39G 



BLADDER, ABNORMAL ANATOMY. 



It does not appear to be well established 

 whether a primitive hernia of the bladder 

 occurs in the direction of the inguinal canal, 

 or whether it escapes directly through the 

 aponeurotic opening of the external abdominal 

 muscle, though the latter opinion is the most 

 probable. It has been remarked in some cases 

 that the spermatic vessels were external to the 

 hernia. 



In consecutive vesical hernia an intestinal 

 hernia primarily exists; the intestine pushes 

 before it the peritoneum which surrounded the 

 ring-, and in proportion as the hernia increases 

 in volume, does the sac augment, the peri- 

 toneum in the neighbourhood of the ring is 

 drawn down, and, as a consequence, that which 

 invests the posterior surface of the bladder, which 

 in its turn is also drawn down, if, on the one 

 hand, the adherence of the peritoneum to the 

 bladder be sufficiently strong, and if, on the 

 other, the latter organ be voluminous and sus- 

 ceptible of displacement. The primitive peri- 

 neal and vaginal hernia? are similarly situated 

 as to the non-existence of a hernial sac, and of 

 the existence of consecutive hernia in these 

 situations we have no record. 



The species of vesical hernia which is most 

 commonly seen is the inguinal ; the tumour is 

 usually confined to the groin, but it may 

 descend into the scrotum, gliding along the 

 spermatic cord.* 



Hernia of the bladder at the crural ring is 

 very rare. It presents the same characters and 

 is subject to the same complications as that 

 which occurs at the inguinal ring. Its form 

 and its seat only are different; it is developed 

 at the same point as a merocele, and like it 

 takes a globular form. 



Vesical hernia at the perineum is an ex- 

 tremely rare disease, and for some time was 

 supposed to occur exclusively in pregnant 

 women, but the observation of Pipelet is con- 

 clusive as to the possibility of its existence in 

 man. In these cases a portion of the bladder 

 passes between the fibres of the levator ani 

 muscle, and it is presented in the form of an 

 ovoid tumour placed at the side of the anus. 

 In each of the three species of hernia which 

 we have described, the bladder suffers certain 

 changes of form : it is contracted at the level of 

 the opening through which it passes, and is again 

 dilated below this point. This circumstance 

 has been observed by Keate, Pott, and Ber- 

 trandi. Sometimes even calculi have been 

 found in the displaced portion of the blad- 

 der.f 



Few occasions have occurred of observing 

 hernia of the bladder through the vagina. In 

 this affection the fundus of the bladder de- 

 presses the anterior parietes of the vagina, and 

 forms a round projection, which is frequently 

 visible externally when it passes the level of 

 the orifice of the vulva. The disease is usually 

 developed during pregnancy when pressure is 

 made by the distended uterus upon the neigh- 

 bouring organs ; but cases have occurred at an 



advanced period of life. Of all the species of 

 hernia of the bladder, that by the vagina occa- 

 sions the most pressing symptoms, and these 

 symptoms are principally owing to the devia- 

 tion which is produced in the canal of the 

 urethra, which is drawn downwards and for- 

 ward by the fundus of the organ, so as to 

 prevent the passage of the urine along it. In 

 this way a complete retention of urine is pro- 

 duced, together with tension, pain and aug- 

 mentation of volume in the abdomen, agitation, 

 sleeplessness, sympathetic irritation of the 

 heart and the brain. 



Considerable doubt has usually been ex- 

 pressed, whether hernia of the bladder is sus- 

 ceptible of true strangulation ; whether the 

 sensibility of this organ is of the same na- 

 ture as that of the intestines, and whether its 

 constriction might give rise to similar sym- 

 ptoms. In the case described by Plater,* 

 strangulation does, however, appear to have 

 occurred, but the symptoms which he detailed 

 were not well marked. The symptoms given 

 by J. L. Petit f do not appear sufficient to 

 enable us to distinguish strangulation where 

 the bladder is implicated from that in which 

 the intestine suffers. Hiccup, says Petit, pre- 

 cedes vomiting in hernia of the bladder, while 

 in intestinal hernia the latter precedes the 

 former symptom. If strangulation should 

 occur, the method of relief proposed by Du- 

 rand, viz. to empty the tumour by puncture 

 with a trocar, appears rational. 



Inflammation. Inflammation of the blad- 

 der may be produced by a variety of causes : 

 among them we may mention external violence, 

 incised wounds of the organ, contusions on 

 the hypogastric or perineal region, concus- 

 sions of various kinds, the bladder being dis- 

 tended, the compression consequent upon 

 pregnancy, upon a laborious accouchement, 

 upon the use of the forceps, upon the pre- 

 sence of a pessary or a hernial displacement ; 

 the presence within the organ of foreign bodies, 

 whether introduced from without, generated 

 within, or derived from the kidneys, distention 

 consequent upon retention, and the use of 

 cantharides and certain other diuretic me- 

 dicines. It may also be communicated to the 

 bladder by neighbouring organs, such as the 

 kidneys, the urethra, the prostate, the uterus, 

 and the rectum. It may be developed during 

 the progress of acute gastro-eriteritis, may 

 succeed to certain articular inflammations, to 

 certain cutaneous affections, and to the sup- 

 pression of a hemorrhoidal or menstrual 

 flux. 



The affection is more common in men than 

 in women, and at the approach of age than at 

 any other period of life. Boisseau describes 

 the disease in a male child of two years old ; 

 Lesaive in a female child of two years and a 

 half. Acute inflammation commonly affects 

 at the same time more than one of the vesical 

 tunics ; there are, however, on record two cases 

 in which acute inflammation was limited to 



* Pott's Surgical Works, vol. i. case 26. 

 t Pott, loc. cit. 



* Obs. lib. iii. p. 830. 



t Traite des Mai. Chir. tome ii. p, 368. 



