 of a nut to that of the fist. It is generally 
 
49 
 
 situated at the lower part of the hypogastric 
 region, but it has been known to appear as 
 high as the umbilicus. The tumor is com- 
 monly a spongy, vascular mass, of an unequal 
 granular appearance, deprived of cuticle, and 
 not particularly sensitive when touched ; its 
 surface is constantly bedewed with a ropy 
 mucus, which defends it from the acrimony 
 of the urine, constantly passing over it from 
 the ureters, which open on its surface about 
 the transverse diameter in infants, but gradu- 
 ally descend, so, that in adults they are found 
 at the sacral edge. They are commonly very 
 much distended ; in a case related by Mr Coop- 
 er, they were found larger than the rectum. 
 This malconformation occurs far more general- 
 ly in males than females, and it is commonly 
 attended with a deficiency of the bones of the 
 pelvis at the pubis, which are usually in such 
 cases connected by a strong membrane, and 
 there is either a separation or deficiency of 
 the recti muscles at the place where the tu- 
 mour protrudes. One case has occurred, in 
 which this deficiency of the bones of the pu- 
 bis was supposed not to take place, no symp- 
 D 
 
50 
 
 tom of it being apparent on external exami- 
 nation.* A malconformation and position of 
 the genital organs likewise takes place ; those 
 of both sexes have been known to be situated 
 as high as the usual situation of the umbili- 
 cus.f The tumour cannot be reduced or di- 
 minished by pressure, yet it has been obser- 
 ved of a small size in the morning, gradually 
 increasing in the course of the day ; it some- 
 times varies in size to more than half its vo- 
 lume, upon any exertion, especially crying. 
 In very rare cases, the skin has been known 
 to cover the tumor ; this was supposed to 
 have taken place in the case of Mr Penchi- 
 nati.^: It has been known to take place in a 
 
 case of a mixed nature, between extroversion 
 of the bladder and epispadias. jj The case in 
 which this occurred, was that of a conscript ; 
 the tumour was about half the size of a ren- 
 
 * Mr Coates, Edin. Med. and Sur. Journal, vol. i. 
 
 f Dr Duncan’s Paper, do. 
 
 J Dr Duncan’s Paper. 
 
 || The former is what we are now considering, the lat- 
 ter is where the urethra is found at the superior part of 
 the penis. 
 
 S 
 
51 
 
 net apple, soft and livid, situated in the re- 
 gion of the pubis, between the symphysis ; it 
 was covered with puckered integuments, dis- 
 appeared on pressure, returned again when it 
 was removed. The urine did not come from 
 the ureters, opening on the exterior surface 
 of the tumour, but they appeared to open 
 near to the semi-canal which appeared on the 
 surface of the penis, at the neck of the blad- 
 der.* 
 
 The symptoms, in such cases, are sufficient- 
 ly obvious, and need not to be recapitulated. 
 The urethra being always imperforated, and 
 the impossibility of reducing the tumour, 
 render hopeless all means of cure by compr es- 
 sion, suture, &c., though Delpech supposed it 
 might sometimes be thus effected. 
 
 * Diet, des Scien. Med.— Epispadias. 
 
,52 
 
 IX.— FOREIGN BODIES IN ITS CAVITY. 
 
 1st. Stones — The causes which determine 
 the precipitation of the salts of the urine, and 
 the formation of urinary calculi, are totally 
 unknown. The comparatively rapid forma- 
 tion of them on the introduction of a foreign 
 body into the bladder, might lead us to sus- 
 pect something analogous to the process of 
 the formation of crystals out of the body, 
 when a nucleus is presented for that purpose, 
 but it does not always take place in the blad- 
 der under such circumstances, nor does it oc- 
 cur so suddenly, nor so regularly ; indeed, a 
 true regular crystallized structure never takes 
 place in a calculus, although crystals are fre- 
 quently formed on the surface, and occasion- 
 ally in cavities throughout ; very rarely a ca- 
 vity is seen in the centre of the calculus, fill- 
 ed with crystals ;* these are usually crystals 
 of triple phosphate. Instances frequently oc- 
 
 * Dr Thomson’s Lectures. 
 
