TOPOGRAPHY FEMALE BLADDER AND URETHRA.
The female bladder distended with air and inspected per ure thrae, by the speculum, as I shall describe farther on, has more or less the form of a hollow ovoid, into which the observer is peeping through a hole in its wall; by turning the speculum, it is possible to gain a view of every portion of the inner mucosa.
Apart from the stellate vessels with their bifurcations and anasto mosing branches, the inner surface of the bladder at first sight ap pears singularly barren in landmarks, and the clinical observer finds it difficult either to convey to others an intelligent idea of lesions noted, or even to keep for himself an accurate record of the progress or decline of local disease. The female bladder is, however, most favorably situated for diagnosis per speculum, and it presents certain well-defined landmarks, so that the lack of a topography of its inter nal surface ought no longer to embarrass the practitioner.
I present the following schema as a preliminary study, which will, I hope, be found sufficient for present practical needs. My topo graphy is based, it will be seen, upon a consideration of : 1. artificial landmarks ; 2. natural landmarks ; 3. the relation of the female bladder to surrounding structures.
Artificial Landmarks. —As I have already observed, the bladder under atmospheric distention appears to one peeping into it as a hollow sphere or ovoid. The two points, the internal orifice and that part of the posterior wall which is directly opposite to it, may be conveniently referred to as the principal "polar points." The "posterior pole" is the point of departure in all examinations, because it is the first portion of the bladder seen as the light is re flected from the head mirror through the speculum turned directly backward. Any disease detected in its neighborhood may be de scribed as extending above or below or around it, or by the term " circumpolar." The posterior pole is a point around which inflammatory lesions are specially likely to be found; it should also be remembered that it is the part of the bladder most liable to trauma from friction with the edge of the speculum carried too far in. The circumpolar area
may be conveniently considered as mapped out by three circles de scribed around the pole as a centre, having radii respectively 1, 2, and 3 cm. in length. It is true that the posterior pole thus located is not a fixed point, but varies with different degrees of distention of the bladder, or with slight movements on the part of the specu lum. In spite of this objection, however, the practical utility of the plan of registration proposed is greater than that of any other plan, and if a point is once fixed as the posterior pole, in any individual case, and a sketch made locating the patch of disease, the same locality is readily found on subsequent examination, as the point of departure for further measurements. One other fixed line in the bladder, always readily accessible in determining localization of dis eases, is an imaginary line produced by sagittal section.
Affections situated about the anterior pole (ostium uretbrre inter num) are best described as circumurethral.
Proceeding another step in our differentiation, we will consider the bladder as divided into an anterior and a posterior hemisphere. The convenience of this division is especially apparent in describing affections of the posterior part of the bladder. Thus, if we imagine the posterior pole as a centre intersected at right angles by vertical and horizontal lines, the posterior hemisphere will be divided into four quadrants, a right upper and lower quadrant, and a left upper and lower quadrant (dexter superior and inferior, q. d. s. and q. d. and sinister superior and inferior, q. s. s. and q. s. i.). The position of the line in the plane of the sagittal suture cleaving the posterior hemisphere vertically is especially easy to determine by the eye, thus keeping right and left sides in the bladder sharply distinct in all its parts. With these purely artificial aids it is possible to locate precisely affections within the areas defined.