1004 THE URINARY ORGANS. 



Projecting from the lower and anterior part of the bladder, and reaching to the 

 orifice of the urethra, is a slight elevation of mucous membrane, called the uvula 

 vesicce. It is formed by a thickening of the submucous tissue. 



The arteries supplying the bladder are the superior, middle, and inferior vesi- 

 cal in the male, with additional branches from the uterine and vaginal in the 

 female. They are all derived from the anterior trunk of the internal iliac. The 

 obturator and sciatic arteries also supply small visceral branches to the bladder. 



The veins form a complicated plexus round the neck, sides, and base of the 

 bladder, and terminate in the internal iliac vein. 



The lymphatics form two plexuses, one in the muscular and another in the sub- 

 mucous coat ; they are most numerous in the neighborhood of the trigone. They 

 accompany the blood-vessels, and ultimately terminate in the internal iliac glands. 



The nerves are derived from the pelvic plexus of the sympathetic and from the 

 third and the fourth sacral nerves ; the former supplying the upper part of the 

 organ, the latter its base and neck. According to F. Darwin, the sympathetic 

 fibres have ganglia connected with them, which send branches to the vessels and 

 muscular coat. 



Surface Form. The surface form of the bladder varies with its degree of distention and 

 under other circumstances. In the young child it is represented by a conical figure, the apex 

 of which, even when the viscus is empty, is situated in the hypogastric 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 situ- 

 ated in the pelvis ; the neck, in the male, corresponding to a line drawn horizontally backward 

 through the symphysis a little below its middle. As the bladder becomes distended, it gradually 

 rises out of the pelvis into the abdomen, and forms a swelling in the hypogastric region which is 

 perceptible to the hand as well as to percussion. In extreme distention it reaches into the um- 

 bilical region. Under these circumstances the lower part of its anterior surface, for a distance 

 of about two inches above the symphysis pubis, 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 syniphysis pubis, 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. Advantage is taken of this by some surgeons 

 in performing the operation of suprapubic cystotomy. The rectum is distended by an India- 

 rubber bag, 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 incision three inches long may be made in the linea alba, from 

 the symphysis pubis upward, without any great risk of wounding the peritoneum. Other sur- 

 geons object to the employment of this bag, as its use is not unattended with risk, and because 

 it causes pressure on the prostatic sinuses and 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 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 bladder may here be punctured 1'rom the rectum, in 

 the middle line, without risk of wounding the serous membrane. 



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 abdomi- 

 nal 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 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 epispadias. The pelvic bones are also arrested 

 in development (see page 183). 



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 anterp-inferior surface alone is, however, very rare. Until recently intraperi- 

 toneal rupture was uniformly fatal, but now abdominal section and suturing the rent with Lem- 

 bert's suture are resorted to, with a very considerable amount of success. The sutures are inserted 

 only through the peritoneal and muscular coats in such a way as to brine; the serous surfaces at 

 the margins of the wound into apposition, and one is 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 



