516 EENAL HEMATURIA
and possess a spine, usually placed at one end, sometimes laterally. Within
the ovum lies the embryo. This may be liberated under the microscope by
pressure upon the cover-glass. When the shell has burst and the embryo es-
capes, it is seen to be an actively motile organism with many cilia. It is ovoid
Fig. 131. — Ovum of Distoma Hematobia. Magnified 500 diameters. (Dr. Pool's case.)
in shape, more blunt at the head end. When swimming it becomes more
elongated. The embryos die in urine after twenty-four hours, but may be
kept alive in water for several days. The life history of the embryo is not
known, nor what its intermediate host may be, nor whether they enter the
human body with such a host or alone.
Occurrence. — The disease is most common on the Nile, and is here very
common, affecting a very large proportion of the population — 42 times in 92
autopsies (Sonsino). It also occurs in many other parts of Africa and in
Syria, Cyprus, Madagascar, India, and other tropical countries of the East.
The cases observed in the United States are chiefly imported, a few doubt-
ful cases only having apparently developed in Indiana and Illinois.
Mode of Infection.— The mode of infection is either through impure drink-
ing water or through bathing, or both. Whether the embryos are swallowed in
an encysted state, or whether they enter through the skin or through the ure-
thra, is not certainly known. The first mode seems the most probable one.
Pathology. — The chief lesions of the disease are found in the genito-urinary
tract, the bladder being most often affected. The adult worms are found in
the branches of the portal system of veins; most often in the veins of the
bladder and rectum ; very rarely free in the genito-urinary tract. In the smaller
veins the female deposits her ova. These finally perforate into the surrounding
PARASITIC DISEASES CAUSING HEMATURIA
.".17
tissues, <:iviiiu' pise to irritative and inflammatory changes, or i n t < > the genito-
urinary tracl or rectum, causing hematuria, or the passage of blood per rectum.
The <>v;i may theu be found in the urine or feces, as the case may be, in large
numbers. As Btated, the bladder is the mosl frequenl Beat of the perforations.
They may be viewed through the cystoscope, and appear, according to O'Neil, 1
" as congested and ecehymosed patches, varying in size from one fourth to half
;m inch in diameter, covered with mucus containing many ova. They are
generally in the posterior part of the bladder." Later in the disease, more
fully developed lesions may consist of vegetations, ami considerable tumor
masses coated with earthy Baits. The 3earcher in the bladder, grating upon
these, gives the sensation of stone. In addition, the wall of the bladder may
be thickened and its capacity reduced. The outgrowths may entirely till the
bladder. Similar lesions may be developed in the ureter and renal pelvis.
k •.
Fig. 13
-Shell of the Ovttm after Migration of the Embryo ok Distoma Hematobia.
Magnified 500 diameters. (Dr. Pool's case.)
Often calculi are formed, and thus the individual is exposed to any of the
destructive lesions of the kidney due to obstruction and infection — i.e., hydro-
nephrosis, pyonephrosis, etc.
The Blood. — A moderate leucocytosis is usually present. An incr
proportion of eosinophiles is commonly observed. In fifty cases studied by
o'Ni'il. Boston Medical and Surgical Journal, October '-'7. 1904,
518 KENAL HEMATURIA
Douglas and Hardy, the eosinophilia amounted on the average to 16.48 per
cent. The large polynuclear cells are reduced in number.
Symptoms and Diagnosis. — Without going into all of the symptoms in
detail, it may be said that the most constant symptom of the disease is hema-
turia, and that the diagnosis depends upon finding the ova in the urine or in
the feces.
In the early stages no other symptoms are necessarily present. Later, in-
flammation of the bladder, vesical or renal calculi, occur. The prostate and
seminal vesicles may be invaded with abscess formation. There may be symp-
toms of proctitis with bloody stools. Profound anemia and exhaustion, sepsis,
or some fatal kidney complication may end life.
I append the history of one of the very few cases found in New York,
through the kindness of Dr. E. H. Pool, who has also permitted me to use the
microphotographs of the urinary sediment here reproduced.
A Case of Bilharzia Hematobia. — The patient was a young man, twenty
years of age, an Algerian by birth, a sailor by occupation. When he was eight
years of age he went to Ismailia on the Suez Canal, Egypt, and remained there
for five years. During that time he went in swimming almost daily, both in the
• :• i
»v ... .
\jtC » • »C
Fig. 133. — Embryo of Dtstoma Hematobia after Migration from the Shell.
Magnified 500 diameters. (Dr. Pool's case.)
