Account of the Muscles of the Ureters; and their effects in the irritable states of the Bladder, by CHARLES BELL, Esq. F. R. S. Ed. Teacher of Anatomy in Great Windmill street. [From the Medico-Chirurgical Transactions, for 1812.] I AM about to describe a set of muscles which seem not to have been observed by former anatomists. They are attached to the orifices of the ureters, and are seated in the bladder. In health they are the instruments of a very peculiar organic action, and in disease the cause of most distressing complaints. Before I proceed to describe the anatomy of this part of the bladder, the subject seems to require, that I should give a short historical review of the opinions repecting it. Of the parts hitherto described as seated at the neck of the bladder-La trigone de la vessie-La Luette-Uvula Vesica -Corpora carnosa Morgagni.-Third lobe of the prostate, &c. &c. In the plates of De Graaff there are represented certain folds extending forward from the orifices of the ureters, where they terminate in the cavity of the bladder; and at the lower part of the orifice of the bladder, there is a tubercle faintly indicated. The same appearance is represented by Bidloo. In Santorini also the natural appearance of these parts is accurately delineated. Morgagni expresses himself to this purpose: "at the points where the ureters terminate in the bladder, there arises from each of them a thick round compact fleshy body, which takes a direction towards the orifice of the bladder. These two bodies having proceeded a little way, are united, and proceed forward, terminating in the caput gallinaceum.*" * See Morgagni Adversaria I. n. 9. Adversaria III. Animadver. XLII. Santorini gives the same description of these parts as Morgagni has delivered. Lieutaud describes these bodies under the term la trigone de la vessie. The learned Portal is incorrect in saying that Lieutaud was the first anatomist who has given their description. Portal has thus described the trigone: at the lower part, the internal tunic of the bladder adheres to a triangular body of a cartilaginous hardness, and this body is always prominent in the cavity of the bladder, especially in old men. He proceeds to say, that, at the extremity of the triangle, backwards, the orifices of the ureters open; and at their anterior extremity, there is an eminence slightly protuberant, to which Lieutaud has given the name of luette. This account leads me again to refer to the plate of the excellent anatomist Dominico Santorini. In his second table the luette and trigone are accurately represented. He has the following explanation on the letter I. "Vesicæ urinæ osculum cui prominulum corpus præfigitur; quod in affectis vesicæ sic prominet aliquando ut urinæ iter prorsus intercludat." This refers to the disease with which Mr. Hunter and Mr. Home have made us familiar. The expression of Santorini recalls us again to the remark of Portal: he says, "I have found in old men who have suffered retention of urine, the trigone de la vessie so enlarged, especially its tubercle, in the form of an uvula (luette) that the orifice of the bladder was shut by itf." Sabatier follows his countryman in his description of this part of the bladder, but adds; "the trigone and luette are the most sensible parts of the bladder; which is the cause why a stone lodging here produces extreme irritation, while if it lodges in any other part of the cavity of the bladder, it causes little inconvenience:" he adds, "the uvula (luette,) which terminates the anterior angle is very subject to swell, and then In the Observationes anatomicæ, cap. x. sec. xxi. † Portal, Cours d'Anatomie Med. T. v. p. 409. it rises in the form of a round tumour which fills the neck of the bladder, and opposes itself to the flow of urine."* Desault, speaking of the tumours which grow in the bladder, has this expression. "Le sommet de ce viscère n'en est pas plus exempt, que son basfond; mais ce sont particulièrement ceux qui croissent près de son col, et que quelques auteurs ont pris pour un gonflement de la luette vesicale, qui occasionnent la retention d'urine." This sentence, which betrays the imperfect knowledge which Desault had of the disease, is followed by other unequivocal marks of unconfirmed principles and practice: and the whole chapter stands in remarkable contrast with the publication of Mr. Home, in this country. In Haller's Element. Physiolog.t we have a description following that of Morgagni under the title colliculi ab uteribus in urethram producti. These authorities discussed, we come now to the more modern observation of Mr. Hunter. Mr. Hunter has described a small portion of the prostate gland which