53 
 
 cur of large calculi being found in the bladder 
 after death, without any thing having hap- 
 pened during life, to give rise to a suspicion 
 of their existence, and without the least ap- 
 pearance of irritation in the bladder' being 
 perceptible on dissection.* Even patients, 
 subject to gravel for years, often die without 
 any stone being produced in consequence. 
 The most robust are liable to this complaint, 
 but it more generally attacks children and 
 old people, than others, and males more fre- 
 quently than females. The comparative 
 width and easy dilatation of the urethra in 
 the latter, and its straightness and shortness, 
 will, in some measure, account for its occur- 
 ring less frequently in them, for this struc- 
 ture allows the stones to be more easily eva- 
 cuated. In females, stones of several ounces 
 have been extracted by the urethra ; and Tul- 
 piusf relates a case, where 300 calculi were 
 excreted at the same time with the urine. 
 
 The formation of calculi has been occasionally 
 observed to be hereditary, and to attack those 
 
 * Howship, Lib. Cit. p. 62^ 
 
 •{• Lib. ii. cap. 4*7. 
 
54 
 
 afflicted with gout. It seems frequently ta 
 be owing to a peculiar diathesis ; the same in- 
 dividual having been frequently cut, and yet 
 the introduction of a foreign body seems not 
 to need such aid. Disease of the prostate may 
 conduce to then- formation, by retaining small 
 quantities of urine in the pouch, necessarily 
 formed by the projection of the gland.* From 
 the less frequent occurrence of the disease in 
 tropical climates, there is probably some con- 
 nection between the functions of the skin and 
 those of thekidneys.j' Depositions of calculous 
 matter often form in the bladder, after its 
 coats have been injured by a wound, and to 
 such a degree sometimes as nearly to fill it ; 
 and seemingly these calculi have no nucleus. ;[ 
 Calculi vary in their size from that of the 
 smallest pea to sixteen inches in length, and 
 from the weight of a few grains to that of 
 several pounds. The 1323 Observ. of Lieu- 
 taud is a case of a calculus so hard as to strike 
 fire with flint, and which weighed g xxxii. 
 
 * Home on the Prostate. 
 
 + Marcet on Calculi. 
 
 X Henneivs Observ. on Military Surg. p, 470. 
 
55 
 
 The very large one mentioned above weighed 
 §xliv. # They may exist in the bladder un- 
 connected with the neighbouring parts, or 
 they may adhere to its parietes, and that so 
 strongly sometimes, that in their extraction 
 the bladder has been tom ; f or they may ad- 
 here to a fungus growing from it ; or be si- 
 tuated between its coats, or in cysts connect- 
 ed with them. In a case which occurred to 
 Mr C. Bell,;}; the sac was situated near the 
 neck of the bladder; was about two inches 
 in diameter, and was connected with the 
 bladder by an opening of a quarter of an 
 inch in diameter. The stones in these cysts, 
 although numerous and small, sometimes at- 
 tain so large a size as to weigh 3083 grains. || 
 They are usually very smooth on the sur- 
 face ; this is commonly ascribed to attrition ; 
 but it has more lately been supposed to be 
 owing to their being contained in separate 
 pouehes.§ 
 
 * Philosoph. Transact. 1809* * * § 
 
 t Tulpius, lib. iii. cap. 5 . 
 t Quarterly Reports, vol. iv. 
 
 || Marcet on Calculi. 
 
 § Dr Thomson’s Lectures. 
 
66 
 
 Urinary calculi are divided by Wollaston 
 into five species. 1st, That composed of 
 uric acid. 2d, The ammoniaeo magnesian 
 phosphate, or fusible calculus. 3d, The ox- 
 alate and phosphate of lime, or mulberry cal- 
 culus. 4th, The phosphate of lime, or bone 
 earth calculus. And, 5th, The cystic oxyde. 
 Sometimes calculi are entirely composed of 
 the first species, and are of a nut brown or 
 yellow colour, of a lamellar and radiated tex- 
 ture, and are smooth. The second is seldom 
 entirely composed of its elements but is 
 more generally blended with uric acid, or 
 phosphate of lime j although layers of these 
 sometimes cover a uric acid calculus. This 
 calculus is distinguished by its softness and 
 smoothness, its white colour and lamellated 
 texture. The white powder, which is preci- 
 pitated from the urine of some patients labour- 
 ing under calculi, is commonly composed of 
 crystals of the phosphate of ammonia and 
 magnesia. The calculus composed of the 
 oxalate and phosphate of lime, is of a dark 
 brown, black, or deep purple colour, with an 
 uneven protuberating surface, as its name 
 imports ; it is often grey within, hard and 
 