Suez itself and in the neighboring streams and ponds. The next five years had
been spent on a Greek ship in the Mediterranean. He had left this vessel two years
ago at Marseilles, and there he contracted gonorrhea four days after intercourse.
He had had with that attack very little pain and frequency of micturition, but had
had a characteristic discharge which disappeared at the end of fifteen days under
PARASITIC DISEASES CAUSING HEMATURIA 519
urethral injections. A fortnight later be wren! back to Algiers, inhere it was intei
hot, and Bhortly after reaching the country, as he supposed on account of the intense
heat, he noticed thai all of bis urine was diffusely red. He remained in Algiers
for three or four months and the condition persisted. He had qo other symptoms
ami was al»lr to go .ii.nwt his regular occupations. A- Boon as he left the country
the diffusely bl ly urine changed to the characteristic hematuria of the disei
\iz. : after he had passed a norma] amount of fairly normal-looking amber-colored
urine and when the bladder was apparently empty, with an involuntary spasm there
was a discharge of a drachm or two of a thin bloody fluid. This condition had per-
sisted up to the present time intermittently. The man spent nine months in Cuba,
and for the last six months had been in the United Stales. At the present time he
also complained of indefinite pain in the loins and of a feeling of weakness which
prevented him from doing any earnest work.
The physical examination showed a well-nourished young man. Examination of
heart, lungs, abd en, rectum, etc., was negative.
The following was the report of the examination of urine:
April 8, 1903. Volume voided in twenty-four hours, 1,950 c.c. Reaction, acid.
Color, amber. Sediment, moderate in amount; reddish white. Specific gravity,
1.011). Albumin, trace. Sugar, negative. Urea, 41,301 grams in twenty-four hour-.
Indican, no excess. Acetone, negative. Chlorid, 13.6 grams in twenty-four hours.
Phosphates, no excess. Examination of sediment obtained by centrifuge showed:
Blood, very small amount; pus, small amount; mucus, small amount; extremely
few hyaline casts; numerous squamous epithelial cells; many ova of the Bilharzia,
and numerous structureless threads.
Examination of blood: Red cells, 3,340,000. Hemoglobin, 86 per cent. Leu-
cocytes, 6,600. Differential count: Small lymphocytes, 31.5 per cent. Large
lymphocytes, 6.5 per cent. Polymorphonuclear neutrophils, 52.5 per cent.
Eosinophils, 9.5 per cent.
Several other animal parasites may cause hematuria, among them Strongy-
lus gigas and Nephrophages sanguinarius. They are, I believe, unknown in
America. The latter occurs in Japan.
CHAPTEE XXIII
THE URINARY BLADDER, ANATOMY, METHODS OF EXAMINATION, AND
CONGENITAL DEFECTS
TOPOGRAPHICAL ANATOMY OF THE BLADDER
{Partly Adapted from MerJceV)
The anterior half of the pelvic cavity is occupied by parts of the genito-
urinary apparatus. The largest part of the space is filled by the urinary
bladder. The other structures — i. e., ureters, vasa deferentia, seminal vesicles,
and prostate — are in apposition to it. The bladder is ordinarily described as
possessing an apex or vertex, a base or fundus and a body, or the main por-
tion of the bladder. Into the base of the bladder empty the ureters, and from
it emerges the urethra, the in-
ternal urinary meatus being
situated at the anterior limit
of the bladder floor. From the
anterior wall, at the apex of the
bladder, the median umbilical
ligament extends upward to the
umbilicus, the remains of the
urachus.
%â–
-A
â– B
-C
The lateral umbilical liga-
ments are the obliterated umbil-
D ical arteries. Thev come into
E
jp contact with the bladder only
when it is much distended.
The external surface of the
bladder is smooth under all con-
ditions, whether full or empty.
The muscular wall of the
bladder is surrounded by a loose-
ly meshed layer of connective
tissue. Through this layer the
upper part of the bladder can
be readily stripped from sur-
rounding structures by blunt dissection with the fingers or a sponge holder;
advantage of this fact is taken in many intrapelvic operations.
520
Fig. 134. — The Urinary Bladder ; the Upper Portion
of the Bladder has been Cut Away; the Observer
is Looking from Above upon the Floor of the
Bladder. Drawing made from the bladder in situ.
Natural size. A. Urethra. B. Uvula vesica?. C. Tri-
gonum. D. Ureter. E. Plica ureterica. F. Fovea
retroureterica. (After Merkel.)
