400 



BLADDER, ABNORMAL ANATOMY. 



not be so in mucous or villous tissues ? 

 Although this reasoning proves nothing, for 

 we cannot judge from analogy in a graphic 

 science like pathological anatomy, yet it is 

 the simple expression of the truth, because it 

 is certain that mucous tunics are softened by 

 inflammation, but this softening does not re- 

 semble in any thing the idiopathic softening. 



liupture. Rupture of the bladder is a 

 more frequent occurrence than that of the 

 oesophagus, the stomach, or the intestines ; it 

 occurs sometimes without external violence, 

 simply by a distention of the organ, from a 

 prolonged retention of urine ; most commonly, 

 however, it is produced by a violent blow, or 

 the passage of the wheel of a carriage over the 

 hypogastrium, or the violent efforts to which 

 a woman is subject during the pains of labour, 

 the bladder being in a state of plenitude. In 

 the first case, the rupture usually occurs near 

 the insertion of the ureters or the neck of the 

 bladder, because it is at these points that the 

 distended organ usually begins to thin and tear. 

 In the second case it is usually at the inferior 

 fundus of the organ that the rupture is found. 



We have already pointed out the circum- 

 stances under the influence of which the blad- 

 der may be ruptured, and we have stated that 

 the extravasation of urine by which it is fol- 

 lowed is commonly productive of fatal con- 

 sequences. 



In a certain but small number of cases, 

 the patient is able to resist the inflammatory 

 symptoms which are developed, urinary ab- 

 scesses are formed, which may open either in 

 the vicinity of the umbilicus, at the hypo- 

 gastrium, in the inguinal region, in the vagina, 

 at the perineum, or in the rectum, and a fistu- 

 lous canal is organised. 



Fistula. Fistulous communications be- 

 tween the bladder and the vagina or in- 

 testines are commonly the result of purely 

 mechanical causes, such as the action of a 

 calculus which may destroy the recto-vesical 

 septum, the action of a foreign body introduced 

 into the anus and penetrating the bladder, 

 the lateral ised or recto-vesical operation for 

 stone, the operation of lithotrity, or as a con- 

 sequence of the pressure produced by the 

 head of the child in parturition. Vesico-in- 

 testinal fistulas sometimes establish a com- 

 munication between the bladder and the ileum 

 or colon,* and then the summit of the bladder 

 is usually the seat of injury. When the com- 

 munication is established between the bladder 

 and the rectum, the posterior surface of the 

 bladder is commonly implicated ; the neck of 

 the bladder may, however, be similarly affected, 

 and then it is commonly owing to the action 

 of a calculus or other foreign body directed 

 upon this portion of the vesical parietes. At 

 other times the lesion succeeds to chronic in- 

 flammation, or to a cancerous ulcer which has 

 extended from the rectum to the bladder ; and 

 then the perforation almost always exists near 

 the neck of the latter. The communication of 



* London Med. Journal for 1784, part 2 ; Edin- 

 burgh Medical Commentaries, vol. ii. part 2. 



the intestine with the bladder is sometimes 

 established without abscess, without external 

 inflammation. Sometimes the urine does not 

 escape by the rectum, while faecal matter and 

 flatus pass from the rectum into the bladder. 



Ordinarily, however, the urine passes into 

 the rectum and often causes diarrhoea; the 

 bladder, distended by intestinal gas, forms a 

 sonorous and painful tumour at the hypo- 

 gastrium. 



Vesico-vaginal fistulae are sometimes though 

 rarely occasioned by the action of a foreign 

 body introduced into the vagina; sometimes 

 they are the result of the progress of a uterine 

 cancer ; but in general the cause by which 

 they are produced is a laborious accouchement, 

 during which the head of the infant has re- 

 mained long in the passage, and has by its 

 pressure determined gangrene of the vesico- 

 vaginal septum. The accident may be pro- 

 duced by the imprudent use of instruments ; 

 but this is a rare occurrence, perhaps for the 

 reason that instruments are comparatively un- 

 frequently employed. In a few days the 

 eschars which are the result of that gangrene 

 are thrown off, and the consequent loss of sub- 

 stance may then be demonstrated. We find 

 that these fistulae have not always the same 

 form, the same direction, nor the same extent. 

 In some cases they are longitudinal, at other 

 times transverse ; in others their form is irre- 

 gular. The extent of the loss of substance is 

 also very variable: sometimes the fundus of 

 the bladder is extensively destroyed, so much 

 so as to allow of the opposite parietes of the 

 organ being implicated in the opening, and 

 forming a true vesico-vaginal hernia. When the 

 disease is a vesico-umbilical fistula, the com- 

 munication is with the summit of the bladder, 

 and is commonly caused by a dilatation of the 

 urachus or by the prolongation of the mucous 

 membrane of the bladder, which is directed 

 along the cord produced by the conversion of 

 the urachus and the vessels by which it is 

 accompanied into a cellular structure.* In 

 either case the disease is almost invariably a 

 consequence of the existence of some ob- 

 stacle to the passage of urine along the 

 urethra. 



The pubic and inguinal fistulae succeed to 

 an accidental opening of the bladder, which, 

 having formed a tumour in those regions, 

 has been taken for an abscess, a hernia, or an 

 encysted tumour; to wounds, to ruptures, 

 puncture, or incision of the organ ; to its per- 

 foration in consequence of a purulent focus 

 being in contact with its parietes, or by a suppu- 

 ration in these parietes themselves. All fistulae 

 of the bladder have this in common, that the 

 urine escapes from their orifice drop by drop, 

 almost continually, often without contraction 

 of the bladder, and without the patient having 

 wished to urine ; sometimes it escapes in 

 greater quantity during those motions of the 

 body which excite the pressure of the abdo- 

 minal muscles. In consequence of the habit 

 which the bladder has acquired of remaining 



* See Van-der-Wiel, Littre, Tenon, and Roux. 