57 
 
 heavy. Phosphate of lime sometimes com- 
 poses the entire substance of a calculus ; al- 
 though more frequently it is mixed with uric 
 acid, or the phosphate of ammonia and mag- 
 nesia disposed with them in layers. It is of 
 a pale brown colour, very smooth, and with 
 a laminated texture. Dr Davy* has seen a 
 calculus of phosphate of lime,, with 20 per 
 cent, of water, and no appreciable animal 
 matter. The cystic oxyde is a kind of calcu- 
 lus which occurs very rarely, there not be- 
 ing above four or five specimens of it to be 
 found. It is yellowish, semi-transparent, and 
 glistening, not distinctly chrystallised or la- 
 minated, and resembles the calculus of the 
 phosphate of ammonia and magnesia. A 
 calculus has been supposed to exist of urate 
 of ammonia; it is less sensibly striated, and 
 its colour is lighter than the pure uric acid 
 calculus ; it exhales a smell of ammonia^ 
 and dissolves in alkaline solutions. Dr Mar- 
 cet doubts the existence of this calculus. He 
 describes two other kinds of calculi ; one 3 
 sui generis, to which he proposes to give the 
 
 * Monro’s Anatomy, vol. iii. 
 
58 
 
 name of zanthic oxyde ; it forms a lemon- 
 coloured precipitate, when acted on by nitric 
 acid. The other corresponds in all its pro- 
 perties to fibrine. Carbonate of lime has 
 likewise been found to constitute calculi. 
 Silix is sometimes found in calculi ; but so 
 rarely, that out of 600 which Fourcroy exa- 
 mined, only two were found containing it. 
 Besides these constituents of calculi, an ani- 
 mal matter, analogous to albumen, is fre- 
 quently found. It appears to give them co- 
 lour and consistence ; it is present in largest 
 quantity in the mulberry calculus ; but it is 
 also found in those which are white and crys- 
 taline. An unusually large quantity of it 
 was found in the large calculus of triple 
 phosphate formerly mentioned. Calculi are 
 sometimes situated at the neck of the blad* 
 der, with a long process projecting into the 
 urethra. They have likewise been found of 
 a circular shape, pierced with many holes, or 
 with only one in the centre.* In urinary 
 fistulas, calculi are sometimes found generated 
 in the passage from the infiltration of urine. 
 
 * Morgagn. Lib. Cit. Epist. 42. Art. 10, &c. 
 
59 
 
 An example of this kind occurred after the; 
 battle of Waterloo from a wound of the 
 bladder. The calculus was found in the fis- 
 tulous passage, near the external wound, ha- 
 ving a splinter of the bones of the pelvis as a 
 nucleus.* A case nearly analogous occurred 
 to Portal. f The calculus was found in the 
 passage of a fistulous communication between 
 the bladder and rectum ; it was rough, with 
 two flat sides, of a grey colour externally and 
 internally, and was easily reduced to powder. 
 It was of the size of a pigeon’s egg ; two 
 small oblong openings were found in the sa- 
 cral fundus of the bladder, which opened by 
 fistulous passages into the perineum. For 
 the most part, calculi have a nucleus, or some- 
 thing upon which they were originally form-r 
 ed; any thing introduced into the bladder, 
 and remaining there may become so : Prune- 
 stones, hair-pins, sewing and knitting neer 
 dies, nails, pieces of bone, wood, lead- 
 bullets, canul^e, ends of bougies or cathe- 
 ters, brass-wire, hair, blood, flints, pieces 
 
 * Dr Thomson’s Lectures, 
 t Cours d’Anat. tom. v. p. 416. 
 
60 
 
 of dressing, ears of corn, &c.* Dr Baillie 
 has met with two instances, in which a matter 
 like mortar was contained in the bladder. 
 He considers this matter as the same with 
 that of calculi. The disease had continued 
 maily years, and was Connected with chronic 
 inflammation of the internal coat. 
 
