448 APPLIED ANATOMY. 



Cystoscopic Examination. The shortness and distensibility of the female 

 urethra make the examination of the interior of the female bladder much easier than 

 that of the male. For purposes of examination it is distended either with air or 

 water. In order to distend it with air it is either injected directly with a rubber bulb 

 or the patient is put in the knee-chest position, or, if on the back, the pelvis is ele- 

 vated, so that the intestines gravitate toward the diaphragm. If a speculum is then 

 introduced and the obturator withdrawn the bladder at once distends. The walls of 

 the bladder are whitish in color with small vessels running over them. The base 

 (trigone) of the bladder is redder than the surrounding walls. The muscular fas- 

 ciculi are often seen as distinct ridges and the mucous membrane may be thrown into 

 folds. The internal orifice of the urethra in the female is just below the lower border 

 of the symphysis. The ureteral orifices can be seen as slightly elevated papillae 2. 5 

 cm. or more behind the urethral orifice and 30 to its side, the trigone, when the 

 bladder is not distended, making an equilateral triangle, with the urethra and ureteral 

 papillae at its angles (Fig. 453). 



Operations. Most of the operations on the bladder are done from above. To 

 relieve distention tapping is done with a fine trocar or aspirating needle. It is to be 

 inserted close to the upper margin of the symphysis and passed downward and back- 



FIG. 453. The picture on the left demonstrates a normal mucous membrane and ureteral orifice. On the 

 right the ureteral orifice will be observed to be small, round, atrophic, and functionless. (Drawn from a case of 

 Dr. Benj. A. Thomas* by Mr. Louis Schmidt.) 



ward. Cystotomy is performed through the median line. In making the incision 

 three layers of fat are divided; first, the superficial fascia between the skin and muscles; 

 second, the fatty pad between the posterior surface of the muscles and the transver- 

 salis fascia; and third, the prevesical fat of the space of Retzius beneath the trans- 

 versalis fascia and between the anterior wall of the bladder and the symphysis pubis. 

 Tumors. Growths and prostatic enlargements are often operated on supra- 

 pubically. These are usually easily within reach of the finger. In incising the blad- 

 der the anterior vesical veins are to be avoided by keeping in the median line. 



THE PROSTATE. 



The normal prostate gland is of the shape of a large chestnut. It is 3 to 4 cm. 

 (i % to I y 2 in. ) wide, 2. 5 to 3 cm. ( i to i ^ in. ) long, and 3 cm. ( i ^ in. ) thick. An 

 indistinct furrow on its under surface separates it into two lateral lobes. There is no 

 median lobe, as the prostatic tissue is continued uninterrupted across the median 

 line. For clinical purposes we may consider the prostate as having an apex, a vesi- 

 cal surface or base, and a rectal or posterior surface. 



The vesical surface is pierced a little anterior to its centre by the urethral open- 

 ing, which leads to the apex. Entering below and posteriorly at the fissure are the 



* Diagnosis of Renal Disease and Sufficiency, Dr. Benjamin A. Thomas, Annals of 

 Surgery, May, 1903. 



