396 SURGICAL APPLIED ANATOMY. [Chap. xvm. 



they enter the bladder, are covered by peritoneum. 

 This recto-vesical pouch of peritoneum in the adult 

 extends to within about three inches of the anus, and 

 does not reach below a line one inch above the base 

 of the prostate. Harrison Cripps gives the distance 

 of the pouch from the anus as 2^ inches when the 

 bladder and rectum are both empty, and as 3i inches 

 when those viscera are distended. (See Bladder in 

 the child, page 400.) 



Puncture of the bladder per rectum. 

 The base of the bladder is adherent to the rectum by 

 dense areolar tissue over a triangular area, the apex 

 of which is formed by the prostate, the sides by the 

 diverging seminal vesicles, and the base by the recto- 

 vesical fold of peritoneum. This triangle is equi- 

 lateral, and in the dissected specimen measures about 

 one and a half inches on all sides. It corresponds to 

 the trigone on the inner surface of the viscus. It is 

 through this triangle, and as near as possible to the 

 prostate, that the bladder is tapped when the opera- 

 tion is performed per rectum. The recto-vesical fold 

 of peritoneum is raised, and is carried still farther 

 from the anus when the organ is distended. 



Rupture of bladder. The bladder may be 

 ruptured by violence applied to the anterior abdo- 

 minal wall apart from pelvic fracture or external 

 evidence of injury. Such a rupture can, however, 

 hardly happen to the empty bladder, which should be 

 full or distended at the time. It is very rare for the 

 rupture to be on the anterior surface only. As a rule, 

 the tear involves the superior or abdominal surface, 

 and implicates the peritoneum. The injury, therefore, 

 is very fatal (five recoveries out of seventy-eight cases). 

 In some cases of vesical rupture the surgeon has 

 opened the abdomen, and has stitched up the rent in 

 the viscus with perfect success. The bladder may be 

 torn by fragments of bone in fractures of the pelvis, 