 The effects of calculi on the bladder ard 
 those in common with any foreign body, 
 chronic inflammation of the mucous coat, 
 ending in ulceration or gangrene ;f thicken- 
 ing of the muscular chat, produced by the 
 increased action from the very frequent calls 
 to make Water, occasioned by the excess of 
 acid in the urine, and the irritation of the 
 stone on the mucous coat. There is likewise 
 an increased and vitiated secretion' of the 
 mucus of the bladder ; sometimes pieces of 
 membrane are voided, covered with small 
 stones ; J occasionally the irritation advances 
 to such a height, that pus and blood are ex- 
 
 * Diet, des Scien. Med. des Corps Etrangers dans la 
 vessie ; and Portal, Lib. Cit. v. ; and Morgagni ut Cit. 
 
 + This gangrene Mr Howship ascribes to debility, and 
 not to inflammation . — Diseases of Ur'in. Organs, p. 77. 
 
 X Tulpius, Lib. ii. Cap. 48 
 
61 
 
 creted with the urine ; and at the places 
 where the irritation has been most severe, 
 fungi sometimes arise. 
 
 Symptoms . — The symptoms which are sup.- 
 posed to indicate stone in the bladder, prior 
 to the introduction of the sound, are very 
 ambiguous, and are modified by its situation 
 being more urgent, the nearer it is to the 
 neck. When situated in the sacral fundus, 
 they have been known to give rise to such 
 symptoms, that no disease was suspected in 
 the bladder ; but were all referable to disease 
 and ulceration high up in the rectum.* The 
 most common symptoms are frequent incli- 
 nation to make water, which is mixed with 
 mucus, and difficulty of retaining it ; it frer 
 quently and suddenly stops, with pain at the 
 glans penis, especially as the last drops are 
 voided. This continues for some time, and 
 is attended with $ sense of weight or pres- 
 sure in the bladder. Tenesmus, itching, and 
 uneasiness about the anus also attend, with 
 a numbness of one or both thighs, and retrace 
 
 * Hovvship, Lib, Cit. p. 62, 
 
62 
 
 tion of the testes. The pain attending this 
 affection is not constant ; but comes in pa- 
 roxysms, and is increased, and the urine ren- 
 dered bloody on any rough motion. The 
 urine exhales an ammoniacal smell ; and to- 
 wards the latter end of the disease becomes 
 black and putrid. In an early stage, a white 
 or pink-coloured sediment is observed in it, 
 denoting the presence of a calculus of ammo- 
 niaco-magnesian phosphate, or of uric acid. 
 If portions of calcareous matter like mortar 
 be mixed with it, then the presence of such a 
 substance in the bladder is ascertained. The 
 symptoms of incysted stone will not be so 
 severe ; indeed, stones are thus frequently 
 found on dissection, where none had been 
 previously supposed to exist ; neither can the 
 knowledge of them be attained without the 
 assistance of the sound. There may be sup- 
 posed to be one sacculated, if it is not found 
 to change its place, or stop the urine while 
 it is flowing ; when in sounding it is felt al- 
 ways at the same point, retires if the bladder 
 be full, and approaches, if it be empty ; and 
 when, after many trials, it is impossible to get 
 the sound round the stone, but only to touch 
 
63 
 
 it. Various other substances, besides stones 
 and tumors, are found in the bladder ; but 
 they have been mostly enumerated under 
 nuclei. It has not unfrequently been found 
 filled with pus from the irritation of stones, 
 &c. &c. 
 
 2. Hair has not only been found in the 
 bladder on dissection, but has been known to 
 be passed by the urethra during life, both as 
 single hairs, and as several from the same 
 bulb. A case of this nature, I believe, has 
 been seen by most practitioners in town. It 
 occurs in the person of a man who is above 
 eighty, and who has been subject to it for 
 about twenty years ; but here it does not 
 come at the time of making water, but in the 
 intervals ; neither does it observe any stated 
 period, for sometimes as much will come 
 away in a week as had taken a month before. 
 Tulpius mentions a case of it occurring peri- 
 odically, viz. every fortnight, and continuing 
 for four days at a time, and attended with a 
 good deal of jlain ; it lasted in this manner 
 four years, with incontinence of urine ; during 
 the period the hairs as they came away were 
 found involved in mucus. In 1262 Obs. of 
 
