Deformities Of The Urinary Bladder The Operations Of Sounding For Stone Of Catheterism And Of Puncturing The Bladder Above The Pubes

Sources: Surgical Anatomy

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

unifo m 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.












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.












FIG. 3, Plate 63.--The urethra being strictured, the bladder has become

sacculated. In the bas fond of the bladder appears a circular opening,

2, leading to a sac of large dimensions, which rested against the

rectum. In such a case as this, the sac, occupying a lower position than

the base of the bladder, must first become the recipient of the urine,

and retain this fluid even after the bladder has been evacuated, either

voluntarily or by means of instruments. If, in such a state of the

parts, retention of urine called for puncturation, it is evident that

this operation would be performed with greater effect by opening the

depending sac through the bowel, than by entering the summit of the

bladder above the pubes.












FIG. 4, Plate 63.--The vesical orifice is obstructed by two portions, 3,

4, of the prostate, projecting upwards, one from each of its lateral

lobes, 6, 6. The bladder is thickened and fasciculated, and from its

summit projects a double sac, 1, 2, which is invested by the

peritonaeum.








FIG. 5, Plate 63.--The prostatic canal is constricted and bent upwards

by the third lobe. The bladder is thickened, and its base is dilated in

the form of a sac, which is dependent, and upon which rests a calculus.

An instrument enters the bladder by perforating the third lobe, but does

not come into contact with the calculus, owing to the low position

occupied by this body.














FIG. 6, Plate 63.--Two sacs appear projecting on either side of the base

of the bladder. The right one, 5, contains a calculus, 6; the left one,

of larger dimensions, is empty. The rectum lay in contact with the base

of the bladder between the two sacs.












FIG. 7, Plate 63.--Four calculi are contained in the bladder. This organ

is divided by two septa, 2, 4, into three compartments, each of which,

1, 3, 5, gives lodgment to a calculus; and another, 6, of these bodies

lies impacted in the prostatic canal, and becomes a complete bar to the

passage of a catheter. Supposing lithotomy to be performed in an

instance of this kind, it is probable that, after the extraction of the

calculi, 6, 5, the two upper ones, 3, 1, would, owing to their being

embedded in the walls of the bladder, escape the forceps.












FIG. 8, Plate 63.-Two large polypi, and many smaller ones, appear

growing from the mucous membrane of the prostatic urethra and vesical

orifice, and obstructing these parts. In examining this case during life

by the sound, the two larger growths, 1, 2, were mistaken by the surgeon

for calculi. Such a mistake might well be excused if they happened to be

encrusted with lithic matter.












FIG. 9, Plate 63.--The base of the bladder, 8, 8, appears dilated into a

large uniform sac, and separated from the upper part of the organ by a

circular horizontal fold, 2, 2. The ureters are also dilated. The left

ureter, 3, 4, opens into the sac below this fold, while the right ureter

opens above it into the bladder. In all cases of retention of urine from

permanent obstruction of the urethra, the ureters are generally found

more or less dilated. Two circumstances combine to this effect--while

the renal secretion continues to pass into the ureters from above, the

contents of the bladder under abdominal pressure are forced

regurgitating into them from below, through their orifices.












FIG. 1, Plate 64.--The bladder, 6, appears symmetrically sacculated. One

sac, 1, is formed at its summit, others, 3, 2, project laterally, and

two more, 5, 4, from its base. The ureters, 7, 7, are dilated, and enter

the bladder between the lateral and inferior sacs.












Fig. 2, Plate 64.--The prostate is greatly enlarged, and forms a narrow

ring around the vesical orifice. Through this an instrument, 12, enters

the bladder. The walls of the bladder are thickened and sacculated. On

its left side appear numerous sacs, 2, 3, 4, 5, 6, 7, 8, and on the

inner surface of its right side appear the orifices of as many more. On

its summit another sac is formed. The ureters, 9, are dilated.












FIG. 3, Plate 64.--The prostate is enlarged, its canal is narrowed, and

the bladder is thickened and contracted. A calculus, 1, 2, appears

occupying nearly the whole vesical interior. The incision in the neck of

the bladder in lithotomy must necessarily be extensive, to admit of the

extraction of a stone of this size.










FIG. 4, Plate 64.--The prostatic canal is contracted by the lateral

lobes, 4, 5; resting upon these, appear three calculi, 1, 2, 3, which

nearly fill the bladder. This organ is thickened and fasciculated. In

cases of this kind, and that last mentioned, the presence of stone is

readily ascertainable by the sound.








FIG. 5, Plate 64.--The three prostatic lobes are enlarged, and appear

contracting the vesical orifice. In the walls of the bladder are

embedded several small calculi, 2, 2, 2, 2, which, on being struck with

the convex side of a sound, might give the impression as though a single

stone of large size existed. In performing lithotomy, these calculi

would not be within reach of the forceps.










FIG. 6, Plate 64.--Two sacculi, 4, 5, appear projecting at the middle

line of the base of the bladder, between the vasa deferentia, 7, 7, and

behind the prostate, in the situation where the operation of puncturing

the bladder per anum is recommended to be performed in retention of

urine.










