THE BLADDER. 



1145 



Cowpefs Gtand.< 



Orifices of ducts 

 of Cowper's Glands 



of which, even when the viscus is empty, is situated in the hypogastrie region, about an inch 

 above the level of the symphysis pubis. In the adult, when the bladder is empty, its apex does 

 not reach above the level of the upper border of the 

 symphysis pubis, and the whole organ is situated in 

 the pelvis ; the neck, in the mule, corresponding to a 

 line drawn horizontally backward through the s5 T mphysis 

 a little below its middle. As the bladder becomes dis- 

 tended it gradually rises out of the pelvis into the 

 abdomen, ^ind forms a swelling in the hypogastric 

 region which is perceptible to the hand as well as to 

 percussion. In extreme distension it reaches into the 

 umbilical region. Under these circumstances it is 

 closely applied to the abdominal wall, without the 

 intervention of peritoneum. so that it can be tapped by 

 an opening in the middle line just above the pubes 

 without any fear of wounding the serous membrane. 

 When the rectum is distended the prostatic portion of 

 the urethra is elongated and the bladder lifted out of 

 the pelvis and the peritoneum pushed upward. Ad- 

 vantage is taken of this in performing the operation of 

 suprapubic cystotomy. The rectum is distended by an 

 india-rubber hair, which is introduced into this cavity 

 empty, and then filled with ten or twelve ounces of 

 water. If now the bladder is injected with about half 

 a pint of some antiseptic fluid, it will appear above the 

 pubes. plainly perceptible to the sight and touch. The 

 peritoneum will be pushed out of the way. and an in- 

 cision three inches long may be made in the linea alba 

 from the symphysis pubis upward without any great 

 risk of wounding the peritoneum. 



\Vhen distended the bladder can be felt in the 

 male, from the rectum, behind the prostate, and fluc- 

 tuation can be perceived by a bimanual examination, 

 one finger being introduced into the rectum and the 

 distended bladder tapped on the front of the abdomen 

 with the finger of the other hand. This portion of the 

 bladder that is. the portion felt in the rectum by the 

 finger is also uncovered by peritoneum, and the blad- 

 der may here be punctured from the rectum, in the 

 middle line, without risk of wounding the serous mem- 

 brane. 



Surgical Anatomy. A defect of development in 

 which the bladder is implicated is known under the 

 name of extroversion of the bladder. In this condition 

 the lower part of the abdominal wall and the anterior 

 wall of the bladder are wanting, so that the posterior 

 surface of the bladder presents on the abdominal sur- 

 face, and is pushed forward by the pressure of the vis- 

 cera within the abdomen, forming a red vascular tumor 

 on which the openings of the ureters are visible. The 

 penis, except the glans, is rudimentary and is cleft on its dorsal surface, exposing the floor of 

 the urethra a condition known as qpixpadiax. The pelvic bones are also arrested in develop- 

 ment (see page 283). 



The bladder may be ruptured by violence applied to the abdominal wall, when the viscus 

 is distended without any injury to the bony pelvis, or it may be torn in cases of fracture of the 

 pelvis. The rupture may be either intraperitoneal or extraperitoneal that is, may implicate the 

 superior surface of the bladder in the former case, or one of the other surfaces in the latter. 

 Rupture of the anterior surface alone is. however, very rare. Until recently intraperitoneal 

 rupture was uniformly fatal, but now abdominal section and suturing the rent with Lembert's 

 suture is resorted to. with a very considerable amount of success. The sutures are inserted only 

 throusrh the peritoneal and muscular coats in such a way as to bring the serous surfaces at the 

 inaririns of the wound into apposition, and orte is inserted just beyond the end of the wound. 

 The bladder should be tested as to whether it is water-tight before closing the external wound. 



The muscular coat of the bladder undergoes hypertrophy in cases in which there is any 

 obstruction to the flow of urine. Under these circumstances the bundles of which the muscular 

 coat consists become much increased in size. and. interlacing in all directions, give rise to what 

 is known as the fasciculated bladder. Between these bundles of muscular fibres the mucous mem- 

 brane may buk r e out. forming sacculi. constituting the sacculated bladder, and in these little 

 pouches phosphatic secretions may collect, forming encysted calculi. The mucous membrane is 

 very loose and lax. except over the trigone. to allow of the distension of the viscus. 



Various forms of tumor have been found springing from the wall of the bladder. The 



Meatut. 



FIG. 735. The bladder and urethra laid 

 open. Seen from above. 