64 
 
 -Lieutaud, a case is mentioned of a woman of 
 sixty -two, who was afflicted with weight in 
 the abdomen and frequent strangury ; a ca- 
 theter was introduced, and a pound of pus 
 mixed with urine came away ; fainting, 
 diarrhoea, and vomiting came on, which soon 
 terminated in death. On dissection the blad- 
 der was found of a green colour, adhering to 
 the uterus ; it contained various fragments of 
 bone, and a small round ball composed of hair 
 swimming in purulent matter. This mix- 
 ture of hair with pieces of bone bears some 
 analogy to what we sometimes find in the 
 ovarium of unmarried women. In some in- 
 stances the analogy is still more complete, for 
 it has been found bound together by that foe- 
 tid greasy matter, which is the case when it 
 occurs in the ovarium ; the following is an 
 example of this : * — A woman aged twenty- 
 four was delivered of a dead child, and died 
 six days after of a malignant putrid fever. 
 On dissection, the bladder was found very 
 much distended, and about one-half of it in a 
 
 * Bulletin de la Faculte de Medicine, No. IV. p. 58. 
 
 1S08. 
 
65 
 
 state of mortification ; it was filled with a 
 thick and foetid matter, mixed with hair, 
 which was united into an oval mass, accom- 
 modating itself to the form of the bladder 
 This mass, with the matter which adhered to 
 it, was five inches long, and three broad ; 
 when the hair was washed, cleaned and dried, 
 it weighed 5 ii ; on cutting into the tumor 
 there was found an osseous substance, and 
 another in small quantity which resembled 
 the brain ; the length of a hair was generally 
 from four to 12 inches. 
 
 * 
 
 3. Worms . — Various kinds of insects have 
 at different times been found in the bladder, 
 but worms are the most common, and of these 
 the common intestinal round worm, and as 
 carides, are the most frequent. Tulpius has 
 observed a kind of a middle nature, between 
 the latter and those found in putrid cheese ; 
 and has likewise seen several of those last. 
 Inspissated mucus and coagulated blood, have 
 at different times been mistaken for worms. 
 The following is a description from Tulpius, 
 of an insect voided with the urine : “ From 
 an obtuse and broad head, (from which pro- 
 
 E 
 
66 
 
 traded two small horns) sensibly terminating 
 in a pointed tail, the apex of which was black 
 and sufficiently conspicuous in those living. 
 But on the convex part or back, they were 
 round and smooth, but depressed in the belly, 
 rough and like millipedes, furnished with in- 
 numerable feet.” In a case mentioned by 
 Mr Lawrence, * the largest were from four 
 to eight inches long, the smallest were semi- 
 transparent, when first voided, but became 
 opaque when immersed in spirits ; they were 
 of a round form, pointed at the two ends ; 
 the larger ones appeared so contracted in the 
 middle, that they looked as if broken, but 
 from this point they increased gradually to- 
 wards either extremity, when they again de- 
 creased. In this case there was about 1000 
 worms passed by the urethra ; and previous 
 to their appearance, very anomalous and 
 painful symptoms were present ; that of a 
 body moving in the bladder, being the only 
 one which could throw the least light on the 
 matter. Tulpius relates a fatal case, which 
 
 * Medico-Chirurg. Transact, vol. ii. 
 
 Medical Essays, vol. vi. 
 
67 
 
 he ascribes to the presence of a red worm in 
 the bladder. 
 
 4. Hydatids. — These are occasionally found 
 in the bladder, either adhering to it or loose, 
 or between its coats ; they are generally full 
 of limpid water, but sometimes they contain 
 a glairy viscid matter ; they produce the 
 usual inconvenience of foreign bodies in this 
 viscus. 
 
 5. Varicose Veins, &zc . — These are general- 
 ly confined to the internal coat of the bladder, 
 and may ( either extend all over its surface, or 
 be confined to a particular part, as the neck ; 
 it has been said that these may exist, to such 
 a degree as to cause retention of urine. 
 Delpech* denies that even a dilatation of the 
 vessels of the bladder can exist to such a de- 
 gree as to cause this without catarrhus vesicae, 
 tumors, or some other disease of the bladder, 
 existing at the same time. When retention 
 does occur from dilatation of the veins, I sus- 
 pectit will more generally be found to arise 
 
 * Malad. Chirurg. Tom. i. p. 568. 
 