lies behind the very beginning of the urethra; and this he describes as subject to swell out like a point into the cavity of the bladder, where it acts like a valve on the mouth of the urethra. This can be seen even when the swelling is not considerable, by looking upon the mouth of the urethra from the cavity of the bladder. It is impossible to mistake this; the swelling he describes is the uvula vesica or luette of Lieutaud. The observations of Mr. Hunter, then, go to inform us, that this tumour is of that part of the prostate gland which is below the urethra, and betwixt the lateral portions of the gland. This discovery carries us back to the great anatomists in whose works we find the elements of all our present knowledge. Morgagni has very fully described the part of the * See also Lieutaud, Hist. Anatomic, medica, tumores vesicæ adnati. + P. 170. †T. v. p. 328. prostate gland which Mr. Hunter mentions, and which he discovered to be the seat of this dangerous malady. Morgagni thus describes it: "Quod si vera ulla propago prostatæ addenda est, ea certe est subrotunda et renitens quasi glandula, quam cum sœpe diligentissimus incisor noster in publicis dissectionibus animadvertisset inter vesicam, et seminales capsulas qua sese mutuo hæ jam contingunt, prominentem et nonnunquam ad angulum conveniendo, efficiunt, prostantem nos accurato instituto examine nihil aliud esse comperimus quam corporis ipsius prostatæ particulam."* In addition to the description of Morgagni we have the authority of Sabatier. "Sometimes," says he, "only that part of the prostate is diseased to which they have given the name of luette vesicale. I have seen several occasions (he continues) in which the uvula forms a tumour with a narrow peduncle: this, moving with a stream of urine, closed the opening of the bladder." Anatomy of the Neck of the Bladder. I have now to lay before the society the anatomy of the neck of the bladder in man. On dissecting up the inner coat of the bladder, there are seen two strong fleshy columns, which descend from the orifices of the ureters towards the orifice of the bladder: they unite and run towards the prostate gland. On the surface, towards the cavity of the bladder, they are denser by the union of the inner coat of the bladder, but they are fibrous, and this fibrous structure is made manifest by dissection from below. They are larger and firmer, but of the same colour and structure with the fleshy columns of the detrusor urina. The variety which we find in their length according with the degree of contraction of the bladder, proves their muscularity. *Morgagni, adversaria anat. IV. animad. XV. Whatever excites the action of the bladder increases the size of these muscles in a remarkable degree, and they always acquire a great increase of power and size when the muscular coat of the bladder becomes more distinct and powerful. In some of my specimens of diseased bladder, I find the cause of this to be stone in the bladder; in others, an ulcer; in many, stricture; but always irritation and the necessity of continual action of the bladder are attended with an enlargement of the muscles of the ureters. When contracted, the course of these columns is distinguishable all the way from the mouths of the ureters to the beginning of the urethra; and there, at their union, they heave up the inner coat of the bladder, producing the appearance of a tubercle at the lower part of the orifice of the bladder.* It is still the form of the inner coat which makes these fleshy columns appear to terminate forward in the caput gallinaceum; which they do not; they only take a firmer insertion. Where these columns unite they are most fleshy, and their fibres are more intricate; then, directing their course towards the lower and backmost part of the prostate, they degenerate into tendon, and are inserted into the portion called the third lobe of the prostate. Although I have described the course of these muscles as proceeding from the back part forward, because it better corresponds with the first view we have of them, yet, I believe it is more correct to consider their connection with the prostate gland as the fixed point, and their connexion with the extremities of the ureters as their insertion. Use. The use of these muscles is, to assist in the contraction of the bladder, and at the same time to close and support the mouths of the ureters. The surface of the bladder where it covers their union on the inside, is endowed with an ex • It is this appearance, presented by the muscles in a state of contraction, which has led so many of our best authorities to confound it with the dis. ease of the third lobe of the prostate gland. |