TOPOGRAPHICAL ANATOMY OF THE BLADDER 521
The lining mucous membrane of the interior of the bladder i-, when empty,
thrown int<» deep folds; as the bladder distends, these folds are gradually ob-
literated. The innermost layer of muscular bundles then becomes visible, ar-
ranged in :i network, the muscular ridges projecting slightly, with slighl hollows
between them. In the hypertrophied bladder these ridges and furrow- become
more marked, so thai the bladder is said to be trabeculated. The interspaces
may even become bo deep as t" harbor a stone or form a deep pocket or diver-
ticulum.
When the normal bladder is distended beyond a medium grade, the ridges
and furrows disappear and the surface becomes quite smooth.
The floor of the bladder, or fundus, is unlike the remainder of the organ;
here no muscular folds or bundles arc to be seen; instead, one finds a flat
Burface- the trigonum vesicae. Throughout this entire area the n 1 1 1<-< »~:t is
firmly adherent to the underlying muscular layer. The trigonum is abundantly
supplied with nerves, and is much the mosl sensitive portion of the bladder,
the remainder being relatively insensitive to touch, but highly sensitive to
distention, as everyone knows from experience. Two slighl folds of mucous
membrane can be noted converging toward the ureteric orifices. The trigonum
is the triangular surface between the ureteric orifice- and the internal urinary
meatus, or urethral orifice. As the ureters pass obliquely through the bladder
wall they create two slight ridges, passing to the ureteric orifice-, the plica
ureterica. Between the orifice- these ridges are prolonged toward the median
line, where they unite. This ridge is more or less marked in different blad-
ders; its center may be interrupted, forming a slight central depression. From
the center another slighl ridge extends forward to the urethral orifice: its
anterior extremity enters the urethral orifice, and here forms a slight eleva-
tion, known as the uvula. In old age, hypertrophic enlargement may occur
at this point, causing obstruction. (See Prostate.) These several ridges are
only seen when the bladder is empty and contracted; when distended, the sur-
face of the trigone is quite flat
The ureteric orifices are about 25 mm. apart, and are distant from the ure-
thral orifice 20 to 25 mm. They are oval slits, 4 to 5 mm. in length, and have
been likened in shape to the month orifice of a flute. The orifice- are created
at the expense of the anterior wall of the canal. In passing the ureteral
catheter, it is important to remember this mechanical detail. The oblique
perforation of the bladder wall by the ureter- explains the valvular action
here exhibited. Increased intravesical pressure compresses the ureters so that
regurgitation from the bladder does not take place. This is shown even in
the dead Madder; air injected into the bladder through the urethra doc- qoI
escape through the ureters.
The urethral orifice is round, or of half-moon shape. It is not usually
depressed or funnel-shaped, but is -imply an orifice in the level bladder floor.
In the normal bladder, as the individual stands erect, the urethral orifice is
usually at the lowest point of the bladder, though sometimes a -light depres-
522
THE URINARY BLADDER
sion exists in front of it before the bladder wall rises behind the symphysis.
Thus, small stones coming down from the kidney are often readily evacuated
during urination, while larger ones may occlude the orifice. In an anatomical
sense the bladder possesses no neck. The so-called collum vesica? does not
exist, though the term is still occasionally used to indicate either the prostatic
urethra or the trigonum.
Ultzmann considered that, physiologically, the prostatic urethra was a part of
the bladder. From a practical point of view his ideas upon this subject were
important. I therefore insert a quotation embodying his ideas upon this point :
When urgency is caused by considerable distention of the bladder the weak
sphincter internus, consisting of organic muscular fibers, is overcome by the de-
trusors of the bladder and the urine forces its way into the pars prostatica. At
that moment the pars prostatica and the bladder form one common cavity and
the existence of a neck of the bladder is distinctly shown. At the moment of
greatest urgency it is onty the sphincter externus, consisting of transversely striped
muscular fibers and under control of the will, that resists the outward course of the
urine. On voluntary relaxation of these muscles the urine immediately rushes
forth in a powerful stream. But the intimate connection between the prostatic
part of the urethra and the bladder is still more strongly attested by the patho-
logical conditions of the prostate. In nearl} T all diseases of the latter, vesical
symptoms with urgency are present and in a large number of diseases of the bladder
the etiological factor may be traced to a simultaneous affection of the prostate,
so that in many cases a successful local treatment of the disease of the bladder can
be carried out only by subjecting the pars prostatica to a simultaneous energetic
local treatment. The weak sphincter internus offers but slight resistance and loses
its power at the least affection of the prostate. These facts alone indicate suf-
ficiently that the term " neck of the bladder," even if not strictly in accordance
with anatomical facts, is for the physician and surgeon an eminently practical
appellation.
