THE BLADDER. 1901 



the bladder-wall, it can be understood that incision of the mucosa over the intra- 

 parietal part of the ureter, for the purpose of extracting a calculus, involves little 

 risk of pelvic cellulitis from extravasation of urine. It cannot be said that there is 

 no risk, as in one case a peritoneal fistula and death resulted (Thornton). 



Operations upon the ureter are frequent for the extraction of a calculus (uretero- 

 lithotomy) ; or the extirpation (ureterectomy) of an infected ureter (tuberculous or 

 pyogenic) either at the same time with its kidney (nephro-ureterectomy) or at a later 

 period; or for the closure of wounds or fistulae, or the relief of stricture, or the 

 implantation of the distal end of the ureter after removal of a diseased, injured, or 

 obliterated portion into the bladder, rectum, or elsewhere. 



The anatomical factors relating to these operations cannot here be described, 

 but it may be said generally that whenever it is possible the extraperitoneal route is 

 selected to lessen the danger of peritonitis, and that the oblique lumbar incision 

 employed to reach the kidney (page 1893) will, if prolonged downward and forward 

 parallel to Poupart's ligament and to the outer edge of the rectus, give access to 

 the whole abdominal ureter and to the upper part of its pelvic portion. Cabot has 

 shown that the ureter is bound to the external or under surface of the peritoneum 

 by fibrous bands, and that when that membrane is stripped up from the posterior 

 abdominal wall the ureter accompanies it. He found that the relation of the ureter 

 to that part of the peritoneum which becomes adherent to the spine is, within a slight 

 range of variation, fairly constant, the ureter lying just outside the line of adhesion. 

 Hence, if the surgeon has stripped up the peritoneum and has come down to that 

 point where it refuses to separate readily from the spinal column, he will find the 

 ureter upon the stripped-up peritoneum at a short distance outside of this point. 

 On the left side the distance from the adherent point to the ureter is from one-half 

 an inch to an inch, while on the right side it is somewhat greater, owing to the 

 ureter being displaced to the outside by the interposition of the vena cava between 

 it and the spine. It should be remembered that the peritoneum adherent to the 

 abdominal portion of the ureter is very thin and may be torn in an attempt to 

 separate it. 



After the ureter dips down into the true pelvis it is less easily located because 

 it has no fixed relation to a bony landmark. Cabot has suggested that osteoplastic 

 resection of the sacrum would give access to this lower pelvic portion of the ureter. 

 In women it can often be reached through the vagina. The ureter is, of course, 

 accessible transperitoneally through its whole route. 



THE BLADDER. 



The bladder (vesica urinaria) the reservoir in which the urine is received from 

 the renal ducts and retained until discharged through the urethra is a muscular sac, 

 lined with mucous membrane, situated in the anterior part of the pelvic cavity imme- 

 diately behind the symphysis pubis. Its form and size, and likewise to a considerable 

 extent its relations, vary with the degree of distention, so that in describing the 

 organ the condition of expansion must be taken into account. When containing little 

 fluid and hardened in situ, the general shape of the bladder is pyriform, presenting a 

 free, slightly convex superior surface, covered with peritoneum and projecting into 

 the pelvic cavity, and a distinctly convex non-peritoneal inferior surface, attached 

 by areolar tissue to the pubic symphysis and the pelvic floor upon which it rests. 

 The urethra, surrounded by the prostate, emerges from the most dependent portion 

 of the lower surface, behind which point the latter ascends to join the upper surface 

 along the indistinct posterior border. The part of the bladder between the urethra 

 and the posterior border constitutes the fundus or base (fundus vesicae), which in the 

 male is in relation with the seminal ducts and vesicles and the recto-vesical pouch 

 and is directed towards the rectum, and in the female is attached to the anterior 

 vaginal wall. In the empty organ the superior and inferior surfaces blend along the 

 sides in the convex lateral borders ; anteriorly these meet at the apex or summit (vertex 

 vesicae), from which a median fibrous band (ligamentum umbilicale medium) that rep- 

 resents the urachus the obliterated segment of the intra-embryonic part of the allan- 

 tois extends to the umbilicus along the abdominal wall. The body (corpus vesicae) 



