Section Ii. the Urinary Bladder.

=Malformations.= Among the most common of these, may be mentioned extroversion, where there is an absence of the anterior walls of the bladder, with a deficiency in the corresponding portion of the abdominal parietes. From the pressure of the abdominal viscera, the posterior walls of the bladder will be crowded forward, and protrude as a rounded tumor, covered by a vascular mucous membrane, while near the lower portion may be seen the orifices of the ureters, through which the urine will be more or less constantly flowing.

Malformations of the external organs of generation, are liable to accompany those of the bladder.

The Urachus sometimes fails to close before birth, leaving thus an open passage from the fundus of the bladder to the umbilicus, through which the urine may be noticed flowing after division of the cord.

=Dilatation.= This is of not unfrequent occurrence, and is the result either of a paralysis of the muscular coat, or of some obstacle to the outflow of the urine. The dilatation may be uniform, or we may find diverticula, formed by a protrusion of the mucous membrane between the fasciculi of muscular fibres. Such partial distensions occur most frequently in the lateral portions, the posterior surface, or the neighborhood of the fundus, and as we should be led to expect from the manner of their formation, are generally destitute of a muscular tunic, or have but a few scattered fibres. Calculi are sometimes found in these pouches after death, the presence of which had escaped notice during life from their concealed position.

=Hypertrophy= of the muscular coat of the bladder, will generally be found attending cases of obstruction to the escape of the urine, either from an enlarged prostate, stricture of the urethra, or from the presence of a calculus. The muscular coat in these cases is greatly thickened, the interlacing bundles of fibres appearing with great distinctness upon the inner surface.

As a result of this condition, we usually find the bladder greatly contracted, its capacity in some cases being reduced to one or two ounces. Inflammation of the mucous coat, with dilatation of the ureters, will also generally attend, hypertrophy of the muscular walls.

=Contraction= of the bladder is met with, as the result either of irritation of the mucous membrane, or hypertrophy of the muscular coat.

=Inflammation= of the bladder is generally seen in its chronic form.

The appearances in acute cystitis are “strong vascular injection of the mucous lining, with brownish patches in the vicinity of the neck and fundus; more or less thickening of the membrane, with exudation of fibrin or pus on the surface, or foci of the latter in its substance. The mucous tissue may be ulcerated at several points, softened or affected by commencing gangrene. Abscesses may form in the substance of the parietes, and open either into the cavity of the bladder, or upon its external surface. Sometimes the mucous membrane is almost completely destroyed, a few shreds or filaments being the only traces remaining, while the muscular tunic is left as if cleanly dissected. This is probably the result of phagedenic ulceration.” The inflammation may spread from the mucous membrane to the muscular coat, but it very rarely reaches the peritoneal covering. In some cases it extends back along the ureters, and even to the kidneys. The morbid action is not often of idiopathic origin, it is more frequently due to the extension of an attack of gonorrhœa, to disease of the prostate, to traumatic causes, to protracted retention of urine, or to the irritation produced by medicines or stimulating drinks. It is sometimes owing to the constitutional poison of rheumatism or gout. It is met with oftener in men than women, and in adults than in children.

Chronic cystitis, called also catarrh of the bladder, is very common in advanced age. The morbid process is excited by some obstacle to the emission of the urine, either paralysis of the viscus, or a stricture, or by presence of a stone in the bladder, or by enlargement of the prostate gland. It may also result from successive attacks of the acute form, or from extension of urethral inflammation.

Various degrees of vascular injection are presented, with dark-reddish, slate-colored or bluish-black discoloration, more or less thickened induration of the parietes, which assume an homogeneous, lardaceous appearance. An acute attack may supervene upon a state of chronic inflammation, leading to ulceration, suppuration, perforation and extravasation of urine, as in the case of primary acute cystitis.

Chronic or sub-acute inflammation is often attendant upon paraplegia, and proves the immediate cause of death.

Morbid Growths.

=Cancer= as a primary disease, is but rarely met with. Encephaloid, forming nodulated prominences or cauliflower-like excrescences, is the form which vesical cancer usually assumes. They are developed in the submucous tissue, but as they grow, the mucous membrane is also destroyed, and either an ulcer is produced or a soft luxuriant fungous mass.

=Tubercle= in the form of separate granulations are sometimes met with about the fundus and neck of the bladder in the male, and usually are accompanied with similar deposits in the testes, prostate, kidneys, etc. They are surrounded by more or less hyperæmia, and by softening give rise to circular ulcers of the mucous membrane covering them.

