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distended bladder is spherical, or oval, with the larger end directed downand backwards. When the pelvic wall prevents further expansion of this , the outline of the organ may become an oval with the larger end directed s and forwards into the abdominal cavity. The highest part of the disbladder lies at some distance above the pelvic brim, and does not correspond ttachment of the urachus at the apex, but to a point farther back (Fig. 994). superior wall of the bladder is raised up during distension it carries with it itoneum, and thus the reflexion of that membrane, from the anterior hal wall' on to the apex of the bladder, comes to lie one and a half inches, or gher, above the upper margin of the symphysis pubis (Fig. 990). It is, e, possible to puncture, or open into the distended bladder, through the abdominal wall above the symphysis pubis, without at the same time into the peritoneal cavity. In a similar manner the line of reflexion of toneum, from the side wall of the pelvis on to the lateral aspect of the is raised higher during distension, and may come to correspond, in part, to I of the ductus deferens, or to that of the obliterated part of the umbilical On the other hand, the level of the reflexion of the peritoneum from the owards the basal aspect of the bladder does not appear to vary much with nsion, or contraction, of the organ (compare Figs. 989 and 990), and thus the ween the bladder and rectum becomes relatively very deep when the bladder is e bladder in normal distension may contain nearly one pint, but in most cases i is emptied when its contents reach from six to ten ounces. Under abnormal ogical conditions the bladder capacity may be very much increased. ing Relationships, according to the degree of Distension of the Bladder. the bladder is distended the obliterated part of the umbilical artery may vards against its side, but when it is empty the obliterated vessel at its oint often lies as much as one and a quarter inches above the lateral the organ. The ductus deferens, during a part of its course, is in contact lateral wall of the distended bladder, but when the organ is empty it lies 1 parallel to the lateral border, only coming into relationship with the ace of the bladder beyond the point where it crosses the ureter. The side e distended bladder is closely related to the obturator vessels and nerves. or of the Bladder. — The mucous membrane lining the bladder is nnected to the muscular coat, and when the bladder is contracted the ning of the upper wall is thrown into a number of prominent wrinkles Fig. 995). At one place only the mucous membrane is firmly connected bjacent muscular coat, and the inner surface of this part of the bladder ooth and free from wrinkles. This smooth area corresponds to a triirface behind the urethral orifice, called the trigonum vesicæ, and to the ne bladder wall which immediately surrounds the opening. The apex ingle lies at the beginning of the urethra, and the base is formed by a 1 between the openings of the ureters into the bladder. Just behind al opening the bladder wall sometimes bulges slightly into the cavity, che presence of the middle lobe of the prostate, which lies beneath the at in this position. When well marked, as it often is in old people, g is termed the uvula vesicæ. Stretching across between the openings ers there is usually to be seen a smooth ridge, due to the presence of a transversely disposed muscle fibres, which lies within this part of the 11, beneath the mucous membrane. This ridge has been called the ericus.” It may be deficient near the median plane, and it is curved convex forwards. The lateral portions of the ridge which lie outside is of the ureters are called the plicæ uretericæ, and are produced by the rts of the ureters as they traverse the bladder wall and lie beneath the at of the bladder (Fig. 995). In old people the region behind the s usually distinctly depressed and forms a shallow fossa, sometimes retro-ureteric fossa. A less distinct shallow depression may sometimes on each side of the trigone. Round the urethral orifice are a number radially disposed folds which, disappearing into the urethra, become with the longitudinal folds of the mucous membrane of the first part of that canal. The ureters pierce the bladder wall very obliquely, and so the minute orificium ureteris, or opening, of each has an elliptical outline. The lateral boundary of each opening is formed by a thin, crescentic fold, which, when the bladder is artificially distended in the dead subject, acts as a valve in preventing water or air from entering the ureter. Hence the term “valvula ureteris” is sometimes used to designate the fold. In the empty bladder the urethral orifice and the openings of the two ureters lie at the angles of an approximately equilateral triangle, whose sides are about one inch in length. When the bladder is distended the distance between the openings may be increased to one and a half înches or more.

Bladder in the Female.—In the female the bladder is related posteriorly to

[graphic][subsumed][merged small][merged small][merged small][merged small]

Trigonum vesica

Torus uretericus

Fig. 995.— EMPTY AND CONTRACTED URINARY BLADDER, OPENED UP BY the REMOVAL OF ITS UPPER WALL The peritoneum is seen spreading out from the lateral and posterior borders of the organ. Compare with

Fig. 1000. the uterus and upper part of the vagina. The anterior surface of the uterus in its upper part is separated from the upper surface of the bladder by the shallow utero apposition. So close is this relationship that the upper surface of the bladder het often shows a slight concavity, due to contact with the convex anterior wall of the uterus. The lower part of the uterus and upper part of the vagina are not separated by peritoneum from the basal surface of the bladder, but are in apposition with it (Fig. 996). Thus, below the level of the utero-vesical pouch, the female bladder is related in much the same manner to the uterus and anterior wall of the vagina as the male bladder is related to the vesiculæ seminales and on a lower level than in the male, so that the organ, even when distended, rises less freely into the abdomen. The bladder as a whole is placed deeper in the pelvis than in the male, and the internal urethral orifice lies just above, or just below, a line drawn from the lower margin of the symphysis to the lower end of the sacrum (p. 1274). The lower level of the internal urethral orifice is probably correlated with the absence of a distinct prostate in the female. It is probable that is female; the conflicting results arrived at by different observers are probably due to the regards capacity no difference exists between the bladder in the male and in the faulty methods which have been employed in estimating the capacity of the orgal

actual

lies

er in the Newly Born Infant and in the Child.—At birth the empty

[graphic][ocr errors][merged small][merged small][merged small][subsumed][subsumed][subsumed][subsumed][subsumed][merged small]

Median umbilical

Ureter

Muscular wall of bladder

Ductus deferens

Seminal

vesicle

is spindle- or torpedo-shaped, and its long axis, which extends from the attachment of the urachus to rnal urethral orifice, is directed

ligament rds and backwards (Fig. 997).