Ductus defer. Ureter y.
The so-called Fovea retroureterica.
Fovea reirotrigonaJis, Bas fond of the
bladder — i. e., a depression of the blad-
der behind the interureteric line — is al-
ways a pathological development. (See
Retroprostatic Pouch, under Vesical
Calculus and Prostatic Hypertrophy. )
Shape and Position of the Bladder. —
The shape and also the position of the
bladder change according to the quan-
tity of fluid it contains. An empty and
contracted bladder has a sagittal and
transverse diameter of 5 to 6 cm. ; a
vertical diameter of 3 cm. On median section the shape of the empty bladder
is triangular ; both the outer wall and the cavity of the organ conform to this
Teste, tern
Vesic. urin.
Prostata
Fig. 135. — Empty Bladder in Profile. (After
Dixon.) * Line of reflection of the peritoneum.
TOPOGRAPHICAL ANATOMY OF THE BLADDER
523
Bhape. The form of the bladder, viewed as a whole, is a tetrahedron. Ai the
four angles are placed, above and in front, the median umbilical ligament,
urachus; on either side, the ureters; below and in front, the urethral orifice.
Ficj. 130. — Mkihan Skc-iion ok tmi: Boi>y, SHOWING tiik SHAPE of tmk Bi.AnnF.n DuJUNQ BLIGHT
Distention. (After Mcrkel.)
The borders of the tetrahedron arc rounded, and, viewed from the side, the
Madder is somewhat pear-shaped (sec Fig. L35). At any rate, the bladder
cannot be described as globular when empty; on the contrary, it is flattened,
and has a superior surface, from the anterior border of which the obliterated
iiraclms ascends. The interior of the Madder has a similar shape to the ex-
terior i. c, it possesses angles. The two lateral angles on either side of the
ureteric orifices ( Recessus Laterales, Luschka), are especially pronounced. They
also explain why it is that in the empty bladder an instrument may be moved
laterally with some freedom (Delbet-Guyon).
When Madder and rectum are both empty, the former lies at the bottom
524 THE UEIXAEY BLADDEE
of the pelvis. When the rectum is distended the bladder is raised, so that
its vertex reaches to, or nearly to, the upper border of the symphysis. When
the bladder begins to distend, the rectum being empty, the distention begins
in the posterior part of the bladder ; the anterior wall remains practically
A-
Fig. 137. — Median Sectiox Through the Male Pelvis. The bladder distended, the rectum empty.
A. Prevesical space (space of Retzius). (After Merkel.)
quiescent ; the lateral recesses also distend, and the transverse diameter reaches
its maximum during the process first, normally 12 cm. (4f in.).
The organ, during moderate distention, is still flattened on its upper sur-
face, and is, on median section, almost wedge-shaped. When further distended,
the anterior wall begins to stretch. The entire bladder rounds itself more and
more ; the vertex rises above the symphysis. The greatest distention, however,
continues to occur in the posterior part ; the anterior wall remains shorter, so
that the median ligament (urachus) does not pass from the summit of the
distended bladder, but from a point on its anterior surface. The trigonum
takes but little part in the distention unless it be extreme, when its transverse
diameter is increased. The lateral distention is limited by the bony and mus-
cular walls of the pelvis, and in extreme distention the bladder must increase
in size chiefly in an upward direction. The shape of the greatly distended
bladder is also considerably modified by the rectum, and its degree of disten-
tion, as well as by the pressure of the overlying intestines. When the rectum
i- emptjj the floor of the bladder descends somewhat, and both anterior and
TOPOGRAPHICAL ANATOMY OF THE BLADDER
.»_'.»
posterior portions may expand considerably in an anterior and posterior direc-
tion, aa well as laterally, -<> thai the bladder may rise only moderately, and
still retain ;i flattened though 3omewha1 globular shape. If, however, the
rectum is distended, the pelvic space is limited, and the bladder musl rise into
the abdominal cavity. The form "I the bladder changes from an ovoid with
it- long ;i\i- horizontal into ;i similar figure with it- long axie more or less
vert ical.