=Tumors.= Polypoid growths, both of a fibrous and adenoid character, may be found in the neck of the bladder, both in children and adults. They vary in size from that of a pea to a cherry.

Cystic tumors of small size are sometimes found within the mucous membrane.

Parasites.

The Sarcina ventriculus, a vegetable parasite, is sometimes found in the bladder, in cases of chronic cystitis.

Of animal parasites, the Eustrongylus, Echinococus, and Ascarides, have found their way into this organ from other parts.

Of the Urethra.

=Malformations.= As congenital malformation, we need mention only Epispadias, fissure on the upper, and Hypospadias, on the lower surface, from arrest of development, and complete closure of the opening, Atresia urethræ.

=Inflammation= of the urethra, of the catarrhal kind, the so-called gonorrhœa, commencing at the anterior extremity, may, in severe cases, extend backwards, even into the bladder. The lining membrane becomes swollen, injected, and covered with mucus or muco-purulent secretion, at first thin, then thicker, and then, as the inflammation subsides, thin and pale again. When a chancre coexists with gonorrhœa, “the discharge has usually a grayish or reddish tint, or sanious aspect.” From an extension of the inflammation deeper into the fibrous structure of the corpus spungiosum, results, sometimes, an exudation of fibrin in the venous cells, suppuration and abscess. Cowper’s gland, the prostate, the vesiculæ seminales, and the testicles, may also be affected by an extension of the inflammation along the continuous mucous lining.

The contact of unhealthy vaginal secretions, whether specific or not, is the most frequent cause of urethritis.

=Dilatation and Contraction.= Dilatation is most frequently the consequence of obstruction to the flow of urine. It occurs generally in the membranous portion, which is expanded into a pouch, occasionally as large as a small orange. The mucous lining of these pouches appears “injected and thickened, presenting fungous vegetations, and occasionally coated with lymph.”

Contraction may result from inflammation of the mucous membrane, and finally end in stricture.

=Stricture= is a very frequent result of inflammation of the urethra. It usually is found in the anterior part of the membranous portion. Contusions and wounds also, often produce stricture.

The simplest form of stricture is, where the canal is partially closed by a fold of membrane passing across it, leaving either a crescentric, or annular opening. In the most common kind of stricture the urethra is narrowed in a much greater extent of its course, sometimes for an inch, or more. When the obstruction occasioned by a stricture is very great, the urethra behind is dilated, often inflamed and sometimes ulcerated, so as to give rise to urinary fistula or effusion of urine.

=Rupture= of the urethra may result from severe contusions, or fracture of the bones of the pelvis, and being followed by extravasation of blood and urine, inflammation, suppuration or gangrene may supervene, or fistulous openings may be thus established.

Morbid Growths.

Warty growths sometimes appear within the urethra near the meatus. They are generally quite vascular, and may cause considerable obstruction.

Tubercles are of rare occurrence in the urethra.

Cancer occurs only as an extension of the disease from the penis, prostate gland or bladder.

=Urinary Calculi.= Calculi of different size, form, and chemical composition, may be found in the urinary bladder, ureters, or sinus of the kidneys.

Uric, or lithic acid calculi, are the most frequent in their presence. They may vary in size, from a pea to that of a hen’s egg. In color, also, they may vary from a fawn or light yellow, to a dark, almost mahogany tint. The surface may be slightly tuberculated, or smooth, and the interior, where a section is made, has a concentric arrangement of layers around a central nucleus.

Oxalate of lime calculi are next in frequency. From the strongly tuberculated character of the surface, they are frequently known as mulberry calculi. They are of an irregular, spherical form, and usually single. In color, they are usually of a dark olive or brown, but may be light and almost white. They seldom acquire so large a size as the lithic acid variety, are very hard, and permit of a high polish.

Phosphatic calculi are characterized by their softness, which permits of their being readily crushed. They are of a grayish-white color, and frequently composed of alternate layers of other deposits. They may be composed wholly of phosphate of lime, or of a triple phosphate—ammonio-magnesian phosphate—or of a combination of the two.

Cystine calculi are very rare; they are yellowish in color, of a waxy appearance, and soluble in aqua-ammonia.

Uric oxide calculi are extremely rare; they resemble uric acid calculi, but present a waxy appearance when polished.