COMMENTARY ON PLATES 63 & 64.
DEFORMITIES OF THE URINARY BLADDER.—THE OPERATIONS OF SOUNDING FOR STONE, OF CATHETERISM AND OF PUNCTURING THE BLADDER ABOVE THE PUBES.
The urinary bladder presents two kinds of deformity—viz., congenital and pathological. As examples of the former may be mentioned that in which the organ is deficient in front, and has become everted and protruded like a fungous mass through an opening at the median line of the hypogastrium; that in which the rectum terminates in the bladder posteriorly; and that in which the foetal urachus remains pervious as a uniform canal, or assumes a sacculated shape between the summit of the bladder and the umbilicus. The pathological deformities are, those in which vesical fistulae, opening either above the pubes, at the perinaeum, or into the rectum, have followed abscesses or the operation of puncturing the bladder in these situations, and those in which the walls of the organ appear thickened and contracted, or thinned and expanded, or sacculated externally, or ridged internally, in consequence of its having been subjected to abdominal pressure while overdistended with its contents, and while incapable of voiding these from some permanent obstruction in the urethral canal.[Footnote] The bladder is liable to become sacculated from two causes—from a hernial protrusion of its mucous membrane through the separated fasciculi of its fibrous coat, or from the cyst of an abscess which has formed a communication with the bladder, and received the contents of this organ. Sacs, when produced in the former way, may be of any number, or size, or in any situation; when caused by an abscess, the sac is single, is generally formed in the prostate, or corresponds to the base of the bladder, and may attain to a size equalling, or even exceeding, that of the bladder itself. The sac, however formed, will be found lined by mucous membrane. The cyst of an abscess, when become a recipient for the urine, assumes after a time a lining membrane similar to that of the bladder. If the sac be situated at the summit or back of the bladder, it will be found invested by peritonaeum; but, whatever be its size, structure, or position, it may be always distinguished from the bladder by being devoid of the fibrous tunic, and by having but an indirect relation to the vesical orifice.
[Footnote: On considering these cases of physical impediments to the passage of urine from the vesical reservoir through the urethral conduit, it seems to me as if these were sufficient to account for the formation of stone in the bladder, or any other part of the urinary apparatus, without the necessity of ascribing it to a constitutional disease, such as that named the lithic diathesis by the humoral pathologists.
The urinary apparatus (consisting of the kidneys, ureters, bladder, and urethra) is known to be the principal emunctory for eliminating and voiding the detritus formed by the continual decay of the parts comprising the animal economy. The urine is this detritus in a state of solution. The components of urine are chemically similar to those of calculi, and as the components of the one vary according to the disintegration occurring at the time in the vital alembic, so do those of the other. While, therefore, a calculus is only as urine precipitated and solidified, and this fluid only as calculous matter suspended in a menstruum, it must appear that the lithic diathesis is as natural and universal as structural disintegration is constant and general in operation. As every individual, therefore, may be said to void day by day a dissolved calculus, it must follow that its form of precipitation within some part of the urinary apparatus alone constitutes the disease, since in this form it cannot be passed. On viewing the subject in this light, the question that springs directly is, (while the lithic diathesis is common to individuals of all ages and both sexes,) why the lithic sediment should present in the form of concrement in some and not in others? The principal, if not the sole, cause of this seems to me to be obstruction to the free egress of the urine along the natural passage. Aged individuals of the male sex, in whom the prostate is prone to enlargement, and the urethra to organic stricture, are hence more subject to the formation of stone in the bladder, than youths, in whom these causes of obstruction are less frequent, or than females of any age, in whom the prostate is absent, and the urethra simple, short, readily dilatable, and seldom or never strictured. When an obstruction exists, lithic concretions take place in the urinary apparatus in the same manner as sedimentary particles cohere or crystallize elsewhere. The urine becoming pent up and stagnant while charged with saline matter, either deposits this around a nucleus introduced into it, or as a surplus when the menstruum is insufficient to suspend it. The most depending part of the bladder is that where lithic concretions take place; and if a sacculus exist here, this, becoming a recipient for the matter, will favour the formation of stone.] [End Footnote]
FIG. 1, Plate 63.—The lateral lobes of the prostate, 3, 4, are enlarged, and contract the prostatic canal. Behind them the third lobe of smaller size occupies the vesical orifice, and completes the obstruction. The walls of the bladder have hence become fasciculated and sacculated. One sac, 1, projects from the summit of the bladder; another, 2, containing a stone, projects laterally. When a stone occupies a sac, it does not give rise to the usual symptoms as indicating its presence, nor can it be always detected by the sound.
Plate 63,—Figure 1.
FIG. 2, Plate 63.—The prostate, 2, 3, is enlarged, and the middle lobe, 2, appears bending the prostatic canal to an almost vertical position, and obstructing the vesical orifice. The bladder, 1, 1, 1, is thickened; the ureters, 7, are dilated; and a large sac, 6, 6, projects from the base of the bladder backwards, and occupies the recto-vesical fossa. The sac, equal in size to the bladder, communicates with this organ by a small circular opening, 8, situated between the orifices of the ureters. The peritonaeum is reflected from the summit of the bladder to that of the sac. A catheter, 4, appears perforating the third lobe of the prostate, 2, and entering the sac, 5, through the base of the bladder, below the opening, 8. In a case of this kind, a catheter occupying the position 4, 5, would, while voiding the bladder through the sac, make it seem as if it really traversed the vesical orifice. If a stone occupied the bladder, the point of the instrument in the sac could not detect it, whereas, if a stone lay within the sac, the instrument, on striking it here, would give the impression as if it lay within the bladder.