The greatly distended bladder does not exactly conform to the shape it
would have were it permitted t<» expand freely in nil directions, it- shape
being determined to ;i great extent liv the resistance, or wanl of resistance, of
Burrounding structures, and especially by the weighl of the intestines, which
tend to crowd it downward, so thai it i- molded, so i" -peak, into the shape
of the pelvic cavity, its vertex being flattened by the same force. When the
Fio. 138. — Median Section <>f the Pelvis. The rectum is empty. TUo bladder is partly filled and
appears Battened on account of the weighl <>f the intestines. (Merkel, after Symington.)
bladder is removed from the body, or even when the abdomen is opened, the
pressure being relieved, the flattened appearance seen in frozen section- dis-
appears, and the vertex heeonies rounded. The position of the bladder is. as
stated, greatly modified by the condition of the rectum. When the rectum
is empty, very considerable distention of the Madder is necessary before it
526
THE URINARY BLADDER
appears above the pubes. When the rectum is distended, on the other hand,
the bladder and the anterior peritoneal fold rise above the pubes, so that the
bladder is readily accessible without encountering peritoneum.
Peterson's bag, or colpeurynter, was formerly much used in the operation
of suprapubic cystotomy, and depended upon these facts for its efficacy. It
is, I believe, scarcely used
at present. A moderate dis-
tention of the bladder with
water, and a little care, ren-
der it quite easy to expose
the bladder above the pubes
without wounding the peri-
toneum. When the space of
Retzius is opened, the fat
and the peritoneal fold are
easily pushed upward with
the finger and held out of
the way with a blunt re-
tractor, if necessary, while
the operation is conducted
upon the bladder.
The bladder may be
freed from peritoneum in
this way, 6 cm. in an an-
teroposterior direction.
In some cases the peri-
toneal fold is adherent to
the symphysis, but the at-
tachment is not firm, and is
easily separated.
The approach to the
bladder by the suprapubic
route is, for obvious reasons, rendered easier by placing the patient in the
Trendelenburg posture.
Fehleisen found the following relations between the peritoneal fold and the
symphysis, under different conditions of distention of the bladder and rectum. 1
Fig. 139. — Median Section Through the Pelvis. Bladder
greatly distended showing the high point to which the peri-
toneal reflection is raised. (Merkel, after Rudinger.)
Bladder.
Rectum.
Peritoneal fold above symphysis.
300 c.c.
200 c.c.
630 c.c.
420 c.c.
Empty.
480 c.c.
Empty.
500 c.c.
0.5 cm.
4.0 cm.
2.0 cm.
8.5 cm.
1 Fehleisen, Archiv fur klin. Chirurgie, vol. xxxii, S. 563, 1885.
TOPOGRAPHICAL anatomy OF THE BLADDEB 527
Capacity of the Bladder, h i- hard i" fix any definite limit on the capacity
of the Qormal bladder; it varies widely among different individuals, and in
the same individual at differenl t imes.
Babil and environment exercise an important influence. An individual
who lives so that he may empty his bladder at any moment will naturally <l"
so iit tin- firsl inclination. Another, Living under other conditions, where he
must often postpone tin- act in -pile of desire, will acquire a more capacious
bladder. Nervous influences have also an important bearing; every one knows
that at certain times h<- mii-i urinate frequently, while at other- his bladder
hears a much greater distention without discomfort. The degree of disten-
tion causing desire t<» urinate varies, a< 'ding to Duchastelet, between L25
and 250 c.c. Testut considers the maximum physiological distention 300
to ;>()0 e.o. Delbet considers 350 C.C. the normal limit. (1. S. Huntington
informs me that the normal limit of distention is ahoiit :;.",<) c.C. ; extreme
normal distention might reach 500 c.c
Such a bladder measures 14 cm. vertically, or through its long axis, 1 1
cm. horizontally from side to side, and 10 cm. antero-posteriorly. In cases of
retention of urine, the Madder may become enormously distended, so that
it reaches to the umbilicus or above, or may even till the greater part of the
abdomen and cause dyspnea, even edema of the legs from pressure on the
vein-. One hundred ounces or more may he withdrawn through a catheter
under such circumstances.
For surgical purposes, cystoscopy or cystotomy, 100 to 125 c.c. is an
abundant quantity to introduce into the bladder. In cases of chronic inter-
stitial cystitis (atrojihied bladder) the capacity of the bladder may he reduced
to a few drachms.
Relations of the Bladder. — Relations with the Peritoneum. — We have
already spoken of the changes in the relations between the bladder, peritoneum,
and abdominal wall, when the bladder and rectum are empty or distended,
respectively. The peritoneum covers the entire superior surface, and the lat-
eral surfaces, down to the line of the obliterated hypogastric artery, or a line
extending from the urachus to a point somewhat below the summit of the
seminal vesicles; and the upper part of the posterior surface to the bottom
of the rectovesical pouch. This pouch is usually filled with coils of small
intestine separating the bladder and rectum. Here peritoneum reaches to a