chap, xvin.] THE BLADDER. 395 



peritoneum being wounded. As the bladder becomes 

 distended, not only does it rise into the abdomen, but 

 it extends also towards the perineum, diminishing the 

 length of the prostatic and membranous urethra. In 

 suprapubic lithotomy that tendency to extend down- 

 wards is prevented by the rectal bag (page 392). 



Between the anterior surface of the bladder and the 

 symphysis, and shut in by the peritoneum above, is a 

 loose layer of connective tissue. The looseness of 

 this connective tissue permits the bladder to readily 

 alter its dimensions without disturbing the connections 

 of the organ. In injuries to the pelvis and to the 

 front of the bladder a diffuse inflammation may be 

 set up in this tissue and assume serious proportions. 

 I have reported a case where an extensive suppuration 

 in this area followed upon aspiration of the bladder 

 above the pubes, and led to death. Like suppuration 

 has followed suprapubic lithotomy. In rupture of 

 the anterior wall of the viscus the urine escapes into 

 this district of cellular tissue ; a limited suppuration 

 may follow and recovery ensue. 



The bladder, although fairly fixed, has been found 

 in inguinal, femoral, and vaginal hernias. In the erect 

 position its neck (in the male) lies on a horizontal 

 line drawn from before backwards through a point a 

 little below the middle of the symphysis, and is placed 

 about one and a quarter inches (3 cm.) behind that 

 articulation (Tillaux). 



Relations to the peritoneum. The anterior surface 

 is entirely devoid of peritoneum, while the superior 

 surface is entirely covered by that membrane. At the 

 sides there is no peritoneum in front of, or below, the 

 obliterated hypogastric arteries. On the posterior 

 aspect of the bladder the serous membrane extends 

 down as far as a transverse line, uniting the upper 

 parts of the two seminal vesicles, so that the upper 

 ends of the vesicles, as well as the ureters, where 



