392 SURGICAL APPLIED ANATOMY. [Chap. xvm. 



should be remembered that the bladder lies at a depth 

 of from two and a half to three inches from the sur- 

 face when the body is in lithotomy position. 



Suprapubic lithotomy. This operation has 

 been revived of late years, and is especially advised 

 in cases of large stones, and in male children, if 

 lithotrity is contra-indicated, to avoid the large wound 

 in the prostatic region. In order to bring the summit 

 of the bladder well above the symphysis, both bladder 

 and rectum are dilated. Into the former viscus, tepid 

 water or boracic lotion is injected. It is found that 

 in the adult eight to ten ounces is sufficient to ensure 

 the desired distension. The rectum is dilated by 

 means of a soft rubber bag. The gut, when thus dis- 

 tended, pushes forward the bladder, and gives it a 

 firm basis upon which to rest. In the adult from ten 

 to fourteen ounces are usually introduced into the bag. 

 Without the rectal bag the bladder, distended by in 

 jection, would sink down towards the pelvic floor 

 Distension of the rectum alone will elevate the bladder, 

 but it will usually have no effect upon the reflectioi/ 

 of peritoneum. In operating upon children the rectal 

 bag is very seldom required. In the case of a male 

 child, aged five, the injection of three ounces of 

 water into the bladder caused the reflection of perito 

 neum to mount more that one inch above the sym- 

 physis. An incision, some three inches in length, is 

 made immediately above the symphysis in the median 

 line. The bladder is exposed below the peritoneum, 

 is drawn forwards by a hook, and opened. 



The bladder. When empty the bladder is 

 flattened and of triangular outline, and lies against 

 the anterior wall of the pelvis. The empty bladder 

 may be found in one of two conditions (as demon- 

 strated by Dr. Hart in the adult female bladder). It 

 may be small, oval, and firm, with its upper wall 

 convex towards the abdomen. In vertical antero- 



