FEMALE BLADDER.
The female bladder occupies the cavity of the pelvis anterior to the uterus and broad ligaments, and above the vagina. It differs decidedly from the male bladder in its topographical relations and the form it assumes upon expansion.
Writers differ in their statements as to the form of the empty bladder. Berry Hart, for example, states that the normal empty female bladder presents an oval form in sagittal section and forms more or less of a continuous canal with the urethra. Schultze states, on the other hand, that in its contracted condition the upper wall comes to rest upon the lower in such a manner that the angle of flexion lies at the utero-vaginal junction. Anteriorly the angle of flexion lies below the top of the symphysis pubis. This gives the bladder the characteristic Y-shape (the stem of the Y being repre sented by the urethra) which has become so familiar through frozen sections. I am able to verify both of these observations. The blad der in a quiescent state assumes the Y-form, the upper hemisphere resting in the lower like one saucer within another. When actively contracting, however, it assumes the ovoid form.
As the bladder fills with urine, the expansion is greatest at the sides, filling out the pockets in front of the broad ligaments, but the body of the uterus which normally lies in contact with it is not ele vated in proportion to the degree of lateral expansion. The form of the distended bladder is an ovoid with its long axis transverse, and a deep depression in the middle, like a pair of saddle-bags.
It is only in cases of extreme distention that the long axis be comes vertical, in which case the uterus is thrown into retroposition and the bladder is brought in contact with the rectum as in the male pelvis. A close approximation to the conditions present in the male is also brought about by the operation for the extirpation of uterus, tubes, and ovaries now so frequently performed.
In considering the origin and course of the various affections of the female bladder it is important to bear in mind its intimate con nection with the vagina, with the anterior part of the cervix uteri, and its relations, through the broad ligaments on either side, to the tubes and ovaries, which become especially intimate when the latter are enlarged and fixed by inflammatory disease and tend to push for ward the broad ligaments so as to encroach upon the anterior part of the pelvis. From the connection thus established pelvic abscesses
may be discharged through the bladder; dermoid cysts have been also known to empty their contents in this way, and I have seen a tubercular tuba-ovarian abscess break through and infect the bladder mucosa.
The importance of being familiar with the peculiar manner in which the bladder distends becomes evident, when we recall the fre quency with which a few years ago the stump of a fibroid uterus was fastened in the lower angle of an abdominal wound, just above the symphysis pubis. In these cases it is at once evident that all possi bility of distention in the median line in an antero-posterior or verti cal direction is taken away. There is also a limitation of the dis tention in the same direction after suspension of the uterus to the anterior abdominal wall for the correction of retroflexion. In a case which appeared to be entirely normal, I have seen the bladder dis tended by about eight ounces of urine almost wholly in front of the left broad ligament. The thickness of the walls of the contracted bladder is ten or more millimetres; they become thinner upon distention, being 3 to 4 mm. thick when moderately distended. The mucous membrane in the contracted state is thrown into innumera ble folds and convolutions, similar to those of the brain. The epi thelium is two layers deep and extremely elastic.
The bladder also contains crypts and numerous branched acinous glands lined with cylindrical epithelium. The inner muscular layer of the bladder is connected with the mucosa by an extremely loose connective-tissue layer, excepting in the neighborhood of the trigo num. This muscular covering consists for the most part of two lay ers of smooth fibres of equal volume, the outer layer having a more or less vertical direction, while the inner is principally horizontal or ring-shaped (Heide). Among the most important anatomical fea tures of the bladder are the ureteral orifices shortly to be spoken of.
In investigating and attempting to record the results of the exam ination of numerous cases of diseases of the bladder coming to my clinic, I have found a fresh study of the topographical relations from a practical standpoint to be absolutely necessary.