(urachus) eral and posterior borders seen dult organ cannot be recognised , nor is there any part of the

wall directed downwards and rds, as is the basal surface of ult organ. In the fætus and child the bladder occupies relamuch higher level than it does

Musculus pubo-vesicalis adult, and, even when empty, ads upwards into the abdominal Its anterior aspect is in con

Fig. 997.- THE URINARY BLADDER OF A NEWLY ith the posterior surface of the BORN MALE CHILD, viewed from the side. r abdominal wall. At birth the The drawing is from a specimen which had been

hardened in situ. neum forming the recto-vesical covers the whole of the posterior surface of the bladder, and reaches as low upper limit of the prostate. The internal urethral orifice is placed at a high and sinks gradually after birth (Fig. 998, A). In the newly born child this

Prostate

Urethra

opening lies on a level with the upper margin of the symphysis pubis, and the openings of the ureters lie almost on a level with the plane of the pelvic brim. The obliterated portions of the umbilical arteries are more intimately related to the bladder in the fætus and child than in the adult, and lie close against its sides as they pass upwards towards the umbilicus (Fig. 999). Peritoneal Relations and Connexions of the Bladder. We have already

seen that the superior surface of the empty bladder is covered by peritoneum, w hich leaves it along the lateral border on each side to reach

the pelvic wall at Urinary bladder

about the level of

the arcus ten: Symphysis pubis

dineus or white line Corpus cavernosum

of the pelvic fascia
Internal sphincter ani To this peritoneal
External sphincter ani
-Anal canal

reflection the term Bulbo-cavernosus

-External sphincter ani lateral false (or peri

toneal) ligament is often applied. The lateral ligaments of

Rectum

penis Corpus cavernosum

urethra

muscle

fibrous

-Uterus

-Rectum

When the

empty

opposite sides are continuous in front, at the bladder apex, where the peritoneum is conducted over the cord of the urachus

to reach the anterior Urinary bladder

abdominal wall,

forming the soSymphysis pubis

called superior false Vagina

(or peritoneal) liga Urethra

ment. Carina urethralis

-Internal sphincter ani

bladder is

-External sphincter ani
Labium ininus

Anal canal
pudendi

the level of this -External sphincter ani anterior reflection

lies just behind, or just below, the

upper margin Fig. 998.— MEDIAN SECTION THROUGH THE PELVIS OF NEWLY BORN CHILD.

symphysis pubis

When the bladder A, Male, and B, Female.

becomes filled the

level of the toneal reflection forming the superior false ligament is raised upwards, and mas reach a point two inches, or more, above the upper margin of the symphysis pubis wall is also carried upwards in distension of the bladder, and may reach the lerel Similarly, the line along which the lateral peritoneal ligament reaches the pelni of the ductus deferens and of the obliterated umbilical artery. wall of the pelvis as low as the lateral border of the organ, and lines a shallow

When the bladder is empty the peritoneum is carried downwards upon the side below the level of the obturator peritoneal fossa (p. 1269), from which it is separata depression which receives the name of paravesical fossa. This peritoneal fossa lies by the ductus deferens. As the bladder fills, the peritoneum is raised off this part of the pelvic wall, and certain structures, such as the obturator vessels and nerv

of the

B

pen

Ductus deferens

ctus deferens,

Urinary bladder

Umbilical artery
Abdominal
In the lateral inguinal ring

Testis pelvis, come

relationship teral aspect of

Epididymis ed bladder. Orly the peri

Gubernaculum ves thesuperior Ductus of the empty deferens

Mesorchium tits posterior is carried back

Internal sper.

matic vessels ming a kind of shelf, or fold,

Psoas major tance of about

Rectum nch, giving at

time a partial Fig. 999. -- View LOOKING FROM ABOVE INTO THE Pelvis AND LOWER to the ductus de- PART OF THE ABDOMINAL CAVITY IN A FETUS OF ABOUT THE nd superior ends SEVENTH MONTH. eminal vesicles. On the left side, which represents a slightly more advanced condition than oneum then sud

the right, the testis has entered the inguinal canal ; on the right side

the testis is still within the abdominal cavity. Os downwards to e bottom of the recto-vesical, or recto-genital, pouch, where it is reflected e anterior surface of the rectum (Fig. 1001). As a rule, no part of the

[graphic]
[graphic]

Median umbilical ligament (urachus) Urinary bladder
Plica vesicalis transversa

Paravesical peritoneal fossa

Obliterated umbilical artery a femorale

Inferior epigastric artery

8:23

al spermatic artery
Ductus deferens

Ureter
Recto-vesical pouch

External iliac artery
Intervertebral fibro-cartilage

Hypogastric artery
Rectum

Sacro-genital fold Fig. 1000.–VIEW LOOKING INTO THE MALE PELVIS FROM ABOVE AND SOMEWHAT BEHIND. n a specimen in which the bladder was firmly contracted and contained but a small amount of fluid. The

paravesical fossa is seen on each side of the bladder. The deep peritoneal pouch in front of the rectum is bounded on each side by crescentic sacro-genital folds or “posterior false ligaments of the bladder," which meet together in the median plane some distance behind the posterior border of the bladder.

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