BLADDER, ABNORMAL ANATOMY. 



395 



Tho bladder is also very small in cases of 

 incontinence of urine and in vesical fistulas 



Increase. The volume of the bladder aug- 

 ments when the whole or a great portion of 

 the urine is retained in its cavity, and under the 

 opposite conditions to those which have just 

 been named. To such an extent may this in- 

 crease proceed, that it may be mistaken for 

 ascites.* Inflammation of the bladder com- 

 monly accompanies its excessive dilatation, 

 but many circumstances related by Morgagni 

 and others prove that this viscus may be con- 

 siderably distended by urine without becoming 

 inflamed. It may, however, lose its contractile 

 power, and the assistance of art may be neces- 

 sary for the evacuation of the urine. A fact 

 stated by Mauchartf shews that a man had 

 ischuria, which had commenced four days before 

 he was sounded. Some days after this he died; 

 the bladder was found inflamed in different 

 points. It was entirely empty and yet very 

 voluminous, without being contracted as it is 

 commonly after death. 



Introversion. Among the acquired changes 

 of conformation of the urinary bladder, there 

 is one which may be termed introversion. In 

 this affection, which is rare, the superior por- 

 tion of the organ is so depressed as to be brought 

 near to its neck, to project into the urethra, 

 and in woman to make its appearance at the 

 external orifice of that canal. Chopart J relates 

 from Percy the following observation : The 

 patient was an abbess aged fifty-two, in whom 

 the f'undus of the bladder was impacted in the 

 neck, having also passed along the urethra, 

 and forming at its external orifice a tumour of 

 the volume of the eye of a pigeon, red, fleshy, 

 unequally tumefied, which, when pressed upon 

 with the finger, returned into the canal and 

 reappeared without any violent exertion. An 

 analogous case occurred to Foubert. The 

 patient died, the body was examined after 

 death, and it was found that the posterior and 

 superior region of the bladder was depressed 

 into the form of a cone whose apex had pene- 

 trated the neck of the bladder, a portion of 

 ileum about six inches long being lodged in 

 this depression. 



When, in the female, the summit of the 

 bladder is engaged in the neck, the simple 

 inspection of the tumour, its increase after 

 walking or in consequence of a fit of coughing, 

 its disappearance with compression, are sym- 

 ptoms sufficient to enable us to recognize the 

 disease. Those aged persons whose bladders 

 are very capacious, and who are become feeble, 

 are most subject to this affection, which is 

 produced by the pressure which the other 

 viscera exercise on this organ. 



Hernia. The absence of information in old 

 authors on the subject of hernial displacement 

 of the urinary bladder induced an opinion 

 which was current for very many years, that the 



* Chopart, Sracllic, Black, 

 t Ephemeridcs Acrid. Nat. Cur., cent, ix.obs. 41. 

 t Traile dcs Maladies dcs Voies Uriuaires, t. i. 

 u. 399. Edit. 1830. 

 $ Mem. do, 1'Acart, de Chir,, t. ii, p. 36. 



affection we are about to consider was of ex- 

 tremely unfrequent occurrence. This, however, 

 is an erroneous opinion, for the experience of 

 modern times has demonstrated, that though 

 less frequent than hernia of the intestines or of 

 the epiploon, cystocele is not an unfrequent 

 disease.* 



The inguinal ring, the crural arch, the peri- 

 neum, and the anterior walls of the vagina 

 may become the seat ot a hernia of the blad- 

 der. At whichever of these points the disease 

 may be manifested, the bladder, fixed deep in 

 the pelvis and hidden behind the pubes, is 

 never completely displaced; only prolongations 

 of the organ can pass these several points. It 

 must be at once evident that besides the dila- 

 tation of the opening through which it passes, 

 there must be a great increase in the capacity 

 of the organ itself, and a great relaxation of 

 its parietes, occasioned most commonly by 

 retention of urine, or by a habit of only rarely 

 attending to a desire for its evacuation. Whe- 

 ther the protrusion occur at the one or the other 

 of the several regions I have named, there are 

 certain general characters by which it may be 

 more or less readily detected. We shall find 

 a soft tumour, accompanied by a fluctuation 

 which is as much more sensible, and which 

 acquires a volume as much more considerable 

 as the time which may have elapsed without 

 an evacuation of urine is greater. This tumour 

 may be easily lessened by compression, but 

 the reduction is immediately followed by an 

 urgent desire to pass the urine. 



This species of hernia is only partially co- 

 vered by peritoneum. Dominique Sala is, 

 according to Bartholin,f the first person who 

 mentioned this peculiarity. The reason of this 

 circumstance is obvious : when the bladder is 

 distended, it is raised to the level of the crural 

 arch and of the inguinal ring ; it pushes before 

 it the peritoneum, and insinuates itself between 

 the peritoneum and the abdominal muscles. 

 If at this time a violent effort determine the 

 escape of the corresponding part of the organ 

 by one or other of these openings, it is the 

 anterior, superior, and lateral part of the 

 organ which will be presented, and this is the 

 portion which is without a peritoneal invest- 

 ment; so that at this time the hernise we have 

 described are completely deprived of a sac. 

 It usually happens, however, that the posterior 

 portion of the organ soon follows, dragging 

 with it the peritoneum by which it is covered; 

 this portion in turn drags down that which is 

 in the vicinity of the ring; and in this way a 

 hernial sac is formed, ready for the reception of 

 the intestine or the omenturn. This is the 

 reason why a hernia of the bladder is so fre- 

 quently accompanied by an intestinal or omen- 

 tal hernia. 



* For a confirmation of this opinion, see Blcgny, 

 Traite des Heruies, 1G88 ; Mcry, Mem. de 1'Arad. 

 dcs Sciences, 1713; Petit, inumc ouvrage, 1717; 

 Lc Dran, Garcngcot, and La Fuye. Heister and 

 Plainer, Instit. Chir. J. G. Giuizii, Obs. an. Chir. 

 de Hernia, Lipsiir, 1744 ; Monro, Levret, Sharp, 

 Pott, Scaipa, Lawrence, and others. 



t Hist. Anat,, cent, xviii. 