68 
 
 from those large ones situated in the loose 
 cellular substance at the neck on the outside. 
 Haemorrhage from the vessels of the bladder, 
 may be the consequence of wounds, falls, or 
 blows on the belly, or perineum ; it has 
 been considered as a thing to be wished for, 
 in certain circumstances, as in cystitis, hae- 
 morrhoids, &c. * I should rather suppose 
 that it should be prevented by all possible 
 means, as a highly dangerous affection, and 
 one which is not easily commanded, as the 
 outlines of a case which occurred to an emi- 
 nent practitioner here will shew, f Catheters 
 having been employed to dilate a stricture, 
 after their use had been persevered in for 
 some time, and the stricture nearly cured with- 
 out any difficulty having been experienced, 
 or an un pleasant symptom having previous- 
 ly taken place, blood was observed to come 
 away with them, after one of the insertions ; 
 this increasing and coagulating in the blad- 
 
 Portal Cours, etc. tom. v. p. 411. 
 
 •J See likewise Howship on Diseases of the Urinary 
 Organs, page 60. In this case, the coagulum filled the 
 whole bladder, and was the immediate cause of death. 
 
 9 
 
69 
 
 der, caused partial retentions of urine ; larger 
 catheters to allow of the more easy exit of the 
 blood, and unusually long ones to penetrate 
 the coagulum, and arrive at the urine were 
 employed, but with little benefit ; at last, 
 almost total retention took place, with eleva- 
 tion of the bladder into the hypogastric re- 
 gion, attended with pain and fever. These 
 symptoms being alarming, as a last resource 
 a strong large brass syringe was adapted to 
 the catheter, and several ounces of blood 
 sucked out, to the immediate relief of the 
 patient. This treatment, with the use of cold 
 applications, was persevered in for some time 
 with ultimate success. 
 
 6. Tumors . — These may be either of a stea- 
 tomatous, scirrhous, polypous, or fungous na- 
 ture, and may be attached to any part of the 
 bladder, external or internal ; the scirrhous 
 and polypous, are very rare, especially the 
 latter : this may be attached to the bladder, 
 either by a small or large neck : * it occa- 
 sionally attains such a size, as to fill the 
 
 * Portal Cours d’Anatom, Tom. v. p. 410. 
 
70 
 
 greater part of this viscus, * it is pretty firm 
 in its texture, and consists of various project- 
 ing masses. In a case of polypous tumor of 
 the bladder, which occurred to Professor 
 Walter,! it adhered to the neck, and pro- 
 truded through the urethra, out of which it 
 extended in the form of a fleshy concretion. 
 The scirrhous, like any other tumor, may be 
 situated at the neck, or at the entrance of 
 the ureters, so as to speedily prove fatal- 
 The 1287 Obs. of Lieutaud, is a case of this 
 kind ; when the catheter could not be intro- 
 duced on dissection, the bladder was found 
 like moistened paper, tore with the slightest 
 touch, and contained a large quantity of 
 mucus, and much sandy matter; a callous 
 carruncla was situated at the sphincter, which 
 shut up the meatus urinarius. These like 
 the former, often attain such a large size, 
 as to fill the whole bladder i, and are covered 
 with varicose veins. It has been supposed 
 that they sometimes degenerate into cancer, 
 
 * Lieutaud, Obs. 1300. 
 
 -J- Med. Journal, vol. 5. 
 
 ± Lieutaud, Obs. 1302. 
 
71 
 
 for patients have been observed to void foetid 
 matter with their urine, and on dissection, 
 similar foetid cancerous matter has been dis- 
 covered in the bladder, along with a scirrhous 
 tumor. 
 
