The pubic and inguinal fistulw 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 empty, it almost always becomes contracted ; in all cases its capacity is considerably di minished.
Hemorrhage from the bladder.—Instead of the mucus which is furnished by the mucous membrane of the bladder when in the state of health, it may be the seat of a sanguineous exhalation. When a sanguineous fluid is excreted from the bladder, it does not of neces sity follow that it has proceeded from the mucous membrane of that organ ; it may be brought by the ureters from the kidneys. When the fluid is produced within the vesical cavity, the mode of production is not uniform : it may be a simple exhalation from the mu cous membrane, or it may be a consequence of the destruction of the mucous membrane by gravel, by a calculus, or by a foreign body introduced from without ; or it may be a con sequence of the rupture of varicosed vessels. Blood is, however, rarely exhaled at the in ternal surface of the bladder, unless the mu cous membrane be in a state of structural disease : yet this exhalation is occasionally manifested as a result of intemperance, or the use of certain irritating diuretic medicines, concussions of the pelvis ; in woman the sud den suppression of the menstrual evacuations, and in man of a hemorrhoidal discharge.
It is very difficult, and sometimes even al most impossible to determine whether the fluid be derived from the kidney or from the bladder; and to arrive at any thing like a sound opinion, it is necessary to consider carefully all the circumstances of the case. Much as it has been relied on, we cannot consider as a sym ptom peculiar to vesical haemorrhage, the mix ture of blood with the urine, and the sensation of burning and weight behind the pubis, at the perineum, and at the extremity of the penis; for these symptoms occur in some cases where there is no effusion of blood, and in others where the blood has arrived from the kidneys.
It is also very difficult to decide as to what is the exact state of the bladder, even when we are convinced that the blood discharged from the urethra is derived from that organ. Chopart found the vesical mucous membrane, more particularly at the fundus, studded with red points in an old man subject to hannaturia; these points appeared to him to be vascular orifices.* In other persons who have suffered from a similar affection, different kinds of fungus have been discovered on this mem brane. A man, aged seventy-three, had hwma turia, but there was no stone in the bladder. As there was no appearance of disease about the kidneys, it was attributed to the rupture of some varicose vessels in the neighbourhood of the neck of the organ. After death the bladder was found of great size, and within the trigone was a fungous rounded ulceration, six lines in diameter, surrounded with varicose veins and small fungous excrescences. Ordi narily, however, gravel or calculi appear to be the exciting causes of this disease.
Fungous tumours.—The information which we possess on the subject of fungous tumours or excrescences of the bladder is not sufficiently precise to enable us to attempt to arrange them according to their variety in structure or development. The tumours which we pro pose to describe are those which do not im plicate the whole of the parietes of the organ, but project into its cavity under the form of more or less perfectly pediculated excrescences. We are, therefore, under the necessity of con sidering simultaneously all those tumours, however variable in structure, which come under the definition which we have given. Many eminent pathologists have expressed an opinion that these tumours are always directly connected with the prostate ; but their occa sional existence in the female sufficiently proves that this opinion is incorrect. In 1750 Mr. Warner removed from the bladder of a woman a fungous tumour of the shape and size of a turkey's egg. Walter* details the case of a young woman in whose bladder he discovered what he calls a polypus, which ex tended itself nearly to the external orifice of the urethra. It is true that these morbid products are more commonly seen at the fundus of the blad der than at any other point of its surface, and it is equally true that a large number of those affections which are described as fungous tu mours of the bladder, were really morbid products arising from the prostate, which will be described in the article on the PROSTATE GLAND.