44 6 APPLIED ANATOMY. 



the extremities of the seminal vesicles and 2.5 to 4 cm. (i to i% in.) above the 

 posterior border of the prostate. 



As held by Greig Smith, the main factor in raising the peritoneum from the 

 front of the bladder above the upper edge of the symphysis is its distention, and 450 

 to 600 c.c. (15 to 20 oz. ) will raise the fold 2.5 to 5 cm. (i to 2 in.). 



When the body is placed in the Trendelenburg posture the contents of the 

 bladder gravitate toward the diaphragm, and therefore push the peritoneum up 

 or away from the upper border of the symphysis : hence this position is usually 

 employed when the bladder is to be opened for operative purposes. The use of a 

 rubber bag in the rectum distended with water has been found to raise the peri- 

 toneal folds so little that its use has been abandoned in favor of the Trendelenburg 

 posture. 



Posteriorly the rectovesical pouch is approximately 8.75 cm. (3% in.) from 

 the anus, but it may be as little as 7.5 cm. (3 in.), or as much as 10 cm. (4 in.). 

 As has already been stated the attachment of the rectovesical pouch to the rectum 

 is so firm that whether the bladder is distended or collapsed its distance from the 

 prostate is but little altered. It does not change its position markedly as does the 

 peritoneum above the pubes. Waldeyer (Joessel and Waldeyer, Topog. Chirurg. 

 Anat., vol. ii, p. 554) gives 1.5 to 2 cm. (f to 4 in.) as the greatest possible 

 variation. 



Tapping the distended bladder is done above the pubes, and care is to be taken 

 to avoid wounding the peritoneum ; this is to be done by knowing how its position 



.x/Postprostatic pouch or bas-fond 

 s* Interureteric fold or ligament 



Ureteric fold 

 -Orifice of ureter 



"Orifice of the urethra 



FIG. 452. View of the interior of the base of the bladder. 



is influenced as just detailed above. In front of the anterior bladder wall and between 

 it and the posterior surface of the symphysis and transversalis fascia is the space of 

 Retzius, filled with loose connective tissue. Care is to be taken not to infect it 

 in operative procedures. It readily becomes infiltrated in extravasation of urine. 



Rupture of the bladder occurs most often through the peritoneum of its posterior 

 surface when the bladder is distended. Extraperitoneal ruptures may occur when it 

 is empty, and are usually the result of wounds by foreign bodies or spicules of bone 

 in fractures. 



Base of the Bladder. On the interior of the base of the bladder the ureters 

 open about 2. 5 cm. ( i in. ) posterior to the urethral orifice, and the same distance 

 (or more if the bladder is distended) from each other. The included triangular 

 space is called the trigone. Its mucous membrane is without the rugae possessed by 

 the rest of the bladder and, if it is distended, is not quite so pale in color. The 

 ureters pass obliquely through the walls a distance of 1.25 cm. (^ in.) and cause 

 slight elevations of the mucous membrane called the plica uretericce or ureteric folds. 

 Joining the two ureteral orifices is a fold of mucous membrane called by Kelly the 

 interiireteric ligament. The part immediately posterior to this fold is the postprostatic 

 pouch or bas-fond. It becomes enlarged in prostatics, and then contains residual 

 urine. Calculi also tend to lodge there (Fig. 452). 



Bladder Walls. The bladder is composed of a muscular wall covered exter- 

 nally by the peritoneum and internally by the submucous and mucous coats. In the 

 undistended bladder blood-vessels can be seen in the mucous membrane, which is 



