446 



ABDOMEN 



When the bladder fills it rises into the hypogastric region, 

 and it is important to note that the peritoneal reflection from 

 the apex is raised along with the organ, and, as a result, a 

 considerable area of the bladder wall, below the ligamentum 

 umbilicale medium (urachus), becomes applied directly to the 

 anterior abdominal wall, no peritoneum intervening. Con- 

 sequently, in those cases of retention of urine in which a 

 catheter cannot be passed into the bladder through the 

 urethra, relief can be given, without fear of injuring the 

 peritoneum, by puncturing the bladder, with a trocar and 

 cannula, immediately above the symphysis pubis in the 

 median plane (Figs. 202, 211). 



Laterally, also, the line of peritoneal reflection is raised 

 until it may appear to leave the lateral border of the bladder 

 along the line of the ductus deferens, as the duct passes back- 

 wards along the side wall of the pelvis, or even as high as the 

 level of the umbilical artery. 



Posteriorly, the sacro-genital folds are opened out am 

 obliterated to provide a covering for the expanding basal 

 portion of the bladder, but the level of the reflection of th< 

 peritoneum which forms the bottom of the recto-vesical excava- 

 tion undergoes no change. When the rectum is distended the 

 recto-vesical reflection assumes a higher level, but that is not 

 due to any change in the position of the peritoneum in 

 relation to the bladder, but to the entire bladder, with th< 

 reflection, being pushed upwards and forwards by the ex- 

 panding gut. 



The Urinary Bladder in New -Born Children. In th< 

 new-born infant the bladder differs both in form and in 

 position from the bladder of the adult. It is more or less 

 piriform, the narrow end passing into the urethra, and there 

 is little or no appearance of a basal portion (Fig. 212). 

 Further, it is placed very much higher. The internal urethral 

 orifice is at the level of the upper border of the symphysis 

 pubis, and the antero-lateral surfaces of the organ, devoid of 

 peritoneum, lie in direct contact with the abdominal wall 

 (Symington). As growth goes on the urethral orifice sinks 

 rapidly from the period of birth up to the fourth year, and 

 more slowly from that period up to the beginning of the 

 ninth year. Then it remains stationary till puberty, aftei 

 which it sinks slowly till it attains its normal adult position 

 (Disse). It should be noted also that the recto-vesical re 