FIG. 7, Plate 64.--A sac, 4, is situated on the left side of the

bladder, 3, 3, immediately above the orifice of the ureter. In the sac

was contained a mass of phosphatic calculus. This substance is said to

be secreted by the mucous lining of the bladder, while in a state of

chronic inflammation, but there seems nevertheless very good reason for

us to believe that it is, like all other calculous matter, a deposit

from the urine.






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FIG. 8, Plate 64, represents, in section, the relative position of the

parts concerned in catheterism. [Footnote] In performing this operation,

the patient is to be laid supine; his loins are to be supported on a

pillow; and his thighs are to be flexed and drawn apart from each other.

By this means the perinaeum is brought fully into view, and its

structures are made to assume a fixed relative position. The operator,

standing on the patient's left side, is now to raise the penis so as to

render the urethra, 8, 8, 8, as straight as possible between the meatus,

a, and the bulb, 7. The instrument (the concavity of its curve being

turned to the left groin) is now to be inserted into the meatus, and

while being gently impelled through the canal, the urethra is to be

drawn forwards, by the left hand, over the instrument. By stretching the

urethra, we render its sides sufficiently tense for facilitating the

passage of the instrument, and the orifices of the lacunae become

closed. While the instrument is being passed along this part of the

canal, its point should be directed fairly towards the urethral opening,

6*, of the triangular ligament, which is situated an inch or so below

the pubic symphysis, 11. With this object in view, we should avoid

depressing its handle as yet, lest its point be prematurely tilted up,

and rupture the upper side of the urethra anterior to the ligament. As

soon as the instrument has arrived at the bulb, its further progress is

liable to be arrested, from these causes:--1st, This portion of the

canal is the lowest part of its perinaeal curve, 3, 6, 8, and is closely

embraced by the middle fibres of the accelerator urinae muscle. 2nd, It

is immediately succeeded by the commencement of the membranous urethra,

which, while being naturally narrower than other parts, is also the more

usual seat of organic stricture, and is subject to spasmodic

constriction by the fibres of the compressor urethrae. 3d, The

triangular ligament is behind it, and if the urethral opening of the

ligament be not directly entered by the instrument, this will bend the

urethra against the front of that dense structure. On ascertaining these

to be the causes of resistance, the instrument is to be withdrawn a

little in the canal, so as to admit of its being readjusted for engaging

precisely the opening in the triangular ligament. As this structure, 6,

is attached to the membranous urethra, 6*, which perforates it, both

these parts may be rendered tense, by drawing the penis forwards, and

thereby the instrument may be guided towards and through the aperture.

The instrument having passed the ligament, regard is now to be paid to

the direction of the pelvic portion of the canal, which is upwards and

backwards to the vesical orifice, 3, d, 3. In order that the point of

the instrument may freely traverse the urethra in this direction, its

handle, a, requires to be depressed, b c, slowly towards the perinaeum,

and at the same time to be impelled steadily back in the line d, d,

through the pubic arch, 11. If the third lobe of the prostate happen to

be enlarged, the vesical orifice will accordingly be more elevated than

usual. In this case, it becomes necessary to depress the instrument to a

greater extent than is otherwise required, so that its point may

surmount the obstacle. But since the suspensory ligament of the penis,

10, and the perinaeal structures prevent the handle being depressed

beyond a certain degree, which is insufficient for the object to be

attained, the instrument should possess the prostatic curve, c c,

compared with c b.



[Footnote: It may be necessary for me to state that, with the exception

of this figure (which is obviously a plan, but sufficiently accurate for

the purposes it is intended to serve) all the others representing

pathological conditions and congenital deformities of the urethra, the

prostate, and the bladder, have been made by myself from natural

specimens in the museums and hospitals of London and Paris.]










In the event of its being impossible to pass a catheter by the urethra,

in cases of retention of urine threatening rupture, the base or the

summit of the bladder, according as either part may be reached with the

greater safety to the peritonaeal sac, will require to be punctured. If

the prostate be greatly and irregularly enlarged, it will be safer to

puncture the bladder above the pubes, and here the position of the organ

in regard to the peritonaeum, 1, becomes the chief consideration. The

shape of the bladder varies very considerably from its state of

collapse, 3, 3, 5, to those of mediate, 3, 3, 2, 1, and extreme

distention, 3, 3, 4. This change of form is chiefly effected by the

expansive elevation of its upper half, which is invested by the

peritonaeum. As the summit of the bladder falls below, and rises above

the level of the upper margin of the pubic symphysis, it carries the

peritonaeum with it in either direction. While the bladder is fully

expanded, 4, there occurs an interval between the margin of the

symphysis pubis and the point of reflexion of the peritonaeum, from the

recti muscles, to the summit of the viscus. At this interval, close to

the pubes, and in the median line, the trocar may be safely passed

through the front wall of the bladder. The instrument should, in all

cases, be directed downwards and backwards, h, h, in a line pointing to

the hollow of the sacrum.