 Sarcomatous, Steatomatous, and Fungous 
 Excrescences. The internal membrane of the 
 bladder, like all those which have the same 
 structure, is subject to fungous growths ; 
 they are most commonly situated about the 
 trigone, and take the shape of a mushroom. 
 In Obs. 1124 of Lieutaud, is a case of stea- 
 tomatous tumor in the bladder, near to the 
 neck, which extended upwards to the ureter, 
 which it comnressed, so that no urine could 
 enter the bladder. In the bladder of a wo- 
 man of forty -five, Walter found a flesh co- 
 loured, fibrous, soft mass, extending over 
 the whole cavity and adhering to its coats. 
 It consisted of a gelatinous matter, with am- 
 monia, lime, muriate of soda, and a little oil. 
 These fungous excrescences are of a loose 
 fibrous structure, and they have sometimes 
 been extracted along with calculi, without 
 the practitioner suspecting it till it was en- 
 
n 
 
 tirely separated. Tulpius* mentions the case 
 of a woman who passed fatty matter by the 
 urethra. Might not this be from a tumour 
 in the bladder, separated by previous mortifi- 
 cation, and now undergoing decomposition ? 
 
 Irregular processes are sometimes observed 
 hanging from the internal surface of the blad- 
 der ; they are either membranous,! or consist 
 of coagulable lymph, from previous chronic 
 inflammation ; or they appear as elongations 
 of the inner membrane ;; these, when cut in- 
 to, are found to consist of a considerable 
 quantity of cellular membrane, intermixed 
 with a little fat. 
 
 Symptoms . — Tumors in the bladder are not 
 accompanied with any symptoms which are 
 not referable to other diseases, or other fo- 
 reign bodies in the same viscus. When they 
 are situated near the neck, they may occa- 
 sionally be perceived, and in the female made 
 partially to protrude by straining ; or they 
 
 * Lib. iii. chap. 19. 
 f Bell’s Quarterly Reports, No. IV. 
 f Baillie’s Morbid Anatomy, p. 303. 
 
73 
 
 may be suspected to be present by the feel- 
 ing communicated to the hand through the 
 medium of the catheter or sound. 
 
 Fungus Hcematodes — Has likewise been 
 observed to attack the bladder, and by some 
 has been considered as the only disease which 
 attacks it as a primary affection.* 
 
 The preceding observations on the Anatomy 
 of the Bladder, lead our attention to some 
 points of practical importance, which the 
 limits of a paper of this nature will not allow 
 me to enlarge upon *, therefore I shall only 
 mention a few of the most obvious, as the 
 very small space at the sacral fundus allowed 
 for puncturing from the rectum : this space 
 is least when the parts are in situ ; for when 
 the bladder is removed from its connection 
 or dried, the cellular substance which con- 
 nected the vesiculas semenales to it being 
 
 * Howship on Diseases, &c., pages 68 and 129. 
 
 F 
 
74 
 
 destroyed, allows them to fall down, and thus 
 a larger space appears than would otherwise 
 be the case. Hence the importance of stu- 
 dying parts in their relative connection. The 
 bladder, in rising above the pubis, leaves a 
 space of two or three inches destitute of peri- 
 toneum ; allows (if not a less dangerous, at 
 least) a larger vacant space where it may be 
 punctured. It is of some importance to re- 
 collect, that when this organ is distended, 
 the increase of capacity is greater at its sacral 
 fundus or base, than in its body.* That the 
 bladder in infants being of a pear shape, and 
 extending to the umbilicus, there is not much 
 fear of wounding it in the operation for im- 
 perforated anus. In lithotomy, sounding, 
 eatheterism, and puncturing from the rec- 
 tum, it must be recollected, that sometimes 
 the sacral fundus of the bladder is a good 
 deal lower than its neck, sometimes on a le- 
 vel with it, and occasionally even higher ; 
 and that, in a few instances, the peritoneum 
 has been observed placed obliquely, and par- 
 tially covering one of the vesiculee.f It is 
 
 * Colles’ Surgical Anatomy. 
 
 + Monro’s Anatomy. 
 
likewise of importance to recollect the direc- 
 tion necessary to be given to the catheter, 
 when it is found necessary to introduce it in 
 cases of procidentia uteri ; for here the blad- 
 der forms a portion of the external tumor, 
 dragging with it the meatus urinarius ; so 
 that, in order to introduce a catheter, the point 
 of the instrument must be turned towards 
 the knees of the woman, otherwise it will en- 
 ter the passage, but not reach the bladder. 
 
 FIXIS 
 
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