J368 THE URINOGENITAL ORGANS 



surgeons object to the employment of this bag, as its use is not unattended with risk, since it causes 

 pressure on the prostatic veins and hence produces congestion of the vessels over the bladder 

 and a good deal of venous hemorrhage. 



When distended, the bladder can be felt in the male, from the rectum, behind the prostate, 

 and fluctuation can be perceived by a bimanual examination, one finger being introduced into the 

 rectum and the distended bladder being 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 uncovered by peritoneum. 



Applied Anatomy. A certain 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 surface, and is pushed forward by the pressure of the 

 viscera within the abdomen, forming a red, vascular protrusion, on which the openings of the 

 ureters are visible. The penis, except the glans, is rudimentary, and is cleft on its dorsal sur- 

 face, exposing the floor of the urethra a condition known as epispadias. The pelvic bones 

 are also arrested in development (see p. 220). 



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

 distended without injury to the bony pelvis, or it may be torn in case 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 antero-inferior surface alone is, however, very rare. Until recently intraperitoneal rupture 

 was uniformly fatal, but now abdominal section and suturing the rent with Lembert sutures 

 often saves the patient. The sutures are inserted only through the peritoneal and muscular 

 coats in such a way as to bring the serous surfaces at the margin of the wound into apposition, 

 and one is also inserted just beyond each end of the wound. The bladder should be tested as to 

 whether it is water-tight before closing the external incision. 



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

 sistent 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 ail directions, give rise 

 to what is known as the fasciculated bladder. Between these bundles of muscle fibres the mucous 

 membrane may bulge out, forming sacculi, constituting the sacculated bladder, and in these little 

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

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



Various forms of tumors have been found springing from the wall of the bladder. The inno- 

 cent tumors are the papilloma and the mucous polypus, arising from the mucous membrane; the 

 fibrous tumor, from the deep mucous tissue; and the myoma, originating in the muscle tissue; 

 and, very rarely, dermoid tumors, the exact origin of which it is difficult to explain. Of the 

 malignant tumors, epitheliomata are the most common, but sarcomata are occasionally found in 

 the bladders of children. 



Puncture of the bladder is performed above the pubes without wounding the peritoneum. 

 Suprapubic cystotomy is considered above under the heading of Surface Form. This operation 

 may be employed to permit of the removal of a calculus, and is then called suprapubic lithotomy. 



THE MALE URETHRA (URETHRA VIRILIS) (Figs. 1119, 1120). 



The urethra in the male extends from the neck of the bladder at the internal 

 orifice of the urethra (orificium urethrae internum) to the meatus urinarius, the 

 external orifice of the urethra (orificium urethrae externum), at the end of the penis. 

 The internal orifice has been described (p. 1365). The urethra presents a double 

 curve in the flaccid state of the penis (Fig. 1111), but in the erect state of this 

 organ it forms only a single curve, the concavity of which is directed upward. 

 It presents three important constrictions (1) at the beginning, (2) in the mem- 

 bran OILS .portion, (3) at the end. Its length varies from seven to eight incheT 

 (17 to 20 cm.); and it is divided into three portions, the prostatic, membranous, 

 and spongy, the structure and relations of which are essentially different. Except 

 during the passage of the urine or semen, the urethra is a mere transverse, T-shaped, 

 or crescentic cleft or slit (Fig. 1120), with its upper and under surfaces in contact. 

 At the meatus urinarius the slit is vertical, and in the prostatic portion somewhat 

 arched (Fig. 1120). 



The prostatic portion (pars prostatica) (Figs. 1119 and 1154), the widest and 

 most dilatable part of the canal is about an inch in length. It is